HX64054152 
R  D32  B47  1 908       A  text-book  of  opera 


Columbia  (Mntt)ertfft|)  /  00  8 

mtljeCttpoOtatigork  Cop.  I 

College  of  $f)pjstciang  anb  burgeons 


Htbrarp 

GIFT  OF 
DR.  JOHN  B.WALKER 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/textbookofoperat1908bick 


A  TEXT-BOOK 


OF 


Operative  Surgery 


COVERING  THE  SURGICAL  ANATOMY  AND 
OPERATIVE  TECHNIC  INVOLVED  IN  THE 
OPERATIONS  OF  GENERAL  SURGERY 


DESIGNED    FOR     PRACTITIONERS    AND    STUDENTS 


BY 

WARREN  STONE  BICKHAM,  M.  D.,  Phar.  M. 

Junior  Surgeon,  Touro    Hospital.  New  Orleans  ;    late   Surgeon  to  Manhattan  State  Hospital,  New 

York;  late  Assistant    Instructor  in  Operative    Surgery,  College  of    Physicians  and  Surgeons 

(Columbia  University),  New  York  ;   late   Instructor  in  Surgery,  New  York  Post-Graduate 

Medical   School  and   Hospital;   late   Instructor  in  Surgery,  New  York  Polyclinic 

Medical  School   and  Hospital  ;    late  Yisiting  Surgeon  to  Charity  Hospital, 

New  Orleans  ;   late   Demonstrator  of    Operative    Surgery,  Medical 

Department,  Tulane  University   of   Louisiana,    New  Orleans  ; 

Fellow  of  the  New  York  Academy  of  Medicine,  etc. 


THIRD  EDITION,   GREATLY   ENLARGED 
CONTAINING    854    ILLUSTRATIONS 


PHILADELPHIA    AND      LONDON 

W.    B.    SAUNDERS    COMPANY 

1  908 


Set  up,  electrotyped,  printed,  and  copyrighted  August,  1903       Revised,  reprinted,  and  recopyrighted 

April,  1904.      Reprinted  February,  1905,  February,  1906,  and  September,  1906. 

Revised,  reprinted,  and  recopyrighted  September,  1908. 


Copyright,  1908,  by  W.  B.  Saunders  Company. 


!ESS     O  F 

M  O  E  RS      COMP* 


IN    REVERED   MEMORY   OF   MY    FATHER 

Cbarles  Jasper  36icfebam 

WHOSE  DAILY  LIFE    EMBODIED  THE    HIGHEST  IDEALS  OF  CHRISTIAN 
PHYSICIAN,  I   LOVINGLY  DEDICATE  THIS  WORK 


PREFACE  TO  THIRD  EDITION. 


The  scope  of  the  alterations  in  this  edition  of  the  present  work  is  suffi- 
ciently shown  by  the  additions  and  omissions  here  indicated. 

The  last  edition  of  this  work  contained  984  pages,  including  559  illustra- 
tions. 

The  present  edition  contains  1204  pages,  including  854  illustrations. 

In  the  new  edition  the  following  changes  have  been  made  from  the  old: 
29  pages  of  text,  covering  25  operations,  have  been  dropped;  123  pages  of 
text,  descriptive  of  106  operations,  have  been  added;  42  old  pictures  have 
been  omitted;  45  old  pictures  have  been  redrawn;  and  331  new  pictures 
have  been  added. 

The  Author  especially  desires  to  express  his  appreciation  of  the  kindly 
reception  of  his  efforts  by  the  Profession — Surgical  and  Medical — as  evi- 
denced by  the  demand  for  additional  editions,  and  trusts  that  the  recent 
changes  and  additions  in  the  writings  and  illustrations  will  materially  add 
to  the  general  usefulness  of  the  work. 

Deep  gratitude  is  due  the  author's  Wife  for  her  constant  aid  throughout 
the  work,  and  for  her  unfaltering  encouragement  during  the  many  days  of 
its  preparation. 

The  writer  wishes  to  testify  his  sincere  appreciation  of  the  continuous 
and  substantial  aid  given  him  by  Mrs.  Farnsworth,  his  Assistant,  in  the 
general  work  of  revision,  and  especially  in  the  drawing  of  considerably  the 
larger  number  of  the  new  pictures. 

Thanks  are  again  extended  to  Miss  Fry  for  those  illustrations  made  by 
her. 

The  liberality  of  the  Publishers  in  arranging  the  details  of  the  revision 
and  the  excellence  of  its  execution  are  fully  acknowledged. 

Finally,  the  writer  desires  to  express  his  earnest  esteem  of  the  many 
valuable  intellectual  opportunities,  and  of  the  large  practical  contact  with 
surgical  work,  resulting  from  the  close  professional  and  friendlv  associate- 
ship  with  Professor  Rudolph  Matas,  whose  general  surgical  knowledge, 
marvelous  in  its  extent  and  detail,  is  most  probably  not  exceeded  by  that  of 
any  Surgeon  living. 

W.  S.  B. 

New  Orleans,  September,   1908. 
3521   Prytania  Street. 


PREFACE  TO  THE  FIRST  EDITION. 


The  sub-title  of  the  present  volume  sufficiently  designates  its  intended 
scope — "The  Surgical  Anatomy  and  Operative  Technic  involved  in  the 
Operations  of  General  Surgery."  The  work  is  planned  to  be  a  presentation 
to  the  Student  and  Practitioner  of  the  best  technic  of  modern  Surgeons  in 
the  operations  mentioned — accompanied  by  a  brief  summary  of  the  descrip- 
tive and  surgical  anatomy  of  the  structures  involved. 

The  clinical  aspect  of  Operative  Surgery  has  been  less  fully  dealt  with — 
and  in  generalizations  in  connection  with  groups  of  operations,  rather  than 
specifically  in  connection  with  individual  operations. 

An  apology  for  the  amount  of  Anatomy  given  may  seem,  to  some,  neces- 
sary. From  the  standpoint  of  the  pure  technician,  Operative  Surgery  is, 
largely,  Applied  Anatomy — the  application  of  the  facts  of  Surgical  Anatomy 
during  the  progress  of  Surgical  Manipulations — the  resulting  Operative 
Technic  being  more  or  less  perfect  as  the  knowledge  of  the  Surgical  Anatomy 
and  the  conduction  of  the  Surgical  Manipulations  are  more  or  less  perfect. 
Theoretically,  it  is  proper  to  expect  fourth-year  Students  to  come  into  the 
Operating  Room  with  their  Anatomy  in  an  available  form  for  surgical  work 
— practically,  this  is  rarely  found — and  is  often  absent  in  seasoned  Operators. 

In  the  arrangement  of  this  work  the  subjects  have  been  grouped  under, 
The  Operations  of  General  Surgery  (Part  I),  and,  The  Operations  of  Special 
Surgery  (Part  II) — as  further  detailed  in  the  especially  full  Contents.  In 
dealing  with  each  group  of  tissues,  or  class  of  operations  (in  Part  I),  or  with 
each  organ  (in  Part  II),  the  following  divisions  of  the  subjects  are  taken  up, 
in  order:— (i)  Surgical  Anatomy  (of  the  region  or  organ);  (2)  Surface  Form 
and  Landmarks;  (3)  General  Surgical  Considerations  (in  operating  upon 
that  region  or  organ) ;  (4)  Instruments  (used  in  such  operations) — all  being 
introductory  to  the  specific  operations, — after  which  each  operation  is  taken 
up  in  turn,  under  the  following  headings: — (1)  Title  of  Operation;  (2)  De- 
scription of  Operation  (including  its  general  indications);  (3)  Preparation 
of  Patient;  (4)  Position  of  Patient,  Surgeon,  and  Assistant;  (5)  Landmarks 
of  Operation;  (6)  Incision  for  Operation;  (7)  Steps  of  Operation;  (8)  Com- 
ments. 

In  the  description  of  the  technic  of  the  operations  the  "Incision"  is  given 
a  heading  to  itself — to  emphasize  the  importance  of  this  step  of  the  operation 
— recognizing  that  the  Operator  who  starts  out  aright  is  a  long  way  ahead 
of  the  man  who  takes  his  initial  step  erroneously.  Under  "Operation"  the 
various  steps  are  given  in  numbered  paragraphs — the  different  paragraphs 
usually  indicating,  in  a  general  way,  some  change  in  the  technic  or  in  the 
stage  of  the  operation. 

The  Principles  of  Operative  Surgery,  and  Anesthesia,  as  well  as  the 
Operations  of  Plastic  Surgery,  many  of  the  operations  more  properly  classed 
as  the  operations  of  Special  Branches  of  Surgery,  and  some  of  the  many 
variations  of  the  operations  of  General  Surgery,  have  been  omitted. 


2  PREFACE. 

In  the  preparation  of  these  pages,  obligations  are  hereby  gratefully  and 
fully  acknowledged  to  the  writings  of  many  well-known  Surgeons  in  the 
standard  works  of  the  day  upon  Operative  Surgery,  and  in  the  current  surgical 
literature,  whose  pages  have  been  freely  consulted — and  to  the  work  of  many 
Surgeons,  here  and  abroad,  whose  operative  technic  it  has  been  the  privilege 
of  the  author  to  witness — and  to  writings  upon  Anatomy. 

The  name  of  the  deviser  of  an  operation  is  given,  in  brackets,  after  the 
title  of  the  operation,  wherever  known  to  the  author.  Where  slight  de- 
partures from  the  manner  of  doing  the  operation  as  performed  by  its  originator 
occur,  such  omission  is  accidental — or,  where  the  original  description  is 
ambiguous,  the  operation  is  given  as  it  seems  to  be  interpreted  by  the  majority 
of  Surgeons. 

Appreciation  of  encouragement  shown  during  the  preparation  of  the 
manuscript  is  gratefully  acknowledged  to  Professors  Bull,  Dennis,  Hal- 
sted,  Hartley,  Matas,  Richardson,  Senn,  Weir,  and  Wyeth — and  to  my 
co-workers,  Doctors  Peck,  Schmitt,  and  Taylor,  in  the  Department  of  Op- 
erative Surgery  at  the  College  of  Physicians  and  Surgeons — and  to  Doctor 
Gessner,  my  former  co-worker  in  the  Laboratory  of  Operative  Surgery 
of  Tulane  University — and  to  Doctors  Armstrong  and  LeBeuf — and  to 
other  friends  whose  kindly  words  have  aided  and  lightened  the  work  of 
preparation. 

The  author  feels  deeply  indebted  to  Miss  Eleanora  Fry,  who  has  drawn, 
under  his  close  directions,  all  the  illustrations  for  the  book,  during  many 
weeks  of  conscientious  work  and  unflagging  interest — the  large  majority  of 
the  five-hundred  and  fifty-nine  illustrations  being  original,  and  the  remainder 
so  largely  modified  as  to  be,  in  many  instances,  practically  new  pictures. 

I  wish  to  thank  the  Publishers  for  the  courteous  consideration  they  have 
shown  my  every  expression  of  wish  throughout — for  their  interest  in  the 
manuscript — and  for  the  quality  of  their  finished  work. 

I  desire  to  express  my  high  valuation  of  my  Wife's  ever-ready  and  untiring 
aid  in  all  the  proof-readings  of  the  manuscript  during  the  many  months 
of  its  preparation. 

The  imperfections  of  the  present  work  are  very  fully  realized — and  the 
author  will  be  glad  to  receive  all  criticisms  which  may  tend  to  the  bettering 
of  the  text  and  illustrations. 


WARREN  STONE  BICKHAM. 


10  East  58TH  Street, 
New  York  City. 


CONTENTS. 


PART    I. 
THE  OPERATIONS  OF  GENERAL  SURGERY. 


CHAPTER   I. 
OPERATIONS   UPON   ARTERIES. 

I.  Ligation  of  arteries — General  considerations,  17. 

II.  Surgical  Anatomy  and  Ligation  of  following  Arteries  of  Head  and  Neck:— Innominate, 
by  angular  incision  (Mott's  operation),  27 — By  oblique  incision,  30 — By  partial  bony  resection 
(Bardenheuer's  operation),  31 — By  splitting  of  manubrium  sterni,  31 — Common  carotid,  above 
omohyoid,  34 — Below  omohyoid,  35 — External  carotid,  below  digastric,  37 — Above  digastric, 
behind  ramus  of  jaw,  38 — Lingual,  near  origin,  39 — Beneath  hyoglossus,  39 — Facial,  near 
origin,  41 — Over  inferior  maxilla,  41 — Occipital,  near  origin,  42 — Behind  mastoid  process, 
42 — Temporal,  just  above  zygoma,  43 — Internal  maxillary  (surgical  anatomy),  44 — Trunk 
of  middle  meningeal,  in  cranium,  through  trephine-opening  exposed  by  curved  oblique  incision, 
47 — Anterior  branch  of  middle  meningeal,  through  trephine-opening  exposed  by  horseshoe 
incision,  48 — Posterior  branch  of  middle  meningeal,  through  trephine-opening  exposed  by 
horseshoe  incision,  49 — Internal  carotid,  near  origin,  50 — First  part  of  right  subclavian,  by 
angular  incision,  52 — First  part  of  left  subclavian,  by  angular  incision,  52 — Second  part  of 
subclavian,  53 — Third  part  of  subclavian,  53 — Vertebral,  near  origin,  55 — Inferior  thyroid,  57. 

III.  Surgical  Anatomy  and  Ligation  of  following  Arteries  of  Upper  Extremity  and  Thorax: 
— Internal  mammary,  in  second  intercostal  space,  58 — First  part  of  axillary,  by  curved  trans- 
verse incision  below  clavicle,  60 — Third  part  of  axillary,  62 — Brachial,  in  mid-arm,  64 — At 
bend  of  elbow,  65 — Radial,  in  upper  third,  69 — In  lower  third,  70 — Deep  palmar  arch,  72 — 
Ulnar,  in  middle  third,  74 — In  lower  third,  76 — Intercostal,  by  intercostal  incision,  76 — Inter- 
costal, by  partial  subperiosteal  excision  of  rib  (Hartley's  method),  78. 

IV.  Surgical  Anatomy  and  Ligation  of  following  Arteries  of  Trunk: — Abdominal  aorta, 
by  transperitoneal  method,  79 — By  retroperitoneal  method,  80 — Common  iliac,  by  retroperitoneal 
method,  Si — By  transperitoneal  method,  83 — Internal  iliac,  by  retroperitoneal  method,  84 — 
By  transperitoneal  method,  84 — Sciatic,  upon  buttock,  84 — Internal  pudic,  upon  buttock,  87 — 
In  perineum,  87 — Gluteal,  on  buttock,  87 — External  iliac,  by  retroperitoneal  method,  89 — By 
transperitoneal  method,  91. 

V.  Surgical  Anatomy  and  Ligation  of  following  Arteries  of  Lower  Extremity: — Common 
femoral,  at  base  of  Scarpa's  triangle,  93 — Profunda  femoris,  near  origin,  95 — Superficial  femoral, 
at  apex  of  Scarpa's  triangle,  96 — In  Hunter's  canal,  98 — Popliteal,  in  upper  part  of  popliteal 
space,  from  behind,  100 — In  upper  part  of  popliteal  space,  from  inner  side  of  thigh,  Jobert's 
operation,  100 — In  lower  part  of  popliteal  space,  10 1 — Anterior  tibial,  in  upper  third,  104 — 
In  middle  third,  105 — In  lower  third,  105 — Dorsalis  pedis,  just  below  ankle-joint,  107 — Pos- 
terior tibial,  in  upper  third,  above  peroneal  branch,  109 — In  middle  third,  no — In  lower  third, 
112 — Behind  internal  malleolus,  112 — Peroneal,  in  middle  of  leg,  114 — External  plantar  in 
sole  of  foot,  116 — Internal  plantar,  at  origin,  117 — In  sole  of  foot,  117. 

VI.  Temporary  ligation,  118 — Intermediate  ligation,  118 — Arteriorrhaphy,  118 — Closure 
of  wounds  of  larger  arteries  by  special  rubber  plaster  (Brewer's  method),  124 — Aneurismor- 
rhaphy  (Matas'  method),  125 — Operation  for  the  radical  cure  of  anteriovenous  aneurisms,  with 
preservation  of  circulation  in  artery  and  vein  (Matas-Bickham  operation),  133 — Ligation  for 
radical  cure  of  aneurism,  139 — Other  operations  for  radical  cure  of  aneurism,  139 — Arterial 
forcipressure,  140 — Arteriostrepsis,  140 — YVyeth's  treatment  of  vascular  neoplasms,  14 r. 

3 


4  CONTENTS. 

CHAPTER   IE 
OPERATIONS   UPON   VEINS. 

Phlebotomy,  142 — Phleborrhaphy,  142 — Lateral  ligation  of  veins,  143 — Transverse  liga- 
tion of  veins,  144  -Temporary  ligation  of  veins,  144 — Venous  ligation  en  masse,  145 — Venous 
forcipressure,  145 — Phlebostrepsis,  145 — Acupressure  of  veins,  145 — Phlebectomy,  145 — - 
Intravenous  infusion  of  normal  salt  solution,    140. 


CHAPTER    III. 

OPERATIONS   UPON   LYMPHATIC   GLANDS   AND   VESSELS. 

Surgical  anatomy  of  thoracic  duct,  148 — Suture  of  thoracic  duct,  148 — Ligation  of  thoracic 
duct,  149 — Surgical  anatomy  of  antero-lateral  aspect  of  neck,  149 — Removal  of  lymphatic 
glands  of  neck,  151 — Surgical  anatomy  of  axillary  region,  154 — Removal  of  axillary  lymphatic 
glands,  155 — Surgical  anatomy  of  Scarpa's  triangle,  155 — Removal  of  inguinal  lymphatic 
glands,  156. 

CHAPTER    IV. 
OPERATIONS   UPON  NERVES,   PLEXUSES,    AND   GANGLIA. 

I.  Neurotomy,  157 — Neurectomy,  158 — Neurectasy,  158 — Nerve-avulsion,  159— 
Neurorrhaphy,  160 — Neuroplasty,  163 — Nerve-grafting,  165 — Neurolysis,  or  an  operation  for 
relief  of  nerve-compression,  169 — Intraneural  infiltration  for  regional  anesthesia  (operation 
of  Matas  and  Crile),  169 — Paraneural  infiltration  for  regional  anesthesia  (Matas'  method), 
171 — Massive  infiltration  anesthesia  with  weak  analgesic  solutions  (Matas'  modification  of 
Schleich's  method),  172. 

II.  Surgical  Anatomy  and  Exposure  of  following  Nerves  and  Ganglia  of  Head  and  Neck: — 
Gasserian  ganglion  and  three  divisions  of  fifth,  by  direct  infra-arterial  (Cushing's  method),  175 — 
Same,  by  intracranial  exposure  (Hartley-Krause  method),  177 — Same,  by  trephining  through 
pterygomaxillary  fossa  (Rose's  method),  181 — Supraorbital,  at  supraorbital  foramen,  182 — 
Exposure  of  superior  maxillary  nerve  at  foramen  rotundum  by  osteoplasic  resection  of  malar 
and  adjacent  bones  (Kocher's  operation),  183 — Meckel's  ganglion  and  superior  maxillary, 
by  antral  route  (Carnochan's  operation),  185 — Same,  by  orbital  route,  186 — Same,  by  pterygo- 
maxillary route  (Braun-Loessen  operation),  1S6 — Exposure  of  inferior  maxillary  nerve  at  foramen 
ovale  by  osteoplastic  resection  of  malozygomatic  arch  (Kocher's  operation),  188 — Inferior  maxill- 
ary, at  foramen  ovale,  190;  or  superior  maxillary,  at  foramen  rotundum  (Mixter's  operation),  190 
— Inferior  dental,  in  mouth  (Paravicini's  intrabuccal  method),  191 — Through  ascending  ramus 
of  inferior  maxilla,  192 — At  mental  foramen,  from  within  mouth,  193 — Lingual  (gustatory)  of 
inferior  maxillary,  in  mouth,  194 — Facial,  in  front  of  mastoid  process  (Baum's  operation),  195 — 
Spinal  accessory,  at  anterior  border  of  sternomastoid,  195 — Facio-accessory  or  facio-hypoglossal 
anastomosis  for  peripheral  facial  paralysis,  196 — Posterior  divisions  of  first,  second,  and  third 
cervical  nerves  (Keen's  operation),  197 — Brachial  plexus,  in  neck,  198 — Operation  for  brachial 
birth  palsy,  199. 

III.  Surgical  Anatomy  and  Exposure  of  following  Nerves  of  Upper  Extremity  and  Thorax: 
— Median,  in  middle  of  arm,  201 — At  bend  of  elbow,  202 — Ulnar,  above  middle  of  arm:  202 — 
Just  above  internal  condyle  of  humerus,  203 — Musculospiral,  below  middle  of  arm,  203 — 
Intercostal,  between  angle  and  middle  of  rib,  204. 

IV.  Surgical  Anatomy  and  Exposure  of  following  Nerves  of  Lower  Extremity: — Anterior 
crural,  below  Poupart's  ligament,  205 — Obturator,  at  thyroid  foramen,  205 — Superior  gluteal, 
upon  buttock,  205 — Pudic,  upon  buttock,  205 — Great  sciatic,  at  lower  border  of  gluteus  maximus, 
206 — Internal  popliteal,  at  lower  part  of  popliteal  space,  206 — Posterior  tibial,  between  origin 
and  ankle,  207 — Behind  internal  malleolus,  207 — External  popliteal  (peroneal),  behind  tendon 
of  biceps,  207 — Anterior  tibial,  near  origin,  208. 

V.  Surgical  Anatomy  of  Cervical  Sympathetic  Ganglia  and  Cord,  208 — Total  excision 
of  cervical  sympathetic  ganglia  and  cord  (Jonnesco's  operation),  209. 

CHAPTER   V. 
OPERATIONS  UPON  BONES. 

Osteotomy  in  general,  210— Linear  osteotomy,  by  subcutaneous  method,  211— Linear 
osteotomy,  by  open  method,  213 — Cuneiform  osteotomy,  214— The  operative  treatment  of 
fractures  in  general,   214— Operations  for  recent  or  ununited  fractures,  by  resection  of  ends 


CONTENTS.  5 

of  bones,  with  retention  of  coaptated  ends  by  immobilizing  splints,  215 — Same,  by  suturing 
of  ends  of  bones,  with  or  without  resection,  217 — Other  operative  methods  of  approximating 
and  fixing  ends  of  fractured  bones,  221 — Operative  treatment  of  simple  fractures,  225 — Bone- 
grafting  or  bone-implantation,  227 — Operations  for  delayed  union,  non-union,  and  mal-union 
of  fractures,  228 — Operative  treatment  of  compound,  comminuted,  and  complicated  fractures, 
230 — Operative  treatment  of  fractures  involving  joints  and  of  fracture  dislocations,  231 — 
Operative  treatment  of  separated  epiphyses,  232 — Operation  for  recent  or  ununited  fracture 
of  patella,  by  suturing  soft  parts  (Stimson's  method),  233 — Same,  by  wiring  or  suturing  of  bone 
and  soft  parts,  234 — Same,  by  an  encircling  suture  of  soft  parts,  236 — Operation  for  recent 
or  ununited  fracture  of  olecranon,  by  wiring  or  suturing  of  bone  and  soft  parts,  238 — Seques- 
trotomy,  239 — Osteoplasty,  240 — Excision,  240. 


CHAPTER    VI. 
OPERATIONS   UPON    JOINTS. 

Exploratory  puncture  of  joints,  241 — Arthrotomy,  241 — Arthroplasty,  241 — Arthrodesis, 
242 — Erasion,  or  arthrectomy,  242 — Operation  for  dislocated  semilunar  cartilages,  244 — 
Excision,  244. 

CHAPTER    VII. 

OPERATIONS    UPON   MUSCLES. 

Myotomy,  245 — Myorrhaphy,  245 — Muscle-lengthening,  246. 

CHAPTER    VIII. 
OPERATIONS   UPON   TENDONS  AND  TENDON-SHEATHS. 

Tenotomy,  249 — Tenorrhaphy,  251 — Tendon-lengthening,  254 — Tendon-shortening,  259 — 
Tendon-grafting,  261 — Operation  for  uniting  tendon  to  periosteum  (Lange's  method),  263 — ■ 
Operation  for  uniting  tendon  to  bone  (Wolff's  method),  264 — Transplantation  of  tendon  with 
its  osseous  insertion,  265 — Repair  of  ruptured  or  divided  tendon-sheaths,  265 — Excision  of 
tendon-sheaths,  267. 

CHAPTER    IX. 

OPERATIONS   UPON   LIGAMENTS. 

Syndesmotomy,  267 — Suturing  of  ligaments,  267 — Lengthening  of  ligaments,  267 — Shorten- 
ing of  ligaments,  267. 

CHAPTER    X. 

OPERATIONS   UPON   FASCIAE. 

Fasciotomy  or  aponeurotomy,  269 

CHAPTER   XI. 
OPERATIONS   UPON   BURS^E. 

Puncture  of  bursas,  270 — Incision  of  bursa?,  270 — Excision  of  bursa?,  270. 

CHAPTER    XII. 
AMPUTATIONS  AND   DISARTICULATIONS. 

I.  General  considerations,  271 — The  general  technic  in  amputating,  274 — Location  of 
line  of  bone-section,  or  disarticulation,  274 — Location  of  limits  of  skin  incisions,  275 — Incision 
of  skin  and  fascia,  276 — Freeing  of  skin  and  fascia,  279 — Retraction  of  skin  and  fascia,  2S0 — 
Division  of  muscles  in  circular  methods  of  amputation,  2S1 — Division  of  muscles  in  flap  methods 
of  amputation,   284 — Freeing  and  retracting  of  muscles,   2S8 — Making  musculo-periostcal,   or 


6  CONTENTS. 

periosteo-capsular,  covering  for  end  of  bone,  289 — Retraction  of  soft  parts  preparatory  to  sawing 
bone,  292 — Sawing  bone  or  bones,  292 — Removing  splintered  bone,  294 — Ligating  arteries  and 
veins,  295 — Treatment  of  nerves,  tendons,  and  tags  of  muscle,  fascia,  and  skin,  297 — Trimming 
of  flaps,  297 — Re-amputation  for  improperly  made  flaps,  297 — Adjustment  and  suturing  of 
musculo-periosteal,  or  periosteo-capsular,  covering,  297 — Quilting  of  muscles,  298 — Drainage, 
300 — Suturing  of  stump,  300 — Dressing  of  wound,  301 — Removal  of  dressings,  301. 

II.  The  methods  of  amputation,  301 — The  evolution  of  amputation  methods,  301 — Sum- 
mary of  amputation  methods,  303 — Circular  methods  of  amputation,  303 — Ordinary  circular 
amputation  (Amputation  circulaire  infundibuliforme),  303 — Cuff  method  of  circular  amputation 
(Circular  amputation  a  la  manchette),  305 — Modified  circular  amputation  (mixed  method), 
306 — Oval  method,  307 — Racket  method,  308 — Flap  methods  of  amputation,  309 — Amputating 
by  single  flap  of  skin  and  muscle,  309 — By  single  flap  of  skin,  311 — By  equal  flaps  of  skin  and 
muscle,  311— By  equal  flaps  of  skin,  311 — By  unequal  flaps  of  skin  and  muscle,  313 — By  unequal 
flaps  of  skin,  314 — By  unequal  rectangular  flaps  of  skin  and  muscle  (Teale's  method),  314 — 
Elliptical  method,  315 — Osteoplastic  amputations,  317 — Irregular  methods  of  amputation, 
3*7 — Selection  of  amputation  method,  317 — Primary,  intermediate,  and  secondary  amputa- 
tions, 319. 

III.  The  amputation  stump,  319 — Qualities  of  a  good  stump,  319 — Characteristics  of 
a  bad  stump,  320 — Conditions  influencing  vitality  of  stump,  320 — Contractility  of  tissues  of 
stump,  321 — Position  of  stump  cicatrices,  321 — Function  of  amputation-stumps,  321 — Site 
of  amputation  in  connection  with  the  resulting  stump  and  its  adaptability  to  an  artificial  limb, 
322. 

IV.  Surgical  Anatomy,  Surface  Form  and  Landmarks,  General  Surgical  Considerations 
and  Methods  in  Amputations  and  Disarticulations  about  the  Fingers: — Amputation  through 
last  phalanx,  by  palmar  flap,  327 — At  second  phalangeal  joint,  by  palmar  flap,  329 — Same, 
by  short  dorsal  and  long  palmar  flaps,  329 — Through  second  phalanx,  by  palmar  flap,  330 — 
Same,  by  short  dorsal  and  long  palmar  flaps,  330 — At  first  phalangeal  joint,  by  palmar  flap, 
331 — Same,  by  short  dorsal  and  long  palmar  flaps,  331 — Through  first  phalanx,  by  palmar 
flap,  331 — Same,  by  short  dorsal  and  long  palmar  flaps,  332 — At  metacarpophalangeal  joints 
of  fingers  in  general,  by  oval  method,  332 — Same  of  thumb,  by  oval  method,  334 — Same  of  thumb, 
by  oblique  palmar  flap  (Farabeuf),  335 — Same  of  index,  by  externo-palmar  flap  (Farabeuf), 
335 — Same  of  little  finger,  by  interno-palmar  flap  (Farabeuf),  336. 

V.  Same,  in  Amputations  and  Disarticulations  about  the  Hand: — Amputation  of  finger, 
in  general,  with  part  of  its  metacarpals,  by  racket  method,  341 — Of  thumb,  with  part  of  its 
metacarpal,  by  racket,  342 — Of  little  finger,  with  part  of  its  metacarpal,  by  racket,  342 — Of  two 
contiguous  inside  fingers,  with  part  of  their  metacarpals,  by  racket,  342 — Of  three  innermost 
fingers,  with  parts  of  their  metacarpals,  by  racket,  342 — Same,  by  equal  dorsal  and  palmar 
flaps,  343 — Of  all  fingers  (except  thumb),  with  parts  of  their  metacarpals,  by  anterior  ellipse, 
343 — Of  an  inner  finger,  with  its  metacarpal,  by  racket,  344 — Of  index,  with  its  metacarpal,  by 
racket,  344 — Of  little  finger,  with  its  metacarpal,  by  racket,  344 — Of  thumb,  with  its  metacarpal, 
by  racket,  345 — Of  two  continuous  inside  fingers,  with  their  metacarpals,  by  racket,  346 — 
Of  three  inside  fingers,  with  their  metacarpals,  by  rackets,  346 — Of  three  inner  fingers,  with  their 
metacarpals,  by  equal  dorsal  and  palmar  flaps,  346 — Of  all  fingers  (except  thumb),  with  their 
metacarpals,  by  anterior  ellipse,  348 — Of  fingers  and  thumb,  at  carpo-metacarpal  articulation, 
by  palmar  flap,  348. 

VI.  Same,  in  Disarticulations  about  the  Wrist-joint: — Disarticulation  at  wrist-joint  by 
anterior  ellipse,  351 — By  palmar  flap,  352 — By  external  lateral,  or  radial,  flap  (Dubrueil's  method), 
353- 

VII.  Same,  in  Amputations  about  the  Forearm: — Through  lower  third,  by  modified  cir- 
cular, 356 — By  circular  (cuff  variety),  357 — Through  upper  two-thirds,  by  equal  anterior  and 
posterior  flaps,  358. 

VIII.  Same,  in  Disarticulations  about  Elbow-joint: — Disarticulation  of  elbow-joint,  by 
anterior  ellipse  (Farabeuf),  362 — By  posterior  ellipse,  363 — By  long  antero-internal  and  short 
postero-external  flaps,  364. 

IX.  Same,  in  Amputations  about  the  Arm: — Amputation  through  lower  third,  by  modified 
circular,  368 — Through  upper  two-thirds,  by  long  anterior  and  short  posterior  flaps,  370 — 
Through  surgical  neck,  by  single  external  flap,  370. 

X.  Same,  in  Disarticulations  about  the  Shoulder-joint: — Disarticulation  at  shoulder-joint 
by  anterior  racket  (Spence's  operation),  378— By  external  racket  (Larrey's  operation),  381— 
By  external  or  deltoid  flap,  382. 

XI.  Amputation  of  Upper  Limb,  together  with  Scapula  and  part  of  Clavicle,  by  antero- 
inferior (or  pectoro-axillary)  and  postero-superior  (or  cervico-scapular)  flaps  (Berger's  opera- 
tion), 383. 

XII.  Surgical  Anatomy,  Surface  Form  and  Landmarks,  General  Surgical  Considerations, 
and  Methods  in  Amputations  and  Disarticulations  about  the  Toes: — Amputation  through 
last  phalanx,  by  plantar  flap,  388— At  second  phalangeal  joint,  by  plantar  flap,  389— Through 


CONTENTS.  7 

second'  phalanx,  by  plantar  flap,  390 — At  first  phalangeal  joint,  by  oval,  390 — Through  first 
phalanx,  by  oval,  392 — Same,  by  circular,  392 — At  metatarso-phalangeal  joints  of  toes  in  general, 
by  oval  method,  392 — At'  same  of  great  toe,  by  interno-plantar  flap  (Farabeuf),  393 — At  same 
of  little  toe,  by  externo-dorsal  flap  (Farabeuf),  394 — Disarticulation  of  two  adjoining  toes  at 
metatarso-phalangeal  joints,  by  oval  method,  395 — Of  toes  en  masse,  at  metatarso-phalangeal 
joint,  by  equal  short  dorsal  and  plantar  flaps,  395. 

XIII.  Same,  in  Amputations  and  Disarticulations  about  Foot: — Amputation  of  all  toes 
through  the  metatarsus,  by  short  dorsal  and  long  plantar  flaps  (Metatarsal  amputation),  402 — 
Disarticulation  of  toe,  with  its  entire  metatarsal,  by  racket  method,  404 — Of  great  toe  and  its 
metatarsal,  by  racket,  404 — Of  little  toe  and  its  metatarsal,  by  racket,  406 — Of  two  or  three 
contiguous  toes  with  their  entire  metatarsals,  by  oval  or  racket,  407 — Of  all  toes,  at  tarso- 
metatarsal joints,  by  short  dorsal  and  long  plantar  flaps  (Lisfranc's  operation),  407 — Of  all 
toes,  at  tarso-metatarsal  joints,  with  sawing  off  of  end  of  internal  cuneiform,  by  short  dorsal 
and  long  plantar  flaps  (Hey's  operation),  408 — Of  anterior  part  of  foot  at  medio-tarsal  joint, 
by  short  dorsal  and  long  plantar  flaps  (Chopart's  operation),  409 — Of  foot  at  astragalo-scaphoid 
and  astragalo-calcaneal  joints,  subastragaloid  disarticulation,  by  large  interno-plantar  flap 
(Farabeuf),  410 — Of  foot  at  astragalo-scaphoid  and  astragalo-calcaneal  joints,  subastragaloid 
disarticulation,  by  heel-flap,  412. 

XIY.  Same,  in  Disarticulations  about  Ankle-joint: — Disarticulation  of  foot  at  ankle- 
joint,  with  removal  of  malleoli  and  articular  surface  of  tibia,  by  heel-flap  (Syme's  operation), 
414 — Disarticulation  of  foot  at  ankle-joint,  with  removal  of  malleoli,  articular  surface  of  tibia, 
and  anterior  part  of  os  calcis,  by  heel-flap  (Pirogoff's  operation),  415. 

XV.  Same,  in  Amputation  about  the  Leg: — Through  supramalleolar  region,  by  oblique 
elliptical  incision  (Guyon's  supramalleolar  operation),  419 — Through  lower  third,  by  large 
posterior  and  small  anterior  flaps  (Farabeuf),  420 — Osteoplastic  amputation,  by  long  posterior 
and  short  anterior  flaps,  422 — Through  middle  third,  by  long  posterior  and  short  anterior  flaps 
(Hey's  operation),  424 — Through  upper  third,  by  large  external  flap  (Farabeuf),  425 — Same, 
by  bilateral  hooded  flaps  (Stephen  Smith's  method),  427 — Osteoplastic  amputation,  through 
upper  third,  by  antero-internal  flap  (Bier's  method),  429. 

XVI.  Same,  in  Disarticulations  about  the  Knee-joint: — Disarticulation  at  knee-joint 
by  bilateral  hooded  flaps  (Stephen  Smith),  434 — By  an  oblique  curved  incision,  435. 

XVII.  Same,  in  Amputations  about  the  Thigh: — Through  condyles  of  femur,  transcondyloid 
amputation,  by  shorter  anterior  and  longer  posterior  flaps  (Lister's  modification  of  Carden's 
transcondyloid  operation),  440 — Just  above  condyles  of  femur,  with  splitting  of  patella  (supra- 
condyloid  osteoplastic  amputation  of  Gritti-Stokes)  by  longer  anterior  and  shorter  posterior 
flaps,  441 — Femorotibial  osteoplastic  amputation  of  lower  limb,  by  longer  anterior  and  shorter 
posterior  flaps  (Ssabanajeff's  operation),  443 — Through  lower  third  of  thigh  by  oblique  circular 
method,  444 — Through  thigh  in  general,  by  long  anterior  and  short  posterior  flaps,  446 — Same, 
by  equal  anterior  and  posterior  flaps,  448 — Through  thigh  just  below  trochanters,  by  external 
oval  method,  449. 

XVIII.  Same,  in  Excisions  about  the  Hip-joint: — Disarticulation  at  hip-joint  by  Wyeth's 
method,  456 — By  external  racket,  458 — By  anterior  racket,  459 — Interilio-abdominal  amputa- 
tion (Keen's  method),  460. 


CHAPTER   XIII. 
EXCISIONS  AND  OSTEOPLASTIC  RESECTIONS  OF  BONES  AND  JOINTS. 

I.  General  Considerations,  463 — Excision  by  subperiosteal  method,  463 — Excision  by 
open  method,  467 — Excision  of  coccyx,  by  posterior  median  incision,  468 — Surgical  anatomy 
in  excisions  about  superior  maxilla,  excision  of  superior  maxilla,  by  median  incision  (Fergusson's 
operation),  471 — Osteoplastic  resection  of  superior  maxilla,  by  vertical  and  horizontal  incisions, 
473 — Chondroplastic  resection  of  nasal  cartilages,  to  expose  nose  and  anterior  nasopharynx 
by  nasal  route,  by  transverse  incision  (Rouge's  operation),  473 — Osteoplastic  resection  of  superior 
maxilla,  to  expose  nasopharynx  by  palatine  route,  by  transverse  and  median  incisions  (Annan- 
dale's  operation),  474 — Osteoplastic  resection  of  superior  maxilla,  to  expose  nasopharynx  by 
maxillary  route,  by  two  semilunar  incisions  (Langenbeck's  operation),  474 — Surgical  anatomy 
in  excisions  about  inferior  maxilla,  excision  of  temporomaxillary  articulation,  by  angular  incision, 
476 — Excision  of  inferior  maxilla,  by  single  incision  along  inferior  and  posterior  borders,  477 — 
Osteoplastic  resection  of  lower  jaw,  to  expose  structures  in  pharynx  and  upon  floor  of  mouth, 
479 — Excision  of  ribs,  in  general,  479 — Excision  of  entire  rib  and  costal  cartilage  by  parallel 
incision  over  center  of  rib,  480 — Excision  of  clavicle,  in  general,  480 — Total  excision  of  clavicle 
by  long  axial  incision,  481 — Total  excision  of  scapula,  by  straight  incisions  along  spine  and 
vertebral  border,  forming  superior  and  inferior  flaps,  482. 


8  CONTENTS. 

II.  Surgical  Anatomy,  Surface  Form  and  Landmarks,  General  Surgical  Considerations 
and  Methods  in  Excisions  about  the  Fingers: — Excision  of  terminal  phalanges,  by  U-shaped 
incision,  484 — Of  second  phalangeal  joints,  by  two  lateral  incisions,  484 — Of  second  phalangeal 
joint  of  index,  by  dorso  external  incision,  486 — Of  second  phalangeal  joint  of  little  finger,  by 
dorso-internal  incision,  486 — Of  second  phalanges  of  fingers  in  general,  by  dorso-lateral  incision, 
486 — Of  second  phalanx,  by  dorso-external  incision,  for  index-finger,  486 — Of  second  phalanx 
of  little  finger,  by  dorso-internal  incision,  487 — Of  first  phalangeal  joints,  by  same  methods 
as  for  second  phalangeal  joints,  487 — Of  first  phalanges  of  fingers  in  general,  487. 

III.  Same,  in  Excisions  about  Hand: — Excision  of  metacarpophalangeal  joints  of  fingers, 
in  general,  by  dorso  lateral  incision,  487 — Of  metacarpals,  in  general,  by  dorsal  incision,  488 — 
Of  metacarpal  of  thumb,  by  dorso-external  incision,  489 — Of  metacarpal  of  little  finger,  by 
dorso-internal  incision,  489. 

IV.  Same,  in  Excisions  about  Wrist-joint: — Excision  of  wrist  by  radial  and  ulnar  dorsal 
incisions  (Oilier),  490 — Same,  by  single  dorso-radial  incision  (Boeckel-Langenbeck),  491  — 
Excision  of  wrist-joint,  by  single  dorso-ulnar  incision  (Kocher's  method),  492. 

V.  Same,  in  Excisions  about  Bones  of  Forearm: — Total  excision  of  ulna,  by  long  posterior 
incision,  493 — Same,  of  radius,  by  long  externo-dorsal  incision,  494.     ■ 

VI.  Same,  in  Excision  about  Elbow-joint: — Excision  of  elbow -joint,  by  posterior  median 
incision  (Langenbeck),  495 — Same,  by  posterior  bayonet-shaped  incision,  with  or  without  an 
additional  short  vertical  ulnar  incision  (Oilier),  497 — Excision  of  elbow-joint,  by  vertically 
curved  dorso-external  incision  (Kocher's  method),  498 — Excision  of  superior  radio-ulnar  articu- 
lation, by  posterior  vertical  incision,  500. 

VII.  Same,  in  Excisions  about  Humerus: — Excision  of  humerus,  by  long  external  incision, 
501. 

VIII.  Same,  in  Excisions  about  Shoulder-joint  and  vicinity: — Excision  of  shoulder-joint, 
by  anterior  oblique  incision,  502 — Osteoplastic  resection  of  shoulder-joint,  by  posterior  curved 
incision  (Kocher's  method),  503. 

IX.  Same,  in  Excisions  about  the  Toes: — Excision  of  terminal  phalanges,  423 — Of  second 
phalangeal  joints,  506 — Of  second  phalanges,  506 — Of  first  phalangeal  joint,  506 — Of  first 
phalanges,  507. 

X.  Same,  in  Excisions  about  Foot: — Excision  of  metatarso-phalangeal  joints,  507 — Of 
metatarsals,  507 — Of  astragalus,  by  external  curved  incision,  507 — Same,  by  external  angular 
and  internal  curved  incisions,  508 — Of  os  calcis,  by  horizontal  curved  and  vertical  incisions,  510. 

XI.  Same,  in  Excisions  about  Ankle-joint: — Excision  of  ankle-joint,  by  transversely  curved 
external  incision  (Lauenstcin),  511 — Same,  by  external  curved  and  internal  angular  incisions, 
512 — Osteoplastic  resection  of  anterior  tarsus  and  tarsometatarsus,  by  internal  and  external 
dorsolateral  incisions,  513 — Osteoplastic  resection  of  mid-tarsus,  by  external  transverse  curved 
incision,  514 — Osteoplastic  resection  of  posterior  tarsus,  by  external  curved  incision,  515 — 
Osteoplastic  resection  of  foot,  by  transverse  upper  and  lower  and  oblique  lateral  incisions  (Wladi- 
miroff-Mikulicz  operation),  516 — Total  excision  of  tarsus,  by  externo-lateral  curved  incision 
(modification  of  Wladimiroff-Mikulicz  operation),   518. 

XII.  Same,  in  Excisions  about  Bones  of  Leg:— Total  excision  of  tibia,  by  internal  vertical 
incision,  519 — Total  excision  of  fibula,  by  posterior  vertical  incision,  520 — Total  excision  of 
patella,    by    vertical    incision,    520. 

XIII.  Same,  in  Excisions  about  the  Knee-joint: — Excision  of  knee-joint,  by  curved  trans- 
verse anterior  incision,  522 — Excision  of  knee-joint,  by  vertically  curved  external  incision 
(Kocher's  method),  523. 

XIV.  Same,  in  Excisions  about  Femur: — Excision  of  parts  of  diaphysis,  by  external  vertical 
incision,  526. 

XV.  Same,  in  Excisions  about  Hip-joint: — Excision  of  hip-joint,  by  external  straight  incision 
(Langenbeck),  528— Same,  by  anterior  straight  incision  (Barker),  529— Same,  by  posterior 
angular  incision  (Kocher),  530— Excision  of  the  innominate  bone  (Kocher),  531. 


CONTENTS. 
PART     II. 

THE  OPERATIONS  OF  SPECIAL  SURGERY. 


CHAPTER    I. 
OPERATIONS  UPON   THE  HEAD. 

I.  Crano-cerebral  Region: — Surgical  anatomy  of  scalp,  skull,  and  brain,  533 — Chief 
cranial  landmarks,  537 — Cranio-cerebral  topography,  538 — Localization  of  brain  areas,  543 — 
Chipault's  method  of  cranio-cerebral  localization,  540 — Bell's  cyrtometer  in  Chipault's  method 
of  cranio-cerebral  localization,  550 — Reid's  method  of  same,  551 — Kroenlein's  method  of  same, 
553 — Chiene's  method  of  determining  Rolandic  fissure,  554 — General  surgical  considerations 
in  cranio-cerebral  operations,  554 — Instruments,  557 — Craniotomy,  in  general,  557 — Trephining, 
or  circular  craniotomy,  55S — Osteoplastic  resection  of  skull,  565 — Linear  craniotomy,  580 — 
Partial  craniectomy,  581 — Exploratory  puncture  of  brain,  5S4 — Operation  for  intracranial 
hemorrhage,  585 — Ligation  of  middle  meningeal  artery  and  its  anterior  and  posterior  branches, 
586 — Ligation  of  longitudinal  or  lateral  sinuses,  586 — Operation  for  thrombosis  of  lateral  sinus, 
588 — Trephining  for  fracture  of  skull,  590 — Operation  for  bullet-wound  of  brain,  591 — Opera- 
tion for  exposure  of  a  motor  center,  593 — Puncture  and  drainage  of  lateral  ventricles,  594 — 
Incision  of  cerebellar  subarachnoid  space  for  drainage  (Parkin),  595 — Operation  for  cerebral 
abscess,  595 — For  cerebellar  abscess,  596 — For  cerebral  tumor,  597 — For  cerebellar  tumor,  599 
— Operations  upon  mastoid  antrum  and  cells,  599 — Operations  upon  Gasserian  ganglion,  599. 

II.  Bony  (Air)  Sinuses  of  Head  and  Face: — Operations  upon  mastoid  antrum  and  cells, 
600 — Surgical  anatomy,  600 — Surface  form  and  landmarks,  602 — General  surgical  considera- 
tions, 603 — Operation  for  exposure  of  mastoid  antrum  and  cells  (Antrum  operation  of  Schwartze), 
604 — Operation  for  exposing  mastoid  antrum  and  cells,  together  with  interior  of  tympanun 
and  meatus,  and  the  exenteration  of  middle-ear  cavities  (the  tympano-mastoid  exenteration, 
or  radical  operation,  of  Schwartze-Stacke,  or  Schwartze-Zaufal),  606 — Operations  upon  frontal 
sinuses,  608 — Surgical  anatomy,  surface  form  and  landmarks,  and  general  surgical  considera- 
tions, 608,  609 — Instruments,  610 — Exposure  and  drainage  of  frontal  sinuses,  610 — Operations 
upon  maxillary  sinuses,  611 — Surgical  anatomy,  surface  form  and  landmarks,  and  general  surgical 
considerations,  611,  612 — Instruments,  613 — Opening  of  maxillary  sinus  through  its  facial 
aspect,  above  alveolar  margin,  613 — Opening  through  socket  of  second  molar  tooth,  614. 

III.  Eyeball  and  Orbit: — Operations  upon  the  eyeball,  614 — Surgical  anatomy  of  orbit, 
614 — Enucleation  of  eyeball,  615 — Evisceration  of  eyeball,  616 — Exenteration  of  orbit,  616 — 
Exposure  of  entra-orbital  and  retrobulbar  structures  (Kroenlein's  operation),  617. 

IV.  Ear  and  Eustachian  Tube: — Surgical  anatomy  of  membrana  tympani,  61 8 — Intro- 
duction of  ear  speculum  for  examination  of  membrana  tympani,  618 — Paracentesis  tympani, 
619 — Introduction  of  Eustachian  catheter,  619. 

Y.   Xose  and  Nasal  Cavities,  619. 

VI.  Tongue: — Surgical  anatomy,  619 — General  surgical  considerations,  620 — Instruments, 
621 — Excision  of  limited  portion  of  tongue,  622 — Excision  through  mouth,  without  preliminary 
ligation  of  lingual  arteries  (Whitehead),  622 — Excision  through  mouth,  after  preliminary  ligation 
of  Unguals  in  neck,  624 — Excision  of  tongue  by  median  incision  through  lower  lip,  chin,  and 
neck,  with  osteoplastic  division  of  inferior  maxilla  (Kocher),  624 — Excision  of  tongue,  together 
with  cervical  and  submaxillary  glands,  by  an  incision  in  neck,  after  preliminary  tracheotomy 
and  ligation  of  lingual  and  facial  ateries  (Kocher),  627. 

CHAPTER    II. 
OPERATIONS  UPON   THE   SPINE   AND  SPINAL   CORD. 

Surgical  anatomy,  629 — Surface  form  and  landmarks,  632 — General  surgical  considerations, 
642 — Osteoplastic  resection  of  spine,  648 — Laminectomy,  661 — Subarachnoid  puncture  for 
spinal  anesthesia,  666 — Lumbar  puncture  for  diagnosis  and  therapeusis,  669 — Spinal  puncture 
for  drainage  of  subarachnoid  space,  670 — Operative  treatment  of  fractures  of  spine,  670 — 
Operative  treatment  of  dislocations  of  spine,  672 — Operative  treatment  of  fracture-dislocations 
of  spine,  673 — Operative  treatment  of  incised  and  penetrating  wounds  of  cord,  674 — Operative 
treatment  of  gunshot  wounds  of  cord,  675 — Intraspinal  partial  neurectomy  of  posterior  nerve- 


IO  CONTENTS. 

roots,  679 — Spina  bifida,   679 — Operative  treatment  of  posterior  vertebral  tubercular  osteitis 
of  spine,  685 — Operative  treatment  of  anterior  vertebral  osteitis,  Pott's  disease,  685. 

CHAPTER  III. 
OPERATIONS  UPON  THE  NECK. 

I.  Larynx: — Surgical  anatomy  of  neck,  695 — Surgical  anatomy  of  larynx,  695 — Surface 
form  and  landmarks,  695 — Instruments,  696 — Laryngotomy,  697 — Thyrotomy,  698 — Com- 
plete laryngectomy,  699 — Partial  laryngectomy,  700 — Intubation  of  larynx  (O'Dwyer),  701  — 
Other  operations,  702. 

II.  Trachea: — Surgical  anatomy,  702 — Surface  form  and  landmarks,  703 — General  sur- 
gical considerations,  703 — Instruments,  703 — High  tracheotomy,  704 — Low  tracheotomy, 
706 — Other  operations,  706. 

III.  Pharynx: — Surgical  anatomy,  707 — Instruments,  707 — Median  pharyngotomy,  by 
median  vertical  incision  through  mouth,  708 — Lateral  pharyngotomy,  by  curved  lateral  incision 
through  neck  (Kocher),  708 — Subhyoid  pharyngotomy,  by  transverse  curved  incision  through 
neck,  709 — Exposure  of  retro-pharyngeal  space,  by  lateral  cervical  incision  along  posterior 
border  of  sternomastoid  (Chiene),  710. 

IY.  Esophagus: — Surgical  anatomy,  711 — General  surgical  considerations,  712 — Instru- 
ments, 712 — External  cervical  esophagotomy,  712 — Cervical  esophagostomy,  714 — Partial 
cervical  esophagectomy,  714 — Introduction  of  esophageal  bougie,  715 — Other  operations,  715. 

V.  Tonsils: — Surgical  anatomy,  717 — General  surgical  considerations,  717 — Instruments, 
717 — Tonsillotomy,  717 — Partial  tonsillectomy  through  mouth,  718 — Complete  tonsillectomy 
through  mouth,  718 — Complete  tonsillectomy  through  neck  (Cheever),  719. 

VI.  Parotid  Gland  and  Stenson's: — Surgical  anatomy,  721 — Instruments,  722 — Excision, 
722. 

VII.  Submaxillary  Gland  and  Wharton's  Duct: — Surgical  anatomy,  724 — Instruments, 
724 — Excision,  725. 

VIII.  Sublingual  Gland  and  Duct  of  Bartholin: — Surgical  anatomy,  726 — Instruments, 
725 — Excision,  through  floor  of  mouth,  726. 

IX.  Thyroid  Gland: — Surgical  anatomy,  727 — Instruments,  727 — Partial  thyroidectomy, 
by  angular  incision  (Kocher),  727 — Complete  thyroidectomy,  by  transverse  curved  incision 
(Kocher),  729. 

CHAPTER    IV. 

OPERATIONS  UPON   THE   THORAX. 

I.  Thoracic  Wall  and  Contents: — Surgical  anatomy,  731 — Surface  form  and  landmarks, 
733 — Instruments,  734 — Chrondroplastic  resection  of  chest-wall,  by  subcostal  incision  and 
temporary  division  of  seventh,  eighth,  ninth,  and  tenth  costal  cartilages,  734. 

II.  Female  Mammary  Gland: — Surgical  anatomy,  736 — Surface  form  and  landmarks, 
736 — General  surgical  considerations,  736 — Incision  of  breast,  737 — Partial  excision  of  breast 
by  elliptical  incision,  737 — Radical  excision,  by  Meyer's  method,  738 — Radical  excision,  by  Hal- 
sted's  method,  741 — Radical  excision,  by  Warren's  method,  744 — Ordinary  excision,  by  elliptcal 
incision,  745 — Subcutaneous  excision,  by  inferior  curved  incision,  746. 

III.  Superior  Mediastinum: — Surgical  anatomy,  747 — Surface  form  and  landmarks, 
747 — General  surgical  considerations,  747. 

IV.  Anterior  Mediastinum: — Surgical  anatomy,  748 — Anterior  mediastinal  thoracotomy, 
by  long  median  incision  (Milton's  anterior  mediastinotomy),  748 — Anterior  mediastinal  thora- 
cotomy, by  osteoplasic  resection  of  part  of  sternum  corresponding  with  third,  fourth,  and  fifth 
costal  cartilages,  750 — Other  operations,  752. 

V.  Middle  Mediastinum: — Surgical  anatomy,  752 — Operations  upon  middle  medias- 
tinum, 752. 

VI.  Posterior  Mediastinum: — Surgical  anatomy,  752 — Posterior  mediastinal  thoracotomy, 
by  thoracoplastic  flap  (Bryant),  752. 

VII.  Diaphragm: — Surgical  anatomy,  755 — Transthoracic  exposure  of  diaphragm,  by 
partial  excision  of  two  or  three  ribs,  756. 

VIII.  Pleura;: — Surgical  anatomy,  759 — Surface  form  and  landmarks,  760 — Paracentesis 
thoracis,  761 — Intercostal  thoracotomy,  761 — Thoracotomy,  by  partial  excision  of  one  or 
more  ribs,  763 — Partial  pleurectomy  (Estlander's  thoracoplastic  operation),  765 — Partial 
pleurectomy  (Schede's  thoracoplastic  operation),  768 — Total  pleurectomy  (Fowler's  thoraco- 
plastic operation),  770 — Discission  of  pleura  in  chronic  empyema  (Ransohoff's  operation), 
771 — Other  operations,  771. 


CONTENTS.  II 

IX.  Lungs: — Surgical  anatomy,  772 — General  surgical  considerations,  773 — Pneumotomy, 
through  a  cutaneo-muscular  thoracoplastic  flap,  774 — Partial  pneumectomy,  through  cutaneo- 
musculo-osseous  thoracoplastic  flap,  776. 

X.  Pericardium: — Surgical  anatomy,  7S0 — Surface  form  and  landmarks,  780 — Pericardio- 
centesis, 7S1 — Pericardiotomy,  through  intercostal  incision,  7S2 — Exposure  of  pericardium 
and  heart,  by  excision  of  left  fifth  costal  cartilage,  7S4 — Pericardiorrhaphy,  7S5. 

XL  Heart; — Surgical  anatomy,  785 — Paracentesis  of  right  auricle,  787 — Paracentesis  of 
right  ventricle,  787 — Exposure  of  heart  and  pericardium,  by  a  thoracoplastic  flap  (Rotter's 
operation),  788 — Cardiorrhaphy,  790. 

XII.  Thoracic  Trachea: — Surgical   anatomy,   791 — Thoracic  tracheotomy,   791. 

XIII.  Bronchi: — Surgical  anatomy,  791 — Bronchotomy,  791. 

XIV.  Thoracic  Esophagus,  792 — Surgical  anatomy,  792 — Thoracic  esophagotomy,  by 
posterior  mediastinal  osteoplastic  flap  operation,  792. 


CHAPTER    V. 
OPERATIONS   UPON   THE   ABDOMINO-PELVIC  REGION. 

I.  Abdomino- pelvic  Wall: — Surgical  anatomy,  793 — Surface  form  and  landmarks,  797 — 
General  surgical  considerations,  799 — Instruments,  801 — Median  abdominal  section,  801 — 
Anterolateral  abdominal  section,  by  McBurney's  intramuscular  "gridiron"  incision,  S07 — 
Anterolateral  abdominal  section,  by  the  Harrington-Weir  prolongation  of  the  anterolateral 
intra-muscular  incision  through  rectal  sheath,  with  temporary  displacement  of  rectus,  810 — 
Anterior  abdominal  section  through  rectal  sheath,  with  temporary-  displacement  of  rectus,  by 
the  Battle-Jalaguier-Kammerer  method,  811 — Median  inferior  abdominal  section  by  Pfannen- 
stiel's  superficial  transverse  curved,  and  deep  vertical  incisions,  815 — Inferior  anterolateral 
abdominal  section,  by  Meyer's  "hockey  stick"  incision,  817 — Inferior  anterolateral  abdominal 
section,  by  Fowler's  angular  incision,  818 — Superior  anterolateral  abdominal  section,  by  oblique- 
subcostal  incision,  818 — Exposure  of  hypochondriac  regions  by  chondroplastic  resection  of 
chest-wall,  by  subcostal  incision  and  temporary  division  of  seventh,  eighth,  ninth,  and  tenth 
costal  cartilages,  S19 — Lateral  abdominal  section  by  Vischer's  lumbo-iliac  incision,  S19. 

II.  Peritoneum: — Surgical  anatomy,  820 — General  surgical  considerations,  822 — Opera- 
tions for  separation,  division,  or  ligation  of  peritoneal  adhesions,  822 — Paracentesis 
abdominis,  824 — Operative  treatment  of  diffuse  septic  peritonitis  (Murphy's  method),  825 — 
Same  (Blake's  method),  826 — Operative  treatment  of  intra-abdominal  abscess,  829. 

III.  Omentum: — Surgical  anatomy,  830 — General  surgical  considerations,  831 — Ligation 
of  omentum,  831 — Omental  grafting,  832. 

IV.  Mesentery: — Surgical  anatomy,  833 — General  surgical  considerations,  833 — Partial 
excision,  833 — Suturing,  833. 

V.  Intestines: — Surgical  anatomy  of  small  intestines,  833 — Surface  form  and  landmarks 
of  small  intestines,  836 — Surgical  anatomy  of  large  intestines,  836 — Surface  form  and  landmarks 
of  large  intestines,  839 — General  surgical  considerations  in  operations  upon  the  intestines,  S40 — 
Instruments,  840 — Enterotomy,  841 — Enterorrhaphy,  in  general,  841 — By  Lembert's  interrupted 
suture,  S43 — By  Czerny-Lembert  interrupted  suture,  844 — By  Halsted's  interrupted  quilt  or 
mattress  suture,  845 — By  Lembert's  continuous  suture,  846 — By  Cushing's  right-angled  con- 
tinuous suture,  846 — By  combined  overhand  continuous  suture  of  all  coats,  followed  by  inter- 
rupted Lembert  suturing  of  outer  coats,  848 — Enterorrhaphy  for  wounds  of  intestine,  848 — ■ 
Partial  enterectomy,  850 — Entero-enterostomy  (intestinal  anastomosis,  approximation,  and 
implantation)  in  general,  854 — (A)  Entero-enterostomy  by  methods  of  simple  suturing,  in 
general,  855 — By  simple  continuous  overhand  suture  of  all  coats,  followed  by  interrupted  or 
continuous  Lembert  sutures  of  outer  coats,  by  author's  method,  856 — By  perforating  mattress 
sutures  knotted  in  lumen  (Connell's  method),  864 — By  Czerny-Lembert  interrupted  suture, 
867 — By  Halsted's  method  of  interrupted  mattress  or  quilt  sutures,  868 — By  Maunsell's  invagina- 
tion method,  870 — (B)  Entero-enterostomy  by  means  of  absorbable  mechanical  devices  left 
within  the  intestines,  in  general,  878 — By  means  of  absorbable  bobbins,  879 — By  absorbable 
buttons,  880 — By  Ullmann's  modification  of  Maunsell's  method,  881 — By  Coffey's  method, 
883 — (C)  Entero-enterostomy  by  means  of  non-absorbable  mechanical  devices  left  within  the 
intestinal  canal,  in  general,  883 — By  means  of  the  Murphy  button,  885 — Lateral  intestinal 
anastomosis  by  the  Jaboulay  button,  892 — Entero-enterostomy  by  Harrington's  segmented 
rings,  893 — (D)  Entero-enterostomy  by  mechanical  means  temporarily  used  for  approxima- 
ting the  intestinal  edges  during  suturing,  in  general,  895 — By  means  of  Lee's  intestinal  holder, 
895 — Excision  of  ilio-caecum,  899 — Appendicectomy,  by  McBurney's  intramuscular  operation, 
900 — Appendicectomy  through  the  rectal  sheath,  911 — Appendicectomy,  by  the  non-intramus- 
cular method,  911 — Appendicectomy,  by  Weir's  operation,  912 — Enterostomy,  in  general, 
913 — Right  inguinal  enterostomy   (or  ileostomy)   for  establishment  of  temporary  fecal  fistula 


12  CONTENTS. 

of  a  permanent  artificial  anus,  914 — Colostomy,  in  general,  916 — Left  inguinal  colostomy, 
917 — Anterior  intramuscular  colostomy  (Mixter's  operation),  921 — Left  lumbar  colostomy, 
924 — Operation  for  closure  of  fecal  fistula  and  artificial  anus,  927 — Enteroplasty,  930 — Opera- 
tion for  intussusception  (Jessett- Barker  method),  930 — Colopexy,  by  Bryant's  method, 
932 — Rectopexy,  by  Verneuil's  method,  933 — Internal  rectotomy,  934 — External  rectotomy, 
934 — Excision  of  rectum,  in  general,  935 — Excision  by  sacral  route  by  partial  excision  of  sacrum 
(Kraske's  operation),  935 — Excision  by  sacral  route,  by  the  Rehn-Rydygier  osteoplastic  flap 
method,  940 — Excision  of  lower  part  of  rectum  by  perineal  route,  942 — Operation  for  cure  of 
hemorrhoids  by  ligation  and  excision  (Allingham's  method),  944 — Operation  for  cure  of  hemor- 
rhoids by  excision  (Whitehead's  method),  945 — Operation  for  cure  of  hemorrhoids  by  clamp 
and  cautery,  946 — Operation  for  cure  of  fistula-in-ano  by  incision,  947. 

VI.  Stomach: — Surgical  anatomy,  950 — Surface  form  and  landmarks,  951 — General  surgi- 
cal considerations,  951 — Instruments,  952 — Introduction  of  stomach-tube,  952 — Gastrotomy, 
by'  median  incision,  952 — Gastrotomy  by  oblique  subcostal  incision,  954 — Gastrorrhaphy, 
955 — Gastrostomy,  in  general,  956 — Gastrostomy,  by  Ssabanajew-Franck's  method,  957 — 
Same,  by  Witzel's  method,  959 — Same,  by  Marwedel's  method,  962 — Same,  by  Kader's  method, 
964 — Gastro-enterostomy,  in  general,  967 — Anterior  gastro-enterostomy,  by  simple  suturing 
(Wolfler's  method),  968 — Same,  by  the  Murphy  button,  followed  by  single  or  multiple  intestinal 
anastomosis  by  the  Jaboulay-Braun  method,  971 — Posterior  gastro-enterostomy,  by  von  Hacker's 
method,  974 — Same,  by  the  Murphy  button,  978 — Gastrogastrostomy  by  Wolfler's  method, 
979 — Gastroplication,  by  Weir's  modification  of  Bircher's  method,  981 — Same,  Moynihan's 
modification  of  Bircher's  operation,  983 — Gastropexy,  983 — Gastrolysis,  983 — Gastroplasty, 
9S4 — Pyloroplasty,  by  Heineke-Mikulicz  method,  984 — Divulsion  of  pyloric  orifice  of  stomach, 
by  Loreta's  method,  986 — Dilatation  of  cardiac  orifice  of  stomach,  987 — Gastro-duodenostomy 
(Finney's  operation),  987 — Pylorectomy,  in  general,  991 — Pylorectomy,  followed  by  independent 
gastrojejunostomy  (Mayo's  operation),  991 — Pylorectomy,  followed  by  end-in-side  posterior 
gastro-duodenostomy,  by  Kocher's  method,  994 — Pylorectomy  followed  by  end-to-end  gastro- 
enterostomy, by  Billroth's  method,  997 — Partial  gastrectomy,  of  median  portion,  999 — Total 
gastrectomy,  1001 — Operation  for  gastric  ulcer,  1002. 

VII.  Liver: — Surgical  anatomy,  1004 — Surface  form  and  landmarks,  1006 — General 
surgical  considerations,  1006 — Instruments,  100S — Exploratory  puncture  of  liver,  1008 — 
Hepatotomy,  in  general,  1009 — Anterior  subcostal  transperitoneal  hepatotomy,  by  anterior 
oblique  incision  parallel  with  costal  arch,  1010 — Exposure  of  liver  by  anterior  subcostal  trans- 
peritoneal route,  by  anterior  vertical  incision  through  right  linca  semilunaris,  10 12 — Exposure 
of  liver  by  lateral  subcostal  transperitoneal  route,  by  lateral  horizontally  curved  incision  below 
right  twelfth  rib,  1013 — Exposure  of  liver  by  intercostal  subpleural  route,  by  intercostal  incision 
below  level  of  pleura,  10 13 — Exposure  of  liver  by  subpleural  route,  by  partial  excision  of  one  or 
more  ribs  below  level  of  the  pleura,  1014 — Exposure  of  liver  by  subpleural  route,  by  partial 
excision  of  one  or  more  ribs  opposite  the  pleura,  10 14 — Exposure  of  liver  by  transpleural  route, 
by  partial  excision  of  one  or  more  ribs  opposite  the  pleura,  1016 — Exposure  of  liver  by  chon- 
droplastic  resection  of  right  costal  arch,  by  anterior  oblique  subcostal  incision,  1017 — Hepator- 
rhaphy,  1019 — Hepatopexy,  1019 — Partial  hepatectomy,  1019 — Operation  for  cirrhosis  of  liver, 
epiplorrhaphy,  or  epiplopexy  (Talma-Drummond  operation),  1021. 

VIII.  Gall-bladder: — Surgical  anatomy,  102 1 — Surface  form  and  landmarks,  1022 — 
General  surgical  considerations,  1022 — Instruments,  1022 — Cholecystotomy,  by  vertical  sub- 
costal incision,  1022 — Cholecystostomy,  by  oblique  or  vertical  subcostal  incision,  1024 — Cho- 
lecystenterostomy,  by  Murphy  button,  1026 — Cholecystenterostomy  by  simple  suturing,  1028 — 
Cholecystolithotrity,  1028 — Cholecystectomy,  1029. 

IX.  Gall-ducts: — Surgical  anatomy,  1030 — Surface  form  and  landmarks,  1031 — Instru- 
ments, 1031 — General  surgical  considerations,  1031 — Supraduodenal  choledochotomy,  1031  — 
Retroduodenal  choledochotomy  (Haaslers  operation),  1034 — Transduodenal  choledochostcmy 
(Kocher's  operation),   1034 — Cysticotomy,   1035 — Hepaticotomy,   1036. 

X.  Spleen: — Surgical  anatomy,  1036 — Surface  form  and  landmarks,  1037 — General 
surgical  considerations,  1037 — Instruments,  1038 — Exploratory  puncture,  1038 — Splenotomy, 
by  oblique  subcostal  incision,  1038 — Exposure  of  spleen  by  subpleural  route,  by  partial  excision 
of  one  or  two  ribs,  1039 — Splenorrhaphy,  1039 — Splenopexy,  1039 — Partial  splenectomy,  by 
subcostal  incision  parallel  with  ribs,  1040 — Total  splenectomy,  by  vertical  incision  in  left  inea 
semilunaris,  1041. 

XI.  Pancreas: — Surgical  anatomy,  1043 — Surface  form  and  landmarks,  1044 — General 
surgical  considerations,  1044 — Instruments,  1046 — Pancreatotomy,  by  gastrocolic  route,  1046 — 
Partial  pancreatectomy,  by  gastrocolic  route,   1047. 

XII.  Kidneys: — Surgical  anatomy,  104S — Surface  form  and  landmarks,  105 1 — General 
surgical  considerations,  1052 — Instruments,  1053 — Retroperitoneal  exposure  of  kidney  by 
oblique  lumbar  incision,  1053 — Retroperitoneal  exposure  of  kidney,  by  Koenig's  augular  lumbo- 
abdominal  incision,  1056 — Retroperitoneal  exposure  of  kidney,  by  lumbar  intramuscular  method, 
1057 — Transperitoneal  exposure  of  kidney,  by  vertical  incision  in  linea  semilunaris  (Langenbuch's 


CONTEXTS.  13 

operation),  1057 — Transperitoneal  exposure  of  kidney  by  median  abdominal  section,  1059 — 
Exposure  of  kidney  by  combined  abdominolumbar  operation,  by  anterior  transperitoneal  and 
posterior  retroperitoneal  incisions,  1059 — Exploratory  puncture  of  kidney,  1060 — Nephrotomy, 
1061 — Pyelotomy,  1062 — Nephrolithotomy,  1062 — Nephrorrhaphy,  1063 — Nephropexy,  by 
suturing  split  and  everted  proper  capsule  of  kidney  to  lumbar  wall,  Edebohls's  operation, 
1064 — Nephropexy,  by  suturing  split  proper  capsule  and  parenchyma  of  kidney  to  lumbar  wall, 
by  oblique  lumbar  incision,  Tuffier's  operation,  1068 — Nephropexy,  by  simple  suturing,  1069 — 
Total  nephrectomy,  by  oblique  lumbar  incision,  1070 — Partial  nephrectomy,  by  oblique  lumbar 
incision,  1072 — Subcapsular  nephrectomy,  1072 — Total  nephrectomy  by  anterior  transperitoneal 
method,  1072. 

XIII.  Ureters: — Surgical  anatomy,  1073 — Surface  form  and  landmarks,  1074 — General 
surgical  considerations,  1075 — Instruments,  1076 — Exposure  of  ureters,  in  general,  1076 — 
Extraperitoneal  exposure  of  the  kidney  and  the  entire  ureter,  by  oblique  lumbo-iliac  incision, 
1076 — Ureterotomy,  1078 — Ureterorrhaphy,  1079 — Ureteroplasty,  10S0 — Uretero-ureteral  anas- 
tomosis (uretero-uret'-rostomy),  1080 — Implantation  of  ureters,  in  general,  1084 — Implantation 
of  ureters  into  bladder  (ureterocystostomy),  10S5 — Implantation  of  ureters  into  large  intestine 
(ureterorectostomy)  by  Fowler's  method,  1086 — Implantation  of  ureters  upon  skin,  1089 — ■ 
Ureterectomy,  in  general,  1089 — Partial  ureterectomy,  by  oblique  lumbar  incision,  1090 — 
Total  ureterectomy,  together  with  removal  of  kidney,  by  anterior  median  abdominal  section, 
1090. 

XIY.  Bladder: — Surgical  anatomy,  1091 — Surface  form  and  landmarks,  1092 — General 
surgical  considerations,  1093 — Instruments,  1094 — Introduction  of  sound  or  catheter,  1094 — 
Paracentesis  vesica1,  1095 — Cystotomy,  in  general,  1096 — Suprapubic  cystotomy,  1096 — Lateral 
perineal  cystotomy,  for  removal  of  vesical  calculus,  1099 — Median  perineal  cystotomy,  for 
removal  of  vesical  calculus,  1102 — Cystorrhaphy,  1103 — Lithotrity,  1104 — Litholapaxy,  1104 — 
Vesical  drainage,  110S — Partial  cystectomy,  1109 — Total  cystectomy,  by  suprapubic  median 
vertical  and  transverse  incisions,  11 10. 

CHAPTER  VI. 
OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

I.  Penis: — Surgical  anatomy,  11  n — Instruments,  n n — Circumcision,  n  12 — Partial 
amputation  of  penis,  by  flap  method,  11 14 — Total  amputation,  n  16. 

II.  Urethra: — Surgical  anatomy  of  male  urethra,  111S — Surgical  anatomy  of  female 
urethra,  n  19 — Surface  form  and  landmarks,  n  19 — General  surgical  considerations,  n  19 — 
Instruments,  11 20 — Introduction  of  sound  or  catheter,  n  20 — Meatotomy,  11 20 — Urethrotomy, 
in  general,  1120 — Internal  urethrotomy,  by  dilating  urethrotome,  1121 — External  perineal 
urethrotomy,  upon  grooved  staff  (Syme's  operation),  1123 — External  perineal  urethrotomy, 
upon  filiform  guide  (Gouley's  operation),  n  24 — External  perineal  urethrotomy  upon  grooved 
staff  passed  down  to  stricture  (Wheelhouse's  operation),  n 25 — Perineal  section,  or  external 
perineal  urethrotomy  without  a  guide  (Cock's  operation),  1126 — Urethrorrhaphy,  1127 — 
Urethrostomy,  n 27. 

III.  Scrotum  and  Testes: — Surgical  anatomy,  1128 — Paracentesis  tunica  vaginalis,  1129 — 
Partial  excision  of  scrotum,  n  29 — Operation  for  hydrocele,  by  incision  of  tunica  vaginalis, 
Volkmann's  operation,  1131 — Operation  for  hydrocele,  by  eversion  and  suturing  of  tunica 
vaginalis  (Jaboulay's  operat'on),  1132 — Operation  for  hydrocele,  by  incision,  with  partial 
excision  of  tunica  vaginalis,  von  Bergmann's  operation,  1133 — Orchidectomy,  1 134. 

IV.  Spermatic  Cord: — Surgical  anatomy,  113^ — Instruments,  1136 — Partial  vasectomy, 
1 136 — Operation  for  radical  cure  of  varicocele,    Bennett's  modification  of  Howse's  operation, 

II37- 

V.  Vesiculae  Seminales  and  Ejaculatory  Ducts: — Surgical  anatomy,  1138 — Instruments, 
1 139 — Total  excision  of  vesiculae  seminales  and  part  of  ejaculatory  ducts,  by  suprapubic  retro- 
cystic  extraperitoneal  route,  Young's  operation,   1139- 

VI.  Prostate  Gland: — Surgical  anatomy,  1140 — Instruments,  1141 — Prostatotomv — 
Prostatectomy,  in  general,  1141 — Suprapubic  prostatectomy,  by  median  vertical  incision, 
1 142 — Perineal  prostatectomy,  by  transverse  curved  incision,  1143 — Prostatectomy  by  the 
combined  median  suprapubic  and  median  perineal  incisions,  Alexander's  operation,  1144 — 
Note,  1 146. 

CHAPTER    VII. 

OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 

I.  Uterus: — Surgical  anatomy  of  uterus,  broad  ligaments,  round  ligaments,  and  vagina, 
1147— Surface  form  and  landmarks,  1 1 50  —Instruments,  1150 — Partial  abdominal  hysterectomy, 
together  with  removal  of  ovaries  and  tubes  (partial  abdominal  hysterosalpingo-oophorectomy), 


14  CONTENTS. 

1 151 — Total  abdominal  hysterectomy,  together  with  removal  of  ovaries  and  tubes  (total  abdomi- 
nal  hysterosalpingo-oophorectomy),    11 53 — Total   vaginal   hysterectomy,    1153. 

II.  Ovaries: — Surgical  anatomy  of  ovaries,  Fallopian  tubes,  1150 — Ovariectomy,  or  oopho- 
rectomy, with  removal  of  Fallopian  tube  (salpingo-ovariectomy,  or  salpingo-oophorectomy), 
1 1 60— Note,  1 1 62 . 


CHAPTER    VIII. 
OPERATIONS   FOR   HERNIJE. 

I.  Inguinal  Hernia,  1163 — Surgical  anatomy,  1163 — General  surgical  considerations, 
1164 — Instruments,  1166 — Operation  for  radical  cure  of  oblique  inguinal  hernia  (Bassini's 
method),  1166 — Operation  for  radical  cure  of  same  (Halsted's  method),  1171. 

II.  Femoral  Hernia,  1174 — Surgical  anatomy,  1174 — General  surgical  considerations, 
1 1 76 — Operation  for  radical  cure  of  femoral  hernia  (Bassini's  method),  11 76. 

III.  Umbilical  Hernia,  n 78 — Surgical  anatomy,  n 78 — Operation  for  radical  cure  of 
umbilical  hernia  by  excision  of  sac  and  suturing  of  freshened  edges  of  ring,  n  79 — Operation 
for  radical  cure  of  umbilical  hernia  (Mayo's  overlapping  method),  n  81. 


Index 1185 


A  TEXT-BOOK 


OPERATIVE  SURGERY 


BICKHAM 


PART  I. 
THE   OPERATIONS  OF  GENERAL  SURGERY. 


CHAPTER    I. 

OPERATIONS  UPON  THE  ARTERIES. 
LIGATION  OF  ARTERIES. 

GENERAL  CONSIDERATIONS. 

Description. — The  ligation  of  an  artery  signifies  the  constriction  of  the 
artery  by  means  of  a  ligature,  for  the  purpose  of  controlling  the  circulation  in 
that  vessel. 

Varieties  of  Ligation. — A  ligation  may  be  "terminal,"  where  the  cut 
end  of  an  artery  is  tied; — "  in  continuity,"  where  tied  in  its  unbroken  course; 
— "single,"  where  but  one  ligation  is  used; — "double,"  where  two  are  applied 
(as  in  dividing  a  vessel  between  ligatures); — "immediate,"  where  applied 
directly  to  the  artery  proper; — "intermediate,"  where  the  ligature  passes 
around  more  or  less  connective  or  other  tissue  surrounding  the  artery  (as 
in  ligation  for  parenchymatous  hemorrhage); — "permanent,"  where  applied 
to  remain; — or  "temporary,"  where  applied  for  arrest  of  circulation  for  a  brief 
period. 

Indications  for  Ligation  of  Arteries. — Wounds;  aneurisms;  hemor- 
rhage, from  main  trunk  near  site  of  ligation,  or  from  either  main  trunk  or 
one  of  its  branches  at  a  distance  from  site  of  ligation;  rupture  of  vessels; 
angiomata;  to  control  hemorrhage  in  operations  distal  to  site  of  ligation; 
to  lessen  nutrition  of  inoperable  tumors;  to  cause  atrophy  of  an  organ  by 
diminishing  its  blood-supply. 

Preparation. — (i)  General; — -none  is  necessary  for  the  smaller  ligations. 
In  the  case  of  the  ligation  of  the  larger  arteries,  the  constitutional  state  of  the 
patient  should  be  looked  after  as  in  other  major  operations.  (2)  Local; — 
the  usual  antiseptic  preparation  of  the  part — the  patient  coming  to  the  table 
with  the  site  of  operation  in  an  aseptic  dressing. 

Position. — Patient  upon  table  of  proper  height,  and  so  placed  as  to 
bring  the  involved  artery  most  conveniently  and  advantageously  before  the 
surgeon.  Surgeon  stands  where  he  can  best  manipulate,  which  is  generally 
on  the  side  of  the  operation,  and  usually  cuts  downward  on  the  right,  and 
upward  on  the  left.  Assistant  generally  stands  opposite  the  surgeon,  and 
exposes  the  field  of  operation  by  retraction,  or  assists  in  the  steps  of  the 
ligation.  The  position  of  patient,  surgeon,  and  assistant  will  vary  according 
to  the  artery  operated  upon,  and  will  be  given  in  the  individual  operations. 

Instruments. — Esmarch  bandage  and  tourniquet;   scalpels,  heavy  and 
2  17 


18  OPERATIONS  UPON  THE  ARTERIES. 

light;  scissors,  straight  and  curved,  sharp-pointed  and  blunt;  forceps,  dis- 
secting and  toothed;  hemostatic  forceps;  grooved  director;  tenacula;  re- 
tractors, various  sizes  and  shapes;  aneurism-needles,  large  and  small,  straight 
and  laterally  curved;  ligature-carrier;  ligaturing  and  suturing  material  (v.  i.); 
needles,  straight  and  curved,  surgeon's  and  Hagedorn;  needle-holder;  wound- 
hooks;  drainage  materials  (for  special  emergencies);  special  small  needles,  fine 
silk,  and  needle-holder  for  repairing  wounds  of  vessels;  means  of  illuminating 
deep  wounds. 

Ligature  Materials. — Plain  catgut;  chromicized  catgut;  kangaroo 
tendon;  ox  aorta:  silk,  plain  and  floss.  For  the  closure  of  skin-wounds, 
silkworm-gut  or  silk  sutures. 

(i)  For  the  ligation  of  smaller  arteries — plain  catgut.  (2)  For  medium 
arteries — chromicized  catgut.  (3)  For  largest  arteries — kangaroo  tendon 
(flat);  ox  aorta  (flat);  chromicized  catgut;  soft  floss-silk. 

Steps  of  the  Operation  of  Ligation. — For  the  satisfactory  carrying 
out  of  a  ligation,  a  systematic  course  should  be  followed  in  all  cases,  the 
proper  steps  of  which  are  given  below,  in  order. 

(a)  Control  of  Circulation  Preliminary  to  Operation. — In  ligating 
the  arteries  of  the  head,  neck,  and  trunk,  no  attempt  is  usually  made  to 
control  the  circulation  by  any  means  of  pressure.  In  the  limbs,  also,  it  is 
rarely  absolutely  necessary.  But  where  its  use  is  preferred, — and  the  satis- 
faction of  operating  in  a  dry  field  is  unquestionable, — the  limb  is  first  elevated, 
the  soft  parts  massaged  toward  the  trunk,  and  the  tourniquet  of  Esmarch 
(without  the  previous  use  of  the  Esmarch  rubber  bandage)  is  applied  around 
the  limb,  as  high  up  as  indicated.  The  sacrifice  of  the  guiding  pulsation 
(necessitated  by  the  use  of  any  form  of  constrictor)  is  counterbalanced  by 
the  dryness  of  the  field,  especially  in  prolonged  and  difficult  operations. 

(b)  Line  of  Artery. — This  is  determined  in  advance  of  any  operative 
step,  and  is  based  upon  a  knowledge  of  the  anatomy  of  the  part.  A  knowledge 
of  the  chief  variations  in  the  course  of  the  arteries  should  also  be  possessed. 
Acquaintance  with  the  line  of  the  special  artery  is  an  absolute  pre-requisite — 
a  correct  line,  properly  followed,  leading  directly  and  expeditiously  to  the  goal 
of  the  operation; — an  incorrect  line,  once  taken,  often  plunging  the  operator 
into  unnecessary  difficulties  from  the  start,  frequently  requiring  loss  of  time, 
retracing  of  steps,  unnecessary  injury  to  structures,  and  the  regaining  of  the 
right  path  finally  after  considerable  and  humiliating  bungling.  This  line 
of  the  artery  may  be  previously  marked  out  upon  the  body  with  a  sterilized 
dermographic  pencil  (or  nitrate  of  silver  stain) — but  such  marking  is  generally 
unnecessary.  ( 1)  The  line  of  the  artery  is  frequently  modified  by  the  position  of 
the  limb,  and,  in  such  cases,  a  constant  position  should  be  understood  to  apply 
in  speaking  of  such  arteries  (for  instance,  the  line  of  the  brachial  artery  is  one 
thing,  if  the  arm  be  lying  out  supine  at  a  right  angle  to  the  body,  and  another, 
if  resting  on  its  inner  border  parallel  with  the  thorax.  (Fig.  23.)  On  the 
other  hand,  no  change  in  the  position  of  the  foot  causes  a  change  in  the  line 
of  the  dorsalis  pedis  (Fig.  54.)  (2)  The  line  of  an  artery  often  coincides  so 
nearly  with  muscular  or  tendinous  landmarks  that  these  landmarks  are  often 
given  instead  of  the  line  itself  (for  instance,  one  may  speak  of  ligating  the 
brachial  artery  by  incising  along  a  line  extending  from  the  junction  of  the 
anterior  and  middle  thirds  of  the  outer  axillary  boundary,  to  the  middle  of 
the  bend  of  the  elbow,  the  arm  being  at  a  right  angle  to  the  body  and  on  its 
extensor  surface;  or  one  may  also  speak  of  ligating  this  artery  by  incising 
along  the  inner  border  of  the  coracobrachialis  muscle  above,  and  the  biceps 
below,  Fig.  23).  It  is  well  to  know  both  the  commonly  accepted  "line" 
and  the  natural  muscular  or  other  markings — the  former  is  usually  the  more 


LIGATION  OF  ARTERIES.  19 

accurate  guide  to  the  vessel,  especially  in  the  early  stage  of  the  operation  (for 
instance,  in  the  above  case,  the  brachial  artery  is  often  considerably  overlapped 
by  the  biceps  in  a  well-developed  subject),  though  the  latter  are  the  natural 
boundaries,  which  generally  have  to  be  encountered  and  manipulated  before 
finally  reaching  the  artery.  (3)  In  other  cases  the  line  bears  no  relation  what- 
ever to  external  muscular  or  tendinous  elevations  or  furrows,  and,  in  such 
cases,  the  line  alone  has  to  be  blindly  followed,  in  the  early  part  of  the  opera- 
tion, as  a  guide  to  the  course  of  the  artery  (as  in  the  case  of  the  upper  portion 
of  the  ulnar  artery,  Fig.  30). 

(c)  Incision. — (I)  Position  and  Direction  of  Incision: — In  the  great  major- 
ity of  cases  the  line  of  incision  coincides  with  the  line  of  the  artery,  from  begin- 
ning to  end  of  operation,  superficially  and  in  the  deeper  layers  (as  in  ligation 
of  the  popliteal  artery  in  the  middle  of  the  popliteal  space),  and  should  be  so 
placed  as  to  have  its  center  over  the  site  of  ligation.  In  other  cases  the  line 
of  incision  will  follow  a  muscular  marking,  even  if  at  a  slight  variance  with 
the  recognized  "line  of  artery"  (e.  gr,  in  ligating  the  common  carotid  above 
the  omohyoid,  the  incision  is  made  parallel  with  the  inner  margin  of  the 
stern  omastoid,  which,  in  muscular  and  well-developed  necks,  is  known  to 
overlap  and  lie  slightly  to  the  inner  side  of  the  artery,  Fig.  10,  F).  In  other 
cases  the  incision  follows  neither  line  of  artery  nor  muscular  marking,  but  lies 
in  a  course  parallel  with  both  line  of  artery  and  muscular  fibers,  and  is  so  placed 
as  to  reach  the  vessel  most  advantageously  and  with  least  damage  to  neighbor- 
ing structures  (e.  g.,  ligation  of  posterior  tibial  artery  in  middle  of  leg,  Fig.  51, 
I).  In  other  cases  the  incision  may  coincide  with  the  line  of  artery  but  cross  an 
overlying  muscle  at  a  right  angle  (e.  g.,  ligation  of  lingual  artery  beneath  the 
hyoglossus  muscle,  Fig.  10,  L).  In  still  other  cases  the  incision  may  cross  the 
course  of  the  artery  at  a  right  angle  (e.  g.,  ligation  of  external  iliac  extraperi- 
toneally,  by  an  incision  parallel  with  Poupart's  ligament,  Fig.  39).  (2)  Super- 
ficial Incision : — Having  chosen  the  line  of  incision  as  free  from  superficial  vessels 
and  nerves  as  circumstances  permit,  steady  the  area  of  incision  by  means  of  the 
left  thumb  and  forefinger,  which,  by  their  separation,  put  the  parts  under 
slight  tension  and  give  room  for  the  knife-cut  between  them.  Grasp  the  scalpel 
in  the  "pen-position"  for  finer,  more  limited  cuts,  and  in  the  "dinner-knife 
position"  for  heavier,  longer  cuts.  Enter  the  point  of  the  scalpel  at  a  right 
angle  to  the  skin  surface — traverse  the  line  of  incision  with  the  knife-handle  at 
about  45  degrees — and  withdraw  the  knife  with  the  point  of  blade  again  at  a 
right  angle  to  the  surface,  thereby  cutting  to  equal  depth  throughout.  This 
incision  should  pass  through  skin  and  superficial  fascia,  and,  while  not  unnec- 
essarily long,  should  be  amply  long  enough  to  enable  subsequent  manipulations 
to  be  carried  on  without  injury  to  the  structures.  The  length  of  the  incision 
should  rather  be  determined  by  the  depth  of  the  artery  and  the  nature  of 
the  parts  to  be  encountered,  than  by  any  attempt  to  remember  an  arbitrary 
length  of  incision  for  each  artery.  The  deep  fascia  is  similarly  divided  in 
the  original  line — avoiding,  where  possible,  superficial  vessels,  and,  especially, 
nerves.  (3)  Deep  Incision: — Having  passed  through  all  overlying  fascia  in 
the  superficial  incision,  the  muscle  and  tendinous  landmarks  now  come  to  both 
sight  and  touch.  Generally  no  further  cutting  is  necessary — the  rest  of  the 
approach  "and  exposure  of  the  artery  being  accomplished  by  blunt  dissection. 
In  by  far  the  majority  of  cases  arteries  are  henceforth  reached  by  following 
down  between  muscular  planes,  it  being  very  rare  that  muscle-fibers  are 
separated,  and  rarer  still  that  muscles  are  cut  transversely.  At  this  stage  of 
the  operation  the  muscular  or  tendinous  boundaries  are  recognized  and  followed 
to  the  known  position  of  the  artery,  the  intermuscular  planes  being  separated 


20  OPERATIONS    UPON    THE    ARTERIES. 

by  the  handle  of  the  scalpel  rather  than  by  the  blade,  and  this  separation 
being  carried  out  t<>  correspond  with  the  length  of  the  superficial  wound. 
The  three  best  means  of  recognizing  intermuscular  planes,  in  the  order  of 
their  reliability,  are: — sense  of  touch  of  tip  of  left  index-finger  (which  flexion 
of  the  limb  may  assist); — following  down  of  intermuscular  branches  of  the 
artery; — the  white  fascial,  or  yellow  fatty,  so-called  ''line' '  in  the  intermuscular 
spaces.  It  is  of  great  importance  to  recognize  the  proper  intermuscular 
spa<  e  at  the  start,  as,  once  in  a  wrong  intermuscular  interval,  one  may  wander 
on  indefinitely,  completely  off  the  track,  missing  the  artery  and  doing  much 
damage  to  the  parts  (and  injury  to  one's  own  feelings).  Good  retraction 
should  be  freely  used  at  this  stage,  and  muscles  and  tendons  should  be  drawn  to 
their  proper  sides  (flexing  the  limb  often  aiding  considerably  in  this  retraction). 
Important  vessels,  nerves,  and  other  structures  should  be  guarded  during  this 
separation  of  the  parts,  and,  when  in  the  way,  should  be  displaced  to  the  more 
convenient  side  of  the  operation-field — always  remembering  that  nerves  are 
the  most  important  structures  to  be  safeguarded,  in  the  great  majority  of  cases. 
If  an  Esmarch  have  not  been  used,  the  wound  is  kept  comparatively  dry  by 
frequent  sponging  of  the  field  with  dry  gauze-wipes. 

(d)  Exposure  of  Artery. — Having  gotten  down  into  the  region  of  muscles 
and  tendons,  these  should  be  clearly  identified,  and  the  artery  sought  by  its 
known  relation  to  these  structures.  The  muscles  and  tendons  are  the  rallying- 
points  in  the  depth  of  the  wound.  Three  structures,  outwardly  more  or  less 
similar  in  appearance,  and  often  in  sensation,  are  to  be  distinguished: — (I) 
Arteries  are  recognized  by  their  known  course;  their  pulsation,  when  no 
proximal  constriction  is  used  (and  by  the  hard,  unyielding  plaster  or  starch 
injection  in  the  cadaver) ;  their  swelling  proximally  when  compressed  distaily 
(where  no  constrictor  is  used);  their  firm,  round,  resisting,  elastic,  cord-like 
feeling;  their  peculiar  sensation  when  compressed  between  the  fingers,  present- 
ing a  central  depression  and  two  lateral,  elevated  ridges;  their  thicker  walls; 
their  rubber-tube-like  feeling  when  touched  and  tendency  to  glide  from 
beneath  the  fingers;  the  force  required  to  compress  them;  their  regular  outline; 
their  pinkish  or  pinkish-yellow  color.  Of  these  means  of  recognition,  pulsa- 
tion is  the  conclusive  test,  provided  there  can  be  eliminated  all  possibility 
of  error  caused  by  pulsation  transmitted  through  contact  (as  a  vein  or  a  nerve 
made  to  rise  and  fall  by  an  artery  beating  beneath  or  to  one  side  of  it). 

(2)  Veins  are  recognized  by  not  pulsating  (where  no  Esmarch  is  used);  by 
having  thinner  coats;  by  swelling  toward  the  periphery  when  compressed  cen- 
trally (no  constrictor  being  used);  by  being  softer  and  less  resisting  to  touch; 
by  the  flat,  ribbon-like  feeling  throughout  their  whole  width  when  compressed 
between  the  fingers;  by  their  purplish  color;  by  their  wavy,  irregular  contour; 
by  their  accompanying  the  arteries,  in  many  regions,  in  pairs  or  companion 
veins;  by  their  larger  size  than  the  corresponding  arteries;  by  the  ease  with 
which  they  are  compressed.  It  may  be  mentioned  here,  in  connection  with 
the  companion  veins,  that  two  vena?  comites  are  to  be  found  accompanying 
all  arteries  below  the  axilla;  all  arteries  below  the  knee;  most  of  the  small 
and  medium-sized  arteries  of  the  trunk;  and  that  the  arteries  of  the  head 
and  neck  are  accompanied  by  single  veins.  These  veins  generally  run  on 
either  side  of  the  artery,  communicating  across  the  artery  at  frequent  intervals, 
— generally  lying  in  front  of  and  behind  the  artery  when  the  intermuscular 
plane  enclosing  the  artery  lies  anteroposteriorly, — and  usually  lying  to  the 
right  and  left  of  the  artery  when  the  intermuscular  plane  runs  transversely. 

(3)  Nerves  are  distinguished  by  their  known  position;  their  white  color; 
their  round  contour,  unyielding  consistency,  and  non-compressibility;  their 


LIGATION  OF  ARTERIES.  21 

appearance  of  being  made  up  of  parallel  bundles;  their  swelling  neither 
proximally,  like  arteries,  nor  peripherally,  like  veins,  when  compressed  (no 
constrictor  being  used). 

(e)  Opening  the  Sheath. — Having  identified  this  structure  and  brought 
it  well  within  the  field,  its  wall  is  to  be  opened  and  the  contained  artery  ex- 
posed— for  the  purpose  of  clearing  a  path  for  the  aneurism-needle  (Fig.  i). 
Only  the  main  vessels  have  a  distinct  sheath  of  connective  tissue,  and  the 
larger  the  artery,  the  more  distinct  the  sheath.  In  some  cases  the  accom- 
panying vein  and  nerve  are  included  in  a  common  sheath,  together  with 
the  artery — the  sheath  being  composed  of  more  or  less  condensed  connective 
tissue.  The  smaller  arteries  are  surrounded  by  a  less  distinct  layer  of  areolar 
tissue,  generally  not  demonstrable  as  a  sheath.  The  sheath  should  be  opened 
at  least  1.3  cm.  (h  inch)  from  any  branch.  With  a  pair  of  finely  pointed 
forceps,  pick  up  the  sheath  where  it  is  desired  to  pass  the  ligature,  and  in 
such  a  way  as  to  raise  the  sheath  in  a  fold  parallel  with  the  long  axis  of  the 


Fig.  1. — Ligation  of  an  Artery.  Opening  the  sheath.  A,  Retraction  of  adjacent  muscles; 
B,  Toothed  forceps  raising  sheath  of  artery  in  a  longitudinal  fold  ;  C,  Incising  sheath  in  long  axis  of 
artery  ;  D,  Artery  visible  through  incised  sheath. 


vessel  (Fig.  1,  B).  Let  the  forceps  pick  up  the  sheath  upon  its  anterior 
aspect,  but  slightly  to  one  side  of  the  median  longitudinal  line,  thereby  leav- 
ing space  to  incise  the  sheath  exactly  in  the  middle  line.  After  grasping  the 
sheath,  shift  the  forceps  gently  up  and  down  to  see  that  the  sheath,  held  in 
the  bight  of  the  forceps,  glides  over  the  contained  vessel,  proving,  thereby, 
that  no  part  of  the  artery  itself  is  picked  up.  This  longitudinal  fold  of  the 
sheath,  while  held  by  the  forceps  and  lifted  up  from  the  artery,  is  incised  in 
the  long  axis  of  the  artery,  for  a  distance  of  about  6  to  8  mm.  (j  to  § 
inch)  (the  shorter  the  distance  of  separation  of  the  sheath  the  better,  to  pre- 
serve the  vasa  vasorum),  the  flat  surface  of  the  knife  being  turned  to  the 
artery  (Fig.  1,  C).  As  soon  as  the  incision  is  made  in  the  sheath,  a  gap 
appears  between  the  wall  of  the  artery  and  the  wall  of  the  sheath  (Fig.  1 .  D). 
The  hold  of  the  forceps  upon  the  wall  of  the  sheath  should  be  retained,  not 
being  relaxed  after  once  grasping  the  fold  of  sheath.     In  ligating  smaller 


22  OPERATIONS  UPON  THE  ARTERIES. 

arteries,  which  have  no  well-defined  sheath,  the  vessel  is  simply  freed  of  all 
visible  connective  tissue.  (This  axial  division  of  the  sheath  of  the  artery  is 
preferable  to  the  transverse  division  so  often  advised.) 

(f)  Clearing  the  Artery. — A  path  for  the  passing  of  the  ligature  between 
the  outer  wall  of  the  artery  and  the  inner  wall  of  the  sheath  is  now  to  be 
made,  and  the  best  instrument  with  which  to  make  it  is  the  dull,  flat  end  of 
a  curved  aneurism-needle  (Fig.  2).  Having  retained  the  original  hold  of 
the  forceps  upon  the  sheath  (Fig.  2,  B),  insinuate  the  end  of  the  needle  between 
this  wall  of  the  sheath  and  the  artery,  and  while  drawing  this  lip  of  the  sheath 
gently  away  from  the  artery,  carefully  work  the  point  of  the  needle  around 
one-half  of  the  circumference  of  the  artery,  in  the  connective-tissue  plane 
between  artery  and  sheath,  by  a  combination  of  forward  movement,  on  the 
part  of  the  tip  of  the  needle,  with  a  side  to  side  movement,  on  the  part  of  the 
lateral  margins  of  the  curved  tip,  over  a  distance  of  from  6  to  8  mm.  (\  to  |  inch) 
(Fig.  2,  C).     Having  thus  cleared  a  path  around  half  the  vessel,  and  still 


Fig.  2. — Ligation  of  an  Artery.  Clearing  the  artery.  A,  A,  Retraction  of  adjacent  muscles; 
B,  Forceps  grasping  nearer  lip  of  sheath  ;  C,  Aneurism-needle  clearing  artery  in  its  passage  between 
sheath  and  vessel ;  D,  Forceps  grasping  further  lip  of  sheath  ;  F,  Aneurism-needle  emerging  between 
artery  and  further  lip  of  sheath. 


holding  the  tip  of  the  needle  in  the  path  already  cleared,  the  forceps  for  the 
first  time  relinquishes  its  hold  on  the  lip  of  the  sheath  originally  grasped,  and 
grasps  the  opposite  lip  of  the  sheath  and  similarly  draws  this  part  of  the  sheath 
away  from  the  artery  (Fig.  2,  D),  at  the  same  time  also  similarly  working 
the  point  of  the  needle  onward  and  from  side  to  side,  until  it  clears  a  way  com- 
pletely around  the  artery  and  appears  between  the  vessel  and  the  further  lip 
of  the  sheath  (Fig.  2,  E).  Throughout  this  entire  manoeuvre  the  handle  of 
the  needle  is  held  approximately  at  a  right  angle  to  the  vessel,  and  the  tip  of 
the  needle  hugs  the  wall  of  the  artery,  especially  while  working  under  its  deepest 
part,  particularly  where  a  common  sheath  contains  other  structures,  and 
thereby  is  prevented  from  penetrating  the  sheath  and  injuring  the  vessels, 
nerves,  or  viscera  beyond. 

(g)  Passing  the  Ligature. — Once  a  passage  has  been  cleared  between 


LIGATION    OF    ARTERIES. 


23 


artery  and  sheath,  the  aneurism-needle  readily  traverses  it — so  that  as  soon  as 
the  needle  has  appeared  on  the  further  side  of  the  artery,  it  is  withdrawn. 
The  needle  is  now  threaded  and  carefully  passed  between  vessel  and  sheath, 
through  the  previously  cleared  way,  following  precisely  the  same  course  and 
carrying  out  the  same  steps— first  opening  the  entrance  to  the  passage  by 
drawing  the  sheath  away  with  forceps — then  hugging  the  vessel  in  making 
the  circuit — and  finally  emerging  on  the  opposite  side  between  the  vessel  and 
the  further  lip  of  the  sheath,  which  the  forceps  have  now  grasped  and  drawn 
away  (Fig.  3,  F,  B,  C).  An  aneurism-needle  may  be  passed  with  a  fine  silk 
ligature-loop  as  a  carrier,  and  through  this  "carrier"  the  proper  ligature  may 
be  threaded  and  drawn  back.    There  is  no  fixed  rule  for  the  direction  in  which 


Fig.  3.— Ligation  of  an  Artery.  Passing  the  ligature  and  tying  the  knot.  A,  A,  Retraction 
of  neighboring  parts;  B,  Aneurism-needle  carrying  ligature  beneath  artery;  C,  Tenaculum  drawing 
one  end  of  ligature  under  artery,  while  aneurism-needle  is  being  withdrawn ;  D,  Tying  the  knot; 
F,  Retracting  lip  of  sheath. 

Fig.  4. — Knot  Used  in  Ligating  Medium  and  Large  Arteries.  E,  Two  turns  of  a  fric- 
tion-knot followed  by  a  reef-knot,  constituting  a  surgeon's  knot. 


the  needle  should  be  passed  in  each  case;  the  rule  should  be  that  the 
needle  is  to  be  passed  from  the  more  important  structures  toward  the  least  im- 
portant, or  from  the  structures  more  difficult  to  avoid  toward  those  more  easily 
avoided.  Therefore  the  needle  may  enter  the  sheath  in  the  reverse  order 
to  that  in  which  it  has  been  freed  from  the  artery,  or  vice  versa,  as  seems 
safest  and  easiest.  Having  passed  the  needle  completely  around  the  vessel, 
until  its  threaded  eye  protrudes  on  the  opposite  side,  grasp  one  of  the 
threads  of  the  looped  ligature  with  forceps  or  tenaculum,  and,  while  thus 
held,  carefully  withdraw  the  needle,  following  the  curve  of  the  artery 
(Fig.  3,  B,  C).  Thus  a  single  thread  is  left  beneath  the  vessel — an  end 
coming  out  between  the  artery  and  sheath  on  either  side.     Some  surgeons  pass 


24 


OPERATIONS  UPON  THE  ARTERIES. 


the  needle  unthreaded,  and  thread  the  eye  on  the  opposite  side,  then,  holding 
one  arm  of  the  ligature  with  forceps,  withdraw  the  needle — with  the  same 
result.  There  is  no  objection  to  this  method  in  simple  cases  where  the  artery 
is  accessible  and  the  threading  easily  done  with  the  needle  in  situ  (as  in  the 
lower  third  of  the  radial),  but  it  should  not  be  attempted  in  a  region  where 
the  exposure  is  difficult  (as  in  the  retroperitoneal  ligation  of  the  common 
iliac).  Such  an  instrument  as  the  Cleaveland  needle  (ligature-carrier)  is 
preferred  to  the  common  aneurism-needle  by  some — the  instrument,  being 
passed  under  the  artery  empty,  grasps  the  ligature  on  the  opposite  side,  and 
draws  back  one  end  under  the  vessel.  In  arteries  too  small  to  have  sheaths 
the  ligature  is  simply  carried  under  and  around  the  artery,  which  has  been 
freed  of  all  connective  tissue,  the  general  method  being  the  same  as  just 
described. 

(h)  Tying  the  Knot. — The  largest  arteries  are  most  safely  and  satis- 
factorily tied  with  the  "stay-knot"  of 
Ballance  and  Edmunds.  The  stay- 
knot  of  these  surgeons  is  made  by  con- 
ducting two  or  more  bundles  of  soft 
floss-silk — or  two  or  more  pieces  of 
kangaroo-tendon,  catgut,  silk-worm 
gut,  or  plain  silk  around  the  artery, 
parallel  with  each  other  and  side  by 
side; — the  first  hitch  of  a  reef-knot 
is  then  tied  in  each  bundle,  so  that 
two  or  more  knots  lie  side  by  side, 
the  force  to  tie  them  having  been 
sufficient  to  closely  approximate  the 
inner  and  middle  coats  of  the  artery 
and  completely  stop  the  flow,  but 
•r^s^Ol  \       "HA  %         without    rupturing    these    coats  (Fig. 

5,  A,  and  Fig.  7).  A  friction  knot 
is  even  safer  than  the  first  hitch  of  a 
reef-knot,  as  the  preliminary  step — 
especially  in  tying  the  larger  vessels. 
After  tying  these  at  first  lightly,  they 
are  both  taken  up  together  and  gently 
tightened  simultaneously.  The  two 
or  more  ends  of  the  bundles  are  then 
taken  up  on  the  one  side,  and  the  two 
or  more  ends  of  the  other  bundles  on  the  opposite  side, — the  several 
bundles  on  each  side  now  being  regarded  as  one.- — and  these  two  bundles 
are  tied  in  a  single  knot,  after  the  manner  of  the  second  step  of  a  reef-knot 
(Fig.  6,  B).  Thus  a  knot  is  formed  the  first  part  of  which  will  not  slip  while 
the  second  is  being  tied  (which  is  apt  to  be  the  case  in  large  arteries,  especially 
if  they  be  pulsating  at  the  time,  thus  allowing  the  establishment  of  a  small 
stream  of  blood).  By  this  method  a  broad  compression  and  approximation 
of  the  arterial  coats  will  be  accomplished,  which  will  add  strength  to  the  site 
of  ligation  against  secondary  hemorrhage.  This  simple  approximation  is 
sufficient  to  excite  endothelial  proliferation  and  union  of  the  opposed  surfaces. 
It  is  hard  to  draw  such  a  ligature  tight  enough  to  rupture  the  inner  coats.  An 
artery  with  its  two  inner  coats  ruptured  by  ligation  has  only  the  strength  of 
its  outer  coat  to  withstand  the  strain  of  the  circulation  until  the  secondary 
phenomena  take  place,  which  permanently  strengthen  the  site — prior  to  which 


Figs.  5  and  6.— Floss-silk  Stay-knot  of 
Ballance  and  Edmunds.  A,  First  stage;  B, 
Second  stage. 


LIGATION    OF    ARTERIES. 


25 


secondary  hemorrhage  may  occur.  Several  parallel  strands  of  smaller-sized 
chromic  catgut,  led  under  the  artery  by  a  carrier,  are  sometimes  used,  thus 
securing  width  for  the  ligature  and  the  consequent  distribution  of  pressure. 
All  medium-sized  arteries  should  be  tied  with  a  surgeon's  knot  (a  friction-knot 
followed  by  the  second  step  of  a  reef-knot)  (Fig.  4,  E).     All  small  arteries 


^ 


Fig.  7. — The    Stay-knot 
of   Ballance  and   Edmunds. 

Showing  the  first  step  of  tying 
three  kangaroo-tendon  liga- 
tures. 


Fig.  8. — Showing  the  Pleating 
or  the  Coats  or  a  Ligated  Artery 
in  Cross-section.  (Modified  from 
Ballance  and  Edmunds.) 


Fig.  o. — Illustrating  the  Manner 
of  Suturing  the  Wound,  the  Edges  of 
which  are  put  upon  the  Stretch  by 
YYurND-HOOKS  at  Either  End.  Interrupted 
sutures  are  shown  at  one  end  and  continuous 
suturing  at  the  other  end. 


are  safely  tied  with  tne  reef-knot  alone.  In  making  tension  upon  the  ends 
of  the  ligature,  special  care  should  be  taken  not  to  lift  the  artery  out  of  its 
sheath.  To  avoid  this,  the  tips  of  the  right  and  left  forefingers  should  come 
together,  end  to  end,  directly  upon  the  knot  in  the  act  of  being  tied,  and  the 
tightening  should  be  done  by  putting  the  terminal  and  middle  knuckles  of 
the  index-fingers  in  apposition,  back  to  back,  and  using  them  as  fulcra  (Fig. 


26  OPERATIONS    UPON    THE    ARTERIES. 

3,  D).  The  thumbs  may  be  similarly  used  instead  of  the  forefingers.  It  is 
a  disputed  point  as  to  how  much  tension  should  be  used  in  tightening  a  ligature. 
It  may  be  said  that  it  is  best  to  tighten  the  ligature  upon  all  large  vessels  suffi- 
ciently to  thoroughly  approximate  their  inner  wall  in  pleats,  thereby  com- 
pletely closing  the  lumen,  without  rupturing  their  two  inner  coats  (Fig. 
8).  The  same  holds  true  of  all  diseased  vessels,  independently  of  their  size. 
All  medium  vessels  may  be  similarly  ligated.  The  smaller  arteries  generally 
have  their  ligatures  tightened  sufficiently  to  rupture  their  inner  and  middle 
coats.  A  tightening  almost  sufficient  to  sever  all  coats,  especially  when  using 
silk,  is  distinctly  to  be  avoided.  Secondary  hemorrhage  seems  less  frequent, 
and  the  strength  of  the  vessel  greater,  where  the  vessels  are  only  constricted 
enough  to  closely  approximate  the  two  inner  coats,  without  causing  their 
rupture.  All  knots  should  be  cut  comparatively  short.  A  round  ligature 
tightly  drawn  will  rupture  the  inner  coats;  a  broad  ligature  will  do  so  far  less 
readily. 

(i)  Closure  of  Wound. — Where  a  large,  well-marked  sheath  has  been 
opened  in  exposing  the  artery,  although  not  absolutely  necessary,  it  is  well 
to  unite  the  edges  of  the  sheath  by  one  or  two  fine  catgut  sutures.  Where 
anv  muscle  tissue  has  been  incised  in  order  to  reach  the  artery,  it  is  usually 
best  to  repair  the  divided  muscle  tissue  by  catgut  sutures  passed  through 
the  lips  of  the  muscle  wound — which  suture  becomes  buried  in  the  final 
steps  of  the  operation.  Where  deep  intermuscular  planes  have  been  opened 
up,  and  dead  spaces  are  apt  to  be  left,  it  is  advisable  to  put  in  a  few  buried 
catgut  sutures  through  the  muscle  tissue,  drawing  together  the  muscles  into 
their  normal  intermuscular  cleavage  line.  Where  no  muscle  has  been  wounded, 
— and  in  the  final  step  of  those  cases  where  muscle  has  been  incised  and 
sutured, — complete  closure  of  the  wound  is  accomplished  by  a  line  of  inter- 
rupted silkworm-gut  or  silk  sutures,  or  by  a  continuous  silk  suture — the 
suturing,  in  either  case,  being  materially  aided  by  putting  the  wound  on 
the  stretch  by  a  wound-hook  in  either  end  (Fig.  9).  No  form  of  drainage 
is  used  in  clean  cases.  A  simple  gauze  and  cotton  dressing,  held  in  place 
by  a  bandage,  completes  the  dressing. 

(j)  After-treatment. — Very  little  after-treatment  is  indicated  in  the 
ligation  of  the  smaller  arteries.  Where  a  large  artery  is  ligated,  a  splint 
should  be  incorporated  in  the  dressing  where  feasible,  in  order  to  control 
all  movement  of  the  part.  In  the  case  of  the  main  artery  of  a  limb,  the  . 
limb  should  be  encased  in  cotton,  and  artificial  warmth  applied  in  addition, 
until  the  new  circulation  is  established.  The  limb  is  elevated  in  bed  to 
favor  venous  return.  The  skin  sutures  are  removed  on  the  seventh  or  eighth 
day.  A  rest  in  bed  of  from  two  to  four  weeks  is  required  in  the  ligation 
of  the  larger  arteries. 

Local  Results  of  Ligation. — Obliteration  of  artery  at  site  of  ligation. 
Establishment  of  a  new  (collateral)  circulation. 

Chief  Dangers  in  Ligation  of  Arteries. — Secondary  hemorrhage. 
Gangrene. 

Comment. — (1)  Where  it  is  difficult  or  impossible  to  separate  one  or 
more  veins  from  the  artery,  the  artery  and  vein,  or  veins,  may  be  included 
in  the  one  ligature.  (2)  Especial  care  should  be  taken  to  avoid  the  inclusion 
of  the  smallest  nerve  in  the  ligature.  (3)  When  a  large  vein  is  wounded, 
the  wound  should  be  at  once  closed  by  lateral  ligature  (Fig.  99),  or  by  sutur- 
ing (Fig.  98),  preferably  the  former.  If  this  be  not  feasible,  the  vein  should 
be  ligated.  All  medium  and  small  veins  should  be  ligated  if  wounded.  If 
the  ligation  of  the  artery  can  be  accomplished  without  the  likelihood  of 


LIGATION    OF    INNOMINATE    ARTERY. 


27 


again  wounding  the  vein,  it  should  be  completed  at  the  original  site.  If 
there  be  danger  of  further  complication,  a  new  site  should  be  chosen  just 
above  or  below  the  one  originally  selected.  (4)  It  is  held  by  some  that 
secondary  hemorrhage  is  less  likely  if  an  artery  be  ligated  in  two  places, 
from  2.5  to  5  cm.  (1  to  2  inches)  apart,  and  then  divided  between  these  two 
ligatures,  allowing  each  end  to  retract — upon  the  principle  that  the  arteries 
of  the  body  are  constantly  under  longitudinal  tension,  and,  when  ligated  in 
continuity  (especially  where  the  inner  coats  are  severed),  there  are  present 
the  conditions  calculated  to  predispose  to  secondary  hemorrhage.  Practical 
experience  seems  to  have  borne  out  the  claim  of  the  double  ligature  with 
division,  but  the  operation  is  not  always  feasible,  especially  in  the  deeper, 
larger  vessels.  (5)  All  ligature  material  should  be  thoroughly  pliable  before 
being  used. 

SURGICAL  ANATOMY  OF  INNOMINATE  ARTERY. 

Description. — Largest  branch  of  arch  of  aorta.  From  3.8  to  5  cm. 
(lh  to  2  inches)  in  length.  Arises  from  beginning  of  arch  of  aorta,  opposite 
fourth  dorsal  vertebra;  runs  upward,  forward,  and  to  right,  to  upper  border 
of  right  sternoclavicular  articulation,  where  it  divides  into  right  common 
carotid  and  right  subclavian. 

Relations. — Anteriorly:  manubrium;  origin  sternohyoid;  origin  sterno- 
thyroid; right  sternoclavicular  joint;  remains  of  thymus  gland;  left  innominate 
vein;  right  inferior  thyroid  vein;  inferior  cervical  cardiac  branches  of  right 
pneumogastric.  Posteriorly:  trachea;  right  pleura.  To  right:  right  in- 
nominate vein;  right  pneumogastric  nerve;  right  pleura.  To  left :  left  common 
carotid;  remains  of  thymus  gland;  left  inferior  thyroid  vein;  trachea. 

Branches. — Thyroidea  ima  (sometimes) ;  thymic  branch  (sometimes) ; 
bronchial  branch  (sometimes). 

Line  of  Artery. — From  center  of  manubrium,  to  center  of  right  sterno- 
clavicular joint. 

Indications  for  Ligation. — Aneurism  of  right  carotid,  subclavian,  and 
of  innominate  itself. 

Sites  of  Ligation. — From  1.3  to  2  cm.  (h  to  f  inch)  below  bifurcation 
(Fig.  10,  A,  B,  C,  D,  E). 

Comparison  of  Methods  of  Exposure  of  the  Innominate. — Choice 
would  be  given  to.  methods  of  non-division  of  muscles,  with  retraction — 
the  oblique  incision  thus  being  preferable  to  the  angular  one — where  these 
incisions  promise  sufficient  room  for  manipulation.  Where  more  room  is 
necessary,  especially  from  abnormal  displacement  of  the  parts  (as  from 
aneurism),  the  angular  incision,  or  the  methods  of  partial  resection,  give  more 
space  for  the  safe  carrying-out  of  the  necessary  steps;  and  of  these  latter, 
the  method  of  partial  resection  upon  the  right  aspect  of  the  manubrio-clavicular 
region  is  applicable  to  cases  where  a  more  limited  sacrifice  of  bone  will  suffice; 
and  Bardenheuer's  operation — or  the  splitting  of  the  manubrium — where  the 
maximum  space  is  required.  The  innominate  has  also  been  ligated  through 
a  trephine-opening  made  through  the  manubrium  sterni,  after  turning  back 
a  flap  of  soft  parts. 

LIGATION  OF  INNOMINATE  ARTERY 

BY  ANGULAR  INCISION  (MOTT'S  OPERATION  i. 

Position. — Patient  supine,  chest  raised,  head  backward  and  to  opposite 
side.     Surgeon  to  outer  side  of  shoulder.     Assistant  opposite  surgeon. 
Landmarks. — Clavicle;   sternomastoid  muscle;  sternoclavicular  joint. 


28 


OPERATIONS    UPON    THE    ARTERIES. 


Incision. — A-shaped  (on  right).  Horizontal  portion  of  incision  is 
made  along  upper  margin  of  inner  third  of  clavicle,  for  a  distance  of  about 
7.5  cm.  (3  inches).  Oblique  portion  (meeting  horizontal  at  an  acute  angle) 
is  made  along  anterior  margin  of  sternomastoid,  for  about  7.5  cm.  (3  inches) 
(Fig.  10,  A). 


Fig.  10. — Incisions  for  Ligation  of  Chief  Arteries  of  Head  and  Neck  :— A,  A,  Innom- 
inate, by  angular  incision;  B,  B,  Same,  by  oblique  incision;  C,  C,  Same,  by  partial  bony  resection, 
through  an  oblique  incision;  D,  O,  Same,  by  partial  buns  resection  ( Bardenheuer's  operation);  E, 
Same,  by  splitting  manubrium;  F,  Common  carotid,  above  omohyoid;  G,  Same,  below  omohyoid; 
H,  External  carotid,  below  digastric  ;  I,  Same,  above  digastric  ;  J,  Thyroid,  at  origin  ;  K.  Lingual,  at 
origin;  L,  Lingual,  beneath  hyoglossus  ;  M,  Facial,  over  inferior  maxilla;  N,  Occipital,  behind  mas- 
toid process;  O,  Temporal,  just  above  zygoma  ;  P,  Trunk  of  middle  meningeal,  by  trephine-opening 
exposed  by  curved  oblique  incision  (lower  of  two  trephine-openings);  Q,  Anterior  branch  of  middle 
meningeal,  by  trephine-opening  exposed  by  horseshoe  incision  (higher  of  two  trephine-openings  |;  R, 
Posterior  branch  of  middle  meningeal,  by  trephine-opening  exposed  by  horseshoe  incision;  S,  Internal 
carotid,  near  origin  ;  T,  Third  part  of  subclavian  ;  U,  Transversalis  colli  and  suprascapular,  at  outer 
margin  of  sternomastoid  ;  V,  Internal  mammary,  in  second  intercostal  space  ;  W,  First  part  of  axil- 
lary, by  curved  transverse  incision  below  clavicle. 


LIGATION    OF    INNOMINATE   ARTERY.  2g 

Operation. — -Having  incised  skin  and  superficial  fascia,  this  triangular 
flap  is  dissected  upward.  Cut  the  sternal  and  clavicular  attachments  of 
the  sternomastoid,  as  far  as  exposed.  The  sternohyoid  and  sternothvroid 
muscles  are  also  cut,  or  are  nicked  and  drawn  well  inward.  Expose,  ligate 
doubly,  and  cut  the  anterior  jugular  vein  between  its  two  ligatures,  lying 
beneath  the  sternomastoid;  and  also  the  right  inferior  thyroid  vein.  Divide 
the  deep  cervical  fascia  along  the  original  lines  of  incision,  thus  exposing 
the  common  carotid.  Open  its  sheath  and  follow  to  its  origin,  avoiding 
the  recurrent  laryngeal  nerve.  Thus  guided  to  the  innominate,  clear  its 
trunk — with  especial  care  on  the  outer  side,  of  the  pneumogastric  nerve, 
right  innominate  vein,  and  pleura — and  pass  the  needle  from  these  structures. 


Fig.  ii. — Ligation  of  the  Innominate  Artery  by  an  Angular  Incision;  Also  of  the 
Right  Common  Carotid  below  the  Omohyoid,  and  of  the  Vertebral  Near  its  Origin':  — 
A,  A,  Platysma;  B,  B,  B,  B,  Sternomastoid;  C,  C,  Sternohyoid;  D,  D,  Sternothyroid;  E,  Innomin- 
ate artery  bifurcating  into  subclavian  and  common  carotid;  F,  Internal  jugular  vein;  G,  Pneumo- 
gastric nerve;  H,  Vertebral  artery;  I,  Trachea;  J,  Thyroid  gland;  K,  Right  sternoclavicular 
articulation. 


Comment. — (I)  As  the  chief  source  of  failure  is  secondary  hemorrhage, 
the  common  carotid  and  vertebral  arteries  are  also  tied — being  the  chief 
sources  through  which  the  recurrent  flow  occurs.  (2)  This  free  section  of 
muscles  leaves,  by  their  retraction,  a  deep  gap  at  the  root  of  the  neck  for 
infection  and  slow  filling-up.  As  much  repairing  of  cut  muscle  tissue  as 
possible,  by  suturing,  should,  therefore,  be  done  in  completing  the  operation. 
(3)  Artificial  illumination  is  desirable  in  this  operation. 

Collateral  Circulation. — First  aortic  intercostal,  with  superior  inter- 
costal of  subclavian.  Upper  aortic  intercostals,  with  thoracic  branches  of 
axillary  and  intercostals  of  internal  mammary.  Phrenic,  with  musculo- 
phrenic of  internal  mammary.  Deep  epigastric,  with  superior  epigastric 
of  internal  mammary.  Free  communication  of  vertebrals  and  interna] 
carotids  of  opposite  side,  inside  of  skull.  Communication  of  branches  of 
opposite  external  carotids  in  middle  line  of  face  and  neck.  (MacCormac). 


3° 


OPERATIONS   UPON   THE   ARTERIES 


LIGATION  OF  INNOMINATE  ARTERY 

BY   OBLIQUE    INCISION. 

Position — Landmarks. — As  for  Mott's  operation  (page  27). 

Incision. — Begin  at  junction  of  middle  and  lower  thirds  of  anterior 
border  of  right  sternomastoid  muscle — pass  down  along  the  lower  third  of 
its  anterior  margin — thence  sweep  over  upper  edge  of  the  episternal  notch 
onto  the  manubrium  sterni  (Fig.  10,  B,  B). 

Operation. — Incise  skin,  superficial  fascia,  platysma,  and  deep  fascia 
(Fig.  12).     Tie  anterior  jugular  vein  between  two  ligatures — also  ligate  the 


N     0 


Fig.  12. — Ligation  of  Innominate  by  Oblique  Incision;  Also  of  Right  Common 
Carotid  below  Omohyoid;  Vertebral  Near  Origin;  and  Inferior  Thyroid  Near  Origin: 
— A,  Platysma;  B,  Sternomastoid  retracted  outward  and  downward;  C,  Right  sternoclavicular 
articulation;  E,  Manubrium  sterni;  F,  Omohyoid;  G,  Sternohyoid;  H,  Sternothyroid;  I,  Thyroid 
gland;  J,  Innominate  artery  dividing  into  common  carotid  and  subclavian;  L,  Inferior  thyroid; 
M,  Vertebral;  N,  Right  innominate  vein,  with  subclavian  and  internal  jugular;  O,  Pneumo- 
gastric;  P,  Recurrent  laryngeal;  R,  Nerves  from  loop  between  communicans  and  descendens 
hypoglossi;  S,  Superficial  cervical  nerves. 

transverse  branch  between  the  two  anterior  jugulars,  if  in  the  way.  Draw 
the  sternomastoid  outward — and,  if  necessary,  its  inner,  sternal  portion  may 
be  divided.  Draw  inward  the  sternohyoid  and  sternothyroid  muscles — and, 
if  necessary,  their  sternal  attachments  may  be  partly  or  entirely  cut.  Incise 
the  deep  cervical  fascia  over  the  carotid  sheath.  Open  the  sheath  and  follow 
the  common  carotid  behind  the  sternoclavicular  articulation  to  the  subclavian 
and  to  the  innominate,  guarding  the  recurrent  laryngeal  nerve  behind  the 
common  carotid  sheath.     Ligate  the  right  inferior  thyroid  vein.     Clear  the 


LIGATION    OF    INNOMINATE    ARTERY. 


31 


innominate,  avoiding  the  left  innominate  vein  in  front — the  right  pleura 
behind — and  the  right  pneumogastric  nerve,  right  innominate  vein,  and  right 
pleura  to  the  right. 

Comment. — (i)  As  above  mentioned,  under  Mott's  operation,  the 
common  carotid  and  vertebral  arteries  should  also  be  tied — which  can  be 
done  through  this  incision  (2)  By  this  separation  and  retraction  of  muscles 
(or  partial  division)  less  damage  is  done  to  the  parts  and  less  of  a  cavity 
is  left. 


LIGATION  OF  INNOMINATE  ARTERY 

BY  PARTIAL  BONY   RESECTION— THROUGH    TRANSVERSE    AND   VERTICAL 
INCISIONS— (BARDENHEUER'S  OPERATION  |. 

Description. — The  following  parts  are  excised  through  a  combined 
transverse  and  vertical  incision: — the  right  and  left  sternoclavicular  articula- 
tions, sternal  ends  of  right  and  left  first  ribs,  sternal  end  of  right  second  rib, 
and  upper  2.5  cm.  (1  inch)  of  manubrium — thus  exposing  the  innominate. 

Position. — As  in  Mott's  operation  (page  27). 

Landmarks. — Suprasternal  notch  and  manubrium;  sternal  ends  of 
clavicles;  inferior  margin  of  thyroid  cartilage. 

Incisions. — (1)  Transverse  incision — along  upper  border  of  sternum  and 
over  the  surfaces  of  the  inner  thirds  of  both  clavicles.  (2)  Vertical  incision 
— from  lower  border  of  larynx,  down  the  median  line,  and  well  onto  the 
manubrium  sterni  (Fig.  10,  D,  D). 

Operation. — Carry  both  incisions  through  skin,  superficial  and  deep 
fasciae.  In  the  transverse  incision,  divide  sternomastoids,  sternohyoids, 
and  sternothyroids.  Subperiosteally  resect  (with  Gigli  saw,  rongeur,  bone- 
cutting  forceps,  or  chisel)  the  inner  extremities  of  the  left  clavicle  and  left 
first  rib — for  about  1.3  cm.  (^  inch)  of  their  extent.  Having  made  this 
exposure  of  the  upper  and  outer  portion  of  the  manubrium  upon  its  left 
aspect,  free,  through  this  approach,  the  posterior  surface  of  the  manubrium 
subperiosteally.  The  manubrium  is  then  cut  transversely  through  at  a  level 
about  2.5  cm.  (1  inch)  below  its  upper  border — the  division  being  accom- 
plished, preferably,  by  a  Gigli  saw  conducted  beneath  the  bone,  between  it 
and  the  periosteum.  The  sternal  ends  of  the  right  clavicle  and  the  right 
first  and  second  ribs,  after  having  been  well  cleared,  are  divided  close  to  the 
outer  margin  of  the  sternum,  in  the  same  manner  as  the  manubrium  was 
divided.  The  mass  of  bone  detached  by  the  above  cuts  is  now  removed. 
The  periosteum  is  then  incised  in  the  median  line — the  inferior  thyroid 
veins  ligated — the  left  innominate  vein  depressed — the  right  innominate  vein 
retracted — the  right  pneumogastric  nerve  and  pleura  guarded  on  the  outer 
side  and  behind — the  innominate  artery  cleared — and  the  ligature  passed 
from  the  pleura  and  pneumogastric. 


LIGATION  OF  INNOMINATE  ARTERY 

BY  SPLITTING  OF   MANUBRIUM   STERNI. 

Description. — The  manubrium  is  exposed  by  a  transverse  incision — 
divided  transversely  at  its  junction  with  the  gladiolus — then  split  vertically 
at  its  center — followed  by  the  separation  of  the  two  halves  of  the  manubrium 


32  OPERATIONS    UPON    THE    ARTERIES. 

and  the  exposure  of  the  innominate.  Upon  completing  the  operation,  the 
bony  parts  are  returned  to  their  normal  positions — with  or  without  suturing 
of  the  edges  of  the  vertically  divided  manubrium  into  apposition. 

Position. — Patient  supine;  shoulders  raised;  neck  prominent.  Surgeon 
to  right  side.     Assistant  opposite. 

Landmarks. — Sternoclavicular  articulations;  lower  border  of  manubrium 
(marked  by  line  extending  transversely  across  between  the  articulations  of 
the  second  ribs). 

Incision. — Curved  transverse  incision — passing  from  inner  third  of 
anterior  surface  of  one  clavicle  to  the  inner  third  of  the  anterior  surface  of 
the  opposite  clavicle,  and  passing  down  over  the  manubrium  to  the  junction 
of  its  upper  and  middle  thirds  (Fig.  10,  E). 

Operation. — Having  incised  skin,  fascia,  and  anterior  borders  of  the 
platysma  down  to  the  bone,  clamp  and  tie  all  bleeding  vessels.  Free  the 
manubrium  subperiosteally  over  its  anterior  surface,  downward  to  the  junc- 
tion of  the  manubrium  and  gladiolus,  and  upward  to  its  superior  border. 
Follow  the  superior  border  backward  and  downward  along  its  posterior 
aspect — also  freeing  this  surface  subperiosteally  as  far  as  the  junction  of  manu- 
brium and  gladiolus.  Retract  the  overlying  soft  parts  on  the  anterior  aspect 
of  the  manubrium  and  divide  the  sternum  along  the  manubrio-gladiolar 
junction — accomplishing  the  division  with  a  Gigli  saw,  if  one  can  be  conducted 
across  beneath  the  bone,  or  by  bone-cutting  forceps.  Through  the  opening 
thus  made  by  the  transverse  division,  carry  a  Gigli  saw  from  the  center  of 
the  lower  border  of  the  divided  manubrium  to  the  center  of  the  suprasternal 
notch — and  divide  the  manubrium  vertically  in  its  center,  cutting  from  the 
manubrio-gladiolar  junction  upward  toward  the  free  superior  border — the 
Gigli  saw  traveling  between  the  posterior  surface  of  the  manubrium  in  front, 
and  its  periosteum  posteriorly.  After  the  completion  of  the  vertical  section, 
retract  the  two  halves  of  the  manubrium  laterally — incise  the  posterior  perios- 
teum— ligate  the  inferior  thyroid  veins — depress  the  left  innominate  vein, 
retract  the  right  innominate  vein — guard  the  right  pneumogastric  and  pleura 
externally  and  posteriorly — clear  the  innominate — and  pass  the  ligature  from 
the  pleura  and  pneumogastric. 

Comment. — Where  it  is  wished  to  suture  together  the  vertical  borders 
of  the  split  manubrium,  two  or  three  holes  should  be  drilled  on  each  side 
as  soon  as  the  manubrium  has  been  exposed  anteriorly  and  posteriorly,  and 
before  its  division — the  soft  parts  below  being  protected  by  some  thin,  flat 
metallic  instrument  during  the  drilling. 


SURGICAL  ANATOMY  OF  COMMON  CAROTID  ARTERIES. 

Description.— (a)  Right  Common  Carotid  :  About  9.5  cm.  (3I  inches) 
in  length.  Arises  from  bifurcation  of  innominate,  behind  right  sternoclavicular 
articulation — passes  upward  and  outward  and  slightly  backward  to  upper 
border  of  thyroid  cartilage  (opposite  fourth  cervical  vertebra,  according  to 
Morris; — third  cervical  vertebra,  according  to  Gray) — there  dividing  into  ex- 
ternal and  internal  carotids.  In  its  course  it  is  contained  within  a  common 
sheath  of  connective  tissue,  which  also  includes  internal  jugular  vein  and 
pneumogastric  nerve,  each  separated  by  a  fibrous  septum — the  vein  lying  to 
outer  side  and  slightly  overlapping  artery,  and  the  pneumogastric  lying 
between  and  posterior   to   both.     The   omohyoid  muscle   crosses   common 


SURGICAL    ANATOMY    OF    COMMON    CAROTID    ARTERIES.  3$ 

carotid  opposite  lower  border  of  cricoid  cartilage,  and  divides  the  artery, 
surgically,  into  a  lower  part,  deeply  placed^and  an  upper  part,  superfici- 
ally placed,  (b)  Left  Common  Carotid:  About  n. 5  cm.  (4^  inches)  in 
length.  Arises  from  middle  of  transverse  portion  of  arch  of  aorta — ascends 
upward  and  outward  behind,  but  at  some  distance  from,  manubrium  sterni, 
overlapped  by  left  lung  and  pleura,  and  in  front  of  trachea,  to  left  sterno- 
clavicular articulation — whence  its  course,  relations,  and  terminations  are 
same  as  for  right  common  carotid.  The  crossing  and  relations  of  the  omo- 
hyoid muscle  are  also  similar. 

Relations. — (a)  Left  Common  Carotid  in  Thorax :  Anteriorly — 
manubrium  sterni;  origin  sternohyoid;  origin  sternothyroid  (above  three 
structures  being  at  some  distance);  remains  of  thymus;  fatty  areolar  tissue 
of  superior  mediastinum;  left  innominate  vein.  Posteriorly  (from  below 
upward) — trachea;  esophagus;  thoracic  duct;  recurrent  laryngeal  nerve. 
External  (to  left) — left  pleura  and  lung  (slightly  overlapping);  left  pneumo- 
gastric;  left  subclavian  (both  of  latter  being  somewhat  posterior).  Internally 
(to  right) — innominate  artery;  trachea;  remains  of  thymus  gland;  left 
inferior  thyroid  vein,  (b)  Both  Common  Carotids  in  Neck:  Anteriorly 
— skin;  superficial  fascia;  platysma;  deep  fascia;  sternomastoid;  sternohyoid; 
sternothyroid;  omohyoid;  anterior  jugular  vein;  thyroid  body  (often  overlaps); 
middle  thyroid  vein;  superior  thyroid  vein;  lingual  vein;  facial  vein;  middle 
sternomastoid  artery;  descendens  hypoglossi  nerve  (generally  upon,  some- 
times within,  sheath);  communicantes  hypoglossi;  lymphatic  glands.  Poste- 
riorly— pneumogastric  nerve;  sympathetic  nerve;  cervical  cardiac  branches 
of  sympathetic  and  pneumogastric  nerves;  recurrent  laryngeal  nerve;  inferior 
thyroid  artery;  longus  colli;  rectus  capitis  anticus  major.  Externally — 
internal  jugular  vein;  pneumogastric  nerve.  (On  right  side  a  space  is  left 
at  root  of  neck  by  divergence  of  vein,  in  which  pneumogastric  nerve  and 
vertebral  artery  are  found;  on  left  side  the  internal  jugular  vein  overlaps 
this  space).  Internally  (from  below  upward) — trachea;  esophagus;  re- 
current laryngeal  nerve;  branches  of  inferior  thyroid  artery;  lateral  lobe  of 
thyroid  body;  cricoid  cartilage;  thyroid  cartilage;  lower  part  of  pharynx; 
carotid  glands. 

Branches. — None,  ordinarily. 

Line. — (With  head  turned  moderately  to  opposite  side  and  upward) — 
from  sternoclavicular  articulation  to  a  point  midway  between  angle  of  jaw 
and  tip  of  mastoid  process — that  portion  of  this  line  between  the  sterno- 
clavicular articulation  and  the  level  of  the  upper  border  of  the  thyroid  cartilage 
representing  the  common  carotid.  From  the  clavicle  a  little  external  to  the 
sternoclavicular  articulation  would  more  accurately  represent  the  line.  The 
anterior  margin  of  the  sternomastoid  muscle  overlaps  the  carotid  throughout. 
The  omohyoid  muscle  crosses  the  carotid  opposite  and  directly  over  Chas- 
saignac's  "carotid  tubercle"  (costal  process  of  sixth  cervical  vertebra) — 
which  is  about  6.3  cm.  (2^  inches)  above  the  clavicle. 

Indications  for  Ligation. — Wounds  of  itself  and  branches  of  external 
and  internal  carotid;  distal  and  proximal  aneurism;  distal  angiomata;  as  a 
temporary  ligature;  to  limit  growth  of  inoperable  tumors;  hemorrhage  from 
areas  supplied  by  distal  branches. 

Sites    of   Ligation. — Above   the   omohyoid    muscle — place   of   election. 
Below   the  omohyoid — depth   of  artery  and  nature  of  relations  make  the 
operation  more  difficult  and  more  fatal  (Fig.  10,  F  and  G). 
3 


34 


OPERATIONS    UPON    THE    ARTERIES. 


Fig.  13. — Ligation  of  Right  Common  Carotid  above  Omohyoid: — A,  A  Platysma  ;  B,  Ster- 
nomastoid (retracted  outward  I  ;  C,  Omohyoid  1  retracted  downward  I  ;  D,  Sternothyroid;  E,  Common 
carotid  (its  sheath  incised  above  omohyoid);  F,  Sternomastoid  artery;  G,  Internal  jugular  vein; 
H,  Superior  thyroid  vein;  I,  Inferior  thyroid  vein;  J,  Communicating  vein  between  anterior  and 
external  jugular  ;  K,  One  of  transversalis  colli  nerves ;  L,  Nerves  from  loop  between  descendens  and 
communicans  hypoglossi. 


LIGATION  OF  COMMON  CAROTID  ARTERY 

ABOVE    THE    OMOHYOID    MUSCLE. 

Position.— Patient  supine;  shoulders  elevated;  neck  prominent;  chin 
upward  and  to  opposite  side.  Surgeon  on  side  of  operation,  or  on  the  right 
for  both  sides. 

Landmarks. — Line  of  artery;  anterior  border  of  sternomastoid;  cricoid 
cartilage. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  with  center  at  level  of 
cricoid  cartilage — the   incision  lying  in  the  line  of  the  artery  (Fig.  10,  F). 

Operation. — Incise  skin,  superficial  fascia,  and  platysma.  Superficial 
veins  connecting  anterior  and  external  jugulars,  and  sometimes  intercom- 
municating veins  between  facial  and  anterior  jugular,  as  well  as  cutaneous 
nerves,  are  encountered  (Fig.  13).  Divide  the  deep  fascia  along  the  anterior 
border  of  the  sternomastoid  and  open  up  the  cellular  tissue.  The  upper 
border  of  the  omohyoid  is  here  exposed,  either  by  direct  incision  or  by  follow- 
ing up  the  anterior  border  of  the  sternomastoid.  Having  identified  the 
intersection  of  sternomastoid  and  omohyoid,  the  omohyoid  is  retracted 
downward  (or  may  be  divided  if  in  the  way) — and  the  sternomastoid  outward. 
Flexing  the  chin  aids  during  these  manipulations,  by  relaxing  the  parts. 
The  common  carotid  is  now  located  as  it  crosses  the  "carotid  tubercle"  (see 
Anatomy,  "Line,"  page  33).  Clear  its  sheath,  avoiding  or  tying  the 
sternomastoid  artery  and  the  superior  and  middle  thyroid  veins.  Carefully 
incise  the  sheath,  approaching  from  the  inner  side,  to  avoid  the  descendens 


LIGATION    OF    COMMON    CAROTID    ARTERY. 


35 


hypoglossi  nerve  (generally  on  the  antero-external  side  of  the  sheath)  and 
the  internal  jugular  vein,  and  see  that  artery  is  freed  from  its  sheath  in  its 
entire  circumference.  Pass  the  needle  from  the  internal  jugular  and  pneu- 
mogastric  nerve. 

Collateral  Circulation. — Inferior  thyroid,  with  superior  thyroid.  Deep 
cervical,  with  occipital.  Transversalis  colli,  with  occipital.  Branches  of 
two  vertebrals,  with  branches  of  two  external  carotids.     Circle  of  Willis. 


LIGATION  OF  COMMON  CAROTID  ARTERY 

BELOW   THE   OMOHVOID    MUSCLE. 

Position — Landmarks. — As  in  the  ligation  above  the  omohyoid. 

Incision. —About  7.5  cm.  (3  inches)  in  length,  in  line  of  artery — from 
just  below  cricoid  cartilage  to  just  above  sternoclavicular  articulation 
(Fig.  10,  G). 


Fig.  14. — Cross-section  of  the  Neck  at  the  Level  of  the  Seventh  Cervical  Ver- 
tebra:— A,  A,  Scaleni  muscles;  B,  B,  Sternocleidomastoid  muscles;  C,  C,  Sternohyoid  and 
sternothyroid  muscles;  D,  D,  Common  carotid  arteries  and  internal  jugular  veins;  E,  E,  Vertebral 
arteries  and  veins;  F,  F,  Inferior  thyroid  arteries  and  veins.     (Modified  from  Braune.) 

Operation. — Incise  skin,  superficial  fascia,  and  platysma.  Here  are 
encountered  the  superficial  veins  between  the  facial,  anterior  and  external 
jugular  veins,  and  the  cutaneous  cervical  nerves.  Divide  the  deep  fascia 
along  the  anterior  border  of  the  sternomastoid.  Expose  the  inner  border 
of  this  muscle,  flexing  the  head  to  relax  the  parts.  The  sternohyoid  is  then 
exposed,  and  sometimes  the  underlying  sternothyroid.     The  omohyoid  is, 


36  OPERATIONS    UPON    THE    ARTERIES. 

ordinarily,  not  brought  into  the  field  of  operation.  These  muscles,  if  en- 
countered, are  retracted  in  their  respective  directions,  or  may  be  divided 
as  far  as  necessary.  Tie  the  inferior  thyroid  veins.  The  sheath  is  to  be 
exposed  as,  and  with  the  precautions,  mentioned  in  the  above  operation. 
The  recurrent  laryngeal  nerve  and  the  inferior  thyroid  artery  are  to  be  espe- 
cially guarded  in  operating  at  this  site. 

Comment. — The  ligation  of  the  common  carotid  is  more  difficult  on 
the  left  side,  owing  to  the  nearness  of  the  internal  jugular  vein  (see  Anatomy, 
"Relations,"  page  32),  and  the  operation  is  less  frequently  done  than  on 
the  right  side. 


SURGICAL  ANATOMY  OF  EXTERNAL  CAROTID  ARTERY. 

Description.— The  smaller  of  the  two  divisions  of  the  common  carotid. 
About  6.3  cm.  {t.\  inches)  in  length.  Begins  opposite  upper  border  of  thyroid 
cartilage;  passes  upward,  forward,  and  then  backward,  under  the  stylohyoid 
and  posterior  belly  of  the  digastric,  to  the  interval  between  neck  of  condyle 
of  inferior  maxilla  and  the  external  auditory  meatus,  where  it  divides,  in 
the  substance  of  the  parotid  gland,  into  the  internal  maxillary  and  temporal 
arteries. 

Relations. — Anteriorly:  skin;  superficial  fascia;  platysma;  deep  fascia; 
anterior  border  of  sternomastoid;  hypoglossal  nerve;  lingual  vein,  facial  vein; 
posterior  belly  of  digastric;  stylohyoid;  temporomaxillary  vein;  superior 
cervical  lymphatic  glands;  branches  of  facial  nerve;  parotid  gland.  Poste- 
riorly: internal  carotid  artery;  styloglossus;  stylopharyngeus;  glossopharyn- 
geal nerve;  pharyngeal  branch  of  pneumogastric;  stylohyoid  ligament;  parotid 
gland;  superior  laryngeal  nerve.  Externally:  internal  carotid  artery.  In- 
ternally: hyoid  bone;  pharynx;  ramus  of  inferior  maxilla;  stylomaxillary 
ligament;  submaxillary  gland;  parotid  gland. 

Branches  (from  below). — Ascending  pharyngeal;  superior  thyroid; 
lingual;  facial;  occipital;  posterior  auricular;  temporal;  internal  maxillary. 

Line. — Upper  part  of  line  of  common  carotid  artery  (page  33). 

Indications  for  Ligation. — Wounds  and  aneurism  of  trunk  and  branches; 
hemorrhage  from  areas  of  branches;  palliative  in  malignant  growths;  pre- 
liminary to  operations;  aneurism  by  anastomosis  in  the  regions  of  the 
trunks. 

Sites  of  Ligation. — Below  the  digastric  (between  the  superior  thyroid 
and  lingual  branches) — place  of  election — the  operation  is  easier  and  more 
branches  are  thus  controlled.  Above  the  digastric — the  operation  is  more 
difficult  and  more  apt  to  involve  branches  of  the  facial  nerve.  Note: — The 
digastric  muscle  crosses  the  artery  about  3.2  cm.  (\\  inches)  above  its  origin, 
opposite  the  upper  border  of  the  thyroid  cartilage.  The  lingual  arises  oppo- 
site the  great  cornu  of  the  hyoid  bone.     (Fig.  10,  H  and  I.) 

Comment. — (1)  The  external  carotid  may  be  distinguished  from  the  in- 
ternal carotid  by  the  presence  of  its  branches  and  by  being  to  the  inner  side 
of  the  external  carotid.  (2)  The  ligation  of  the  external  carotid  is  now 
generally  done  where  formerly  the  common  carotid  was  ligated  for 
conditions  of  the  former  vessel  and  its  branches — the  practicability  and 
desirability  of  the  operation  having  been  demonstrated  by  the  work  of 
Wyeth. 


LIGATION    OF    EXTERNAL    CAROTID    ARTERY.  37 

LIGATION  OF  EXTERNAL  CAROTID  ARTERY 

BELOW   THE    DIGASTRIC   MUSCLE. 

Position. — As  for  the  common  carotid  (page  34). 

Landmarks. — Sternomastoid;  thyroid  cartilage;  angle  of  jaw. 

Incision. — About  7.5  cm.  (3  inches) — along  the  anterior  border  of  the 
sternomastoid,  or  slightly  in  front  of  border — from  level  of  middle  of  thyroid 
cartilage,  to  near  angle  of  jaw  (Fig.  10,  H). 

Operation. — Incise  skin,  superficial  fascia,  and  platysma  (Fig.  15).  Tie 
any  veins  which  may  lie  in  the  line  of  incision.  Divide  the  deep  fascia  and 
expose  the  anterior  border  of  the  sternomastoid  and  draw  it  outward.     Find 


Fig.  15.— Ligation  of  Right  External  Carotid  below  Digastric  ;  and  also  of  Internal 
Carotid,  Superior  Thyroid,  Lingual,  Facial  and  Occipital,  near  Origin:— A,  Superficial 
fascia;  B,  B,  Platysma  ;  C,  Cervical  fascia  ;  D,  Sternomastoid  (retracted  outward);  E,  Posterior  belly 
of  digastric;  F,  Hyoglossus,  with  lingual  artery  disappearing  beneath  it;  G,  Thyrohyoid  M. ;  H, 
Middle  constrictor  M. ;  I,  Inferior  constrictor  M.  ;  J,  Tip  of  great  cornu  of  hyoid  bone  ;  K  External 
carotid  A.;  L,  Internal  carotid;  M,  Superior  thyroid;  X,  Facial;  O,  Occipital;  P.  Internal  jugular 
V.  ;  Q,  Lingual  and  facial  veins  emptying  into  internal  jugular;  R.  Superior  thyroid  V.;  S,  Hypo- 
glossal N.  ;   T,  Descendens  noni  N. 

the  posterior  belly  of  the  digastric  at  the  upper  angle  of  the  wound.  Next, 
locate  the  hypoglossal  nerve  crossing  the  external  carotid  below  the  origin 
of  the  occipital  artery.  Locate  the  tip  of  the  great  cornu  of  the  hyoid  bone, 
opposite  which  the  lingual  artery  arises.  Having  fixed  the  location  of  these 
three  structures,  and  avoiding  the  superior  thyroid,  facial,  and  lingual  veins; 
expose  the  artery  opposite  the  tip  of  the  great  cornu  of  the  hyoid.  Clear 
the  sheath  and  pass  the  ligature  between  the  superior  thyroid  and  lingual 
branches — guarding  the  descendens  hypoglossi  nerve  in  front,  and  the  supe- 
rior laryngeal  nerve  passing  behind  the  artery — directing  the  needle  from 
the  internal  carotid. 


38  OPERATIONS    UPON    THE    ARTERIES. 

Comment. — (1)  The  operation  is  not  an  easy  one,  and  it  is  often  difficult 
to  recognize  the  branches.  (2)  Jacobson  advises  simultaneous  ligation  of 
the  superior  thyroid,  the  lingual,  and,  if  possible,  the  ascending  pharyngeal 
branches — on  account  of  secondary  hemorrhage.  (3)  Through  this  same 
incision  the  superior  thyroid,  lingual,  facial,  occipital,  and  ascending  pharyn- 
geal may  be  ligated. 

Collateral  Circulation. — Same  as  for  the  ligation  of  the  common  carotid 
above  the  omohyoid  (page  34). 


LIGATION  OF  EXTERNAL  CAROTID  ARTERY 

ABOVE   DIGASTRIC   MUSCLE   AND    BEHIND    RAMI'S   OF  JAW. 

Position. — As  for  the  common  carotid. 

Landmarks. — Line  of  artery;  ramus  of  inferior  maxilla. 

Incision. — From  tragus  of  ear,  to  below  angle  of  inferior  maxilla,  and 
placed  just  behind  the  ramus  of  the  jaw,  in  the  line  of  the  artery  (Fig.  10,  I). 

Operation. — Incise  skin  and  superficial  fascia.  Avoid,  or  doubly  ligate 
and  incise,  the  tributaries  of  the  external  jugular  and  facial  veins.  Divide 
the  deep  fascia.  Expose  the  anterior  border  of  the  sternomastoid  and  retract 
outward.  Expose  the  posterior  belly  of  the  digastric  and  stylohyoid  and 
draw  downward — partially  or  entirely  dividing  them  if  necessary.  Avoid 
the  branches  of  the  facial  nerve.  Expose  the  parotid  gland  and  draw  upward 
and  forward — thus  exposing  the  vessel.  Clear  the  artery  and  open  its  sheath 
— and  pass  the  ligature  around  the  artery  prior  to  its  entrance  into  the  sub- 
stance of  the  parotid  gland.  Repair,  by  suturing,  whatever  muscles  may 
have  been  incised. 


SURGICAL  ANATOMY  OF  LINGUAL  BRANCH  OF  EXTERNAL  CAROTID. 

Description. — The  third  in  order,  and  an  anterior  branch  of  the  external 
carotid.  Arises  opposite,  or  a  little  below,  the  great  cornu  of  the  hyoid  bone, 
about  2  cm.  (|  inch)  above  the  bifurcation  of  the  common  carotid,  (a)  First 
or  Oblique  Portion: — lies  in  superior  carotid  triangle,  extending  obliquely 
upward  to  the  external  border  of  the  hyoglossus, — being  covered  by  skin, 
superficial  fascia,  piatysma,  deep  fascia,  and  hypoglossal  nerve, — and  resting 
on  the  middle  constrictor  and  laryngeal  nerve,  (b)  Second  or  Horizontal 
Portion: — lies  in  the  digastric  triangle,  running  horizontally  beneath  the  hyo- 
glossus muscle,  along  the  superior  border  of  the  hyoid  bone, — being  covered 
by  the  hyoglossus  muscle  (which  separates  the  artery  from  the  hypoglossal 
nerve,  posterior  belly  of  the  digastric,  stylohyoid  muscle,  and  lingual  vein), 
— and  resting  upon  the  middle  constrictor  of  the  pharynx  and  geniohyo- 
glossus.  (c)  Third  or  Ascending  Portion: — ascends  between  the  hyoglossus 
and  geniohyoglossus  to  the  inferior  surface  of  the  tongue,  (d)  Fourth  or 
Terminal  Portion: — runs  forward  to  tip  of  tongue,  lying  between  the  lingualis 
and  geniohyoglossus,  and  covered  only  by  mucous  membrane.  Two  venae 
comites  accompany  the  lingual  artery  beneath  the  hyoglossus.  The  ranine 
vein  runs  on  the  superficial  surface  of  the  hyoglossus,  below  the  hypoglossal 
nerve.     Several  veins  follow  the  dorsalis  linguae  artery. 

Sites  of  Ligature. — Its  first  or  second  portions  are  the  parts  usually 
tied — and  of  these,  the  second  is  preferable  (Fig.  10,  K  and  L). 


LIGATION    OF    LINGUAL    BRANCH    OF    EXTERNAL    CAROTID. 


39 


LIGATION  OF  LINGUAL  BRANCH  OF  EXTERNAL  CAROTID 

NEAR   ITS   ORIGIN. 

Position — Landmarks. — As  for  ligation  of  external  carotid  below  the 
digastric  (page  35). 

Incision. — In  line  of  external  carotid,  with  its  center  opposite  the  body 
of  the  hyoid  bone  (Fig.  10,  K). 

Operation. — Same,  practically,  as  for  ligation  of  external  carotid  below 
the  digastric,  the  main  vessel  being  first  exposed  and  the  origin  of  the  lingual 
then  located. 

Comment. — The  first  part  of  the  lingual  may  also  be  tied,  though  less 
readily,  by  a  transverse  incision  extending  from  the  level  of  the  body  of  the 
hyoid  bone  to  the  anterior  border  of  the  sternomastoid,  the  artery  being 
exposed  and  tied  just  before  passing  under  the  hyoglossus  muscle. 

LIGATION  OF  LINGUAL  BRANCH  OF  EXTERNAL  CAROTID 

BENEATH   THE   HVOGLOSSUS. 

Position. — Patient  supine;  shoulders  raised;  neck  prominent;  head  to 
opposite  side  and  chin  upward.  Surgeon  on  side  of  operation,  cutting  from 
before  backward  on  the  right,  and  vice  versa. 


_      M 


E 

Fig.  16. — Ligation  of  Right  Lingual  Artery  beneath  Hyoglossus: — A,  A,  Platysma; 
B,  Transverse  cervical  fascia  over  submaxillary  gland;  C,  Deep  transverse  cervical  fascia  under 
submaxillary  gland;  D,  Submaxillary  gland;  E,  Hyoid  bone;  F,  Anterior  belly  of  digastric; 
G,  Posterior  belly  of  digastric;  H,  Stylohyoid;  I,  Mylohyoid;  J,  Hyoglossus;  K,  Omohyoid; 
L,  Thyrohyoid;  M,  Lingual  artery  see'n  through  incision  in  hyoglossus;  N,  Submental  A.;  O, 
Tributary  of  temporomaxillary  V.;  P,  Tributary  of  anterior  jugular  V.;  Q,  Ranine  V.  (below); 
R,  Transverse  cervical  nerve;'  S,  Superior  laryngeal  nerve  and  vessels;  T,  Hypoglossal  N. 


40  OPERATIONS    UPON    THE    ARTERIES. 

Landmarks. — Lower  border  of  inferior  maxilla;  facial  artery  crossing 
inferior  maxilla;  hyoid  bone. 

Incision. — Curved  incision — beginning  just  below  and  external  to  sym- 
physis menti — and  ending  just  below  and  internal  to  crossing  of  facial  artery 
over  inferior  maxilla — its  center  being  just  above  the  greater  cornu  of  the 
hyoid  bone  (Fig.  10,  L). 

Operation. — Incise  skin,  superficial  fascia,  platysma,  and  deep  fascia. 
Avoid  or  ligate  tributaries  of  facial,  anterior  jugular,  or  temporomaxillary 
veins.  Incise  the  transverse  cervical  fascia  over  the  submaxillary  gland — 
exposing  the  gland  and  retracting  it  upward,  out  of  its  bed,  over  the  margin 
of  the  lower  jaw  (Fig.  16).  Incise  transversely  the  deep  cervical  fascia 
exposed  by  lifting  out  the  submaxillary  gland — and  identify  the  mylohyoid 
muscle  in  the  anterior  aspect  of  the  wound.  Expose  the  two  bellies  of  the 
digastric  and  firmly  retract  them  downward  at  their  point  of  attachment  to 
the  hyoid  bone — which  steadies  the  parts  and  renders  the  hyoglossus  more 
prominent.  Clear  the  surface  of  the  hyoglossus  and  identify  the  hypoglossal 
nerve  crossing  its  anterior  aspect.  The  ranine  vein  crosses  the  same  surface 
just  below  and  parallel  with  the  nerve  and  at  about  the  same  level  as  the 
artery  lies  on  the  opposite  side  of  the  muscle.  Retract  both  hypoglossal 
nerve  and  ranine  vein  upward.  Divide  the  hyoglossus  transversely  for 
about  1.3  cm.  (|  inch)  just  above  and  parallel  with  the  hyoid  bone.  This 
incision  falls  just  over  the  artery,  which  generally  bulges  into  the  opening 
as  soon  as  it  is  made,  or  through  which  it  is  easily  reached.  Having 
isolated  the  artery,  trace  it  backward  until  the  dorsalis  linguae  branch 
is  reached,  so  that  the  ligature  may  be  placed  upon  its  proximal  side. 
Having  passed  the  ligature,  replace  the  submaxillary  gland  and  close  the 
wound. 

Comment. — The  fascia  of  the  submaxillary  gland  may  be  sutured  over 
it,  and  the  incision  in  the  hyoglossus  may  be  repaired  by  suturing,  if  either 
be  considered  indicated. 


SURGICAL  ANATOMY  OF  FACIAL  BRANCH  OF  EXTERNAL  CAROTID. 

Description. — The  fourth  in  order,  and  an  anterior  branch  of  the  ex- 
ternal carotid.  The  Cervical  Portion  passes  upward  and  forward  in  the 
posterior  part  of  submaxillary  triangle,  under  the  digastric,  stylohyoid, 
submaxillary  gland,  and  horizontal  ramus  of  inferior  maxilla.  The  Facial 
Portion  curves  over  lower  border  of  inferior  maxilla  at  the  anterior  border 
of  masseter  muscle — and,  running  forward  and  upward,  crosses  the  cheek 
to  the  angle  of  mouth — thence  upward  along  side  of  nose  to  end  at  internal 
canthus  of  eye. 

Relations. — Cervical  portion  rests  on  (from  below  upward)  stylo- 
glossus; mylohyoid;  submaxillary  gland  (in  or  under  it); — and  is  covered  by 
(from  below  upward)  posterior  belly  of  digastric;  stylohyoid;  hypoglossal 
nerve  (generally);  submaxillary  gland  (beneath  or  in  its  substance);  inferior 
maxilla;  lymphatic  glands;  fascia;  platysma;  skin.  Facial  portion  rests  on 
(from  below  upward)  inferior  maxilla;  buccinator;  levator  anguli  oris;  levator 
labii  superioris  (sometimes);  infraorbital  branches  of  fifth  nerve; — and  is 
covered  by  (from  below  upward)  risorius;  zygomatici  major  and  minor; 
supramaxillary  and  buccal  branches  of  facial  nerve;  levator  labii  superioris; 
levator  labii  superioris  alaeque  nasi;  infraorbital  branches  of  facial-  The 
cervical  portion  of  the  facial  vein  is  more  direct  than  the  artery,  and  separated 


LIGATION    OF    FACIAL    BRANCH    OF    EXTERNAL    CAROTID. 


41 


from  it  by  submaxillary  gland,  posterior  belly  of  digastric,  stylohyoid  muscle, 
and  hypoglossal  nerve.  The  facial  portion  of  the  facial  vein  is  also  more 
direct  than  the  facial  portion  of  the  facial  artery,  and  is  separated  from  its 
arterv  by  the  zygomatic]  major  and  minor. 

Sites  of  Ligation. — Near  origin  (less  frequently), — over  lower  jaw  (the 
usual  selection)  (Fig.  10,  M). 


LIGATION  OF  FACIAL  BRANCH  OF  EXTERNAL  CAROTID 

NEAR  ORIGIN. 

Position — Landmarks — Incision — Operation. — Practically  the  same  as 
for  ligation  of  the  external  carotid  below  the  digastric. 

LIGATION  OF  FACIAL  BRANCH  OF  EXTERNAL  CAROTID 

OVER   INFERIOR   MAXILLA. 

Position. — Patient  supine;  shoulders  raised;  head  thrown  back  and  to 
opposite  side.     Surgeon  on  side  of  operation,  or  on  right  for  both  sides. 

Landmarks. — Anterior  margin  of  masseter  muscle;  horizontal  portion 
of  inferior  maxilla. 


Fig.  17. — Ligation  of  Right  Facial  over  Border  of  Inferior  Maxilla: — A,  Cervical 
fascia;  B,  Platysma  ;  C,  Deep  cervical  fascia;  D,  Submaxillary  gland;  E,  Mylohyoid  muscle;  F. 
Inferior  maxilla  ;  G,  Masseter  M. ;  H,  Depressor  anguli  oris ;  I,  Facial  A.;  J,  Facial  V. ;  K,  Submen- 
tal A. ;  L,  Supramaxillai  y  N. 


Incision. — About  2.5  cm.  (1  inch)  in  length — placed  along  and  under 
cover  of  lower  border  of  lower  jaw,  with  its  center  over  the  course  of  the 
artery  (at  the  anterior  margin  of  the  masseter  muscle)  (Fig.  10,  M). 

Operation. — Incise  skin,  superficial  fascia,  platysma,  and  deep  fascia, 
when  the  artery  should  come  into  view — with  the  facial  vein  just  posterior 
to  it.     Avoid  branches  of  the  facial  nerve  (Fig.  17). 


42  OPERATIONS    UPON    THE    ARTERIES. 


SURGICAL  ANATOMY  OF  OCCIPITAL  BRANCH  OF  EXTERNAL 

CAROTID. 

Description. — The  fifth  in  order,  and  a  posterior  branch  of  the  external 
carotid — passing  upward  and  backward  to  the  interval  between  mastoid 
process  of  temporal  and  transverse  process  of  atlas — thence  horizontally 
backward  in  the  occipital  groove — thence  upward  onto  the  scalp. 

Relations. — First  Part  (internal  to  sternomastoid) — covered  by  skin, 
fascia,  posterior  belly  of  digastric;  parotid  gland;  temporomaxillary  vein; 
hypoglossal  nerve; — and  rests  on  internal  carotid  artery;  hypoglossal  nerve; 
pneumogastric  nerve;  internal  jugular  vein,  and  spinal  accessory  nerve. 
Second  Part  (beneath  sternomastoid) — covered  by  sternomastoid;  splenius 
capitis;  trachelomastoid;  origin  of  digastric; — and  rests  on  capitis  lateralis,  in 
occipital  groove  of  mastoid  process  of  temporal,  and  on  the  insertion  of 
superior  oblique  muscle.  Third  Part  (external  to  sternomastoid) — covered 
by  skin,  aponeurosis  uniting  occipital  attachments  of  sternomastoid  and 
trapezius — and  resting  upon  the  complexus.  It  perforates  this  aponeurosis 
just  mentioned,  or  the  posterior  belly  itself  of  the  occipitofrontalis,  together 
with  the  great  occipital  nerve — and  follows,  roughly,  the  line  of  the  lambdoid 
suture,  between  the  integument  and  the  cranial  aponeurosis.  Two  venae 
comites  accompany  the  occipital  artery. 

Sites  of  Ligation. — Near  its  origin — and  behind  the  mastoid  process 
of  the  temporal — according  to  site  of  lesion  requiring  ligature  (Fig.  10,  N). 


LIGATION  OF  OCCIPITAL  BRANCH  OF  EXTERNAL  CAROTID 

NEAR   ORIGIN. 

Position — Landmarks — Incision — Operation. — As  for  ligation  of  the 
external  carotid  below  the  digastric  (page  35). 


LIGATION  OF  OCCIPITAL  BRANCH  OF  EXTERNAL  CAROTID 

BEHIND    MASTOID  PROCESS. 

Position. — Patient  supine;  shoulders  and  head  elevated;  head  turned 
well  to  opposite  side  (or  patient  resting  slightly  to  one  side).  Surgeon  stands 
behind,  on  side  of  operation. 

Landmarks. — Mastoid  process;  external  occipital  protuberance. 

Incision. — About  5  cm.  (2  inches)  in  length — beginning  from  tip  of 
mastoid  process  and  extending  toward  the  external  occipital  protuberance 
(Fig.  10,  N). 

Operation. — Having  incised  skin  and  fascia,  divide  the  posterior  half 
of  the  sternomastoid  and  its  strong  aponeurosis — then  the  splenius  capitis — 
then  as  many  fibers  of  the  trachelomastoid  as  are  in  the  way  (Fig.  18).  Relax 
and  retract  the  muscles  by  turning  the  head  to  the  side  of  the  operation. 
Expose  the  artery  deep  down  between  the  mastoid  process  of  the  temporal 
and  the  transverse  process  of  the  atlas,  resting  upon  the  superior  oblique 
and  complexus  muscles.  Having  separated  from  it  the  accompanying  veins, 
and  having  guarded  the  veins  from  the  mastoid  foramen,  the  ligature  is 
passed.     The  lesser  occipital  nerve  runs  on  the  posterior  surface  of  the  sterno- 


LIGATION    OF    TEMPORAL    BRANCH    OF    EXTERNAL    CAROTID.         43 


Fig.  18. — Ligation  of  Left  Occipital  Artery  behind  Mastoid  Process: — \,  Posterior 
cervical  fascia;  B,  Trapezius  muscle;  C,  Sternomastoid;  D,  Splenius  capitis;  E,  Trachelomastoid; 
F,  Occipital  artery  and  vena  comites,  lying  upon  complexus  muscle;  G,  Great  occipital  nerve; 
H,  Lesser  occipital  nerve;  I,  Posterior  external  jugular  vein. 

mastoid,  near  its  posterior  border,  and  the  great  occipital  nerve  pierces  the 
trapezius  muscle  near  its  outer  border. 


SURGICAL  ANATOMY  OF  TEMPORAL  BRANCH  OF  EXTERNAL 

CAROTID. 

Description. — The  seventh  in  order  and  the  smaller  but  more  direct 
of  the  two  terminal  branches  of  the  external  carotid.  Arises  in  substance 
of  parotid  gland,  opposite  neck  of  inferior  maxilla — and  runs  upward,  beneath 
parotid  gland,  between  condyle  and  external  auditory  meatus — thence  upward, 
crossing  the  posterior  root  of  the  zygoma — and  continuing  upward  under  the 
attrahens  aurem  muscle  and  temporal  aponeurosis  for  3.8  cm.  to  5  cm.  (1^ 
to  2  inches),  where  it  divides  into  anterior  and  posterior  branches.  A  plexus 
of  sympathetic  nerves  surrounds  the  vessel — -it  is  crossed  by  the  temporofacial 
division  of  the  facial  nerve — and  is  accompanied  by  the  auriculotemporal 
nerve. 

Sites  of  Ligation. — The  main  trunk  may  be  ligated  just  above  root  of 
zygoma.  The  anterior  and  posterior  branches  may  be  ligated  at  their  bifurca- 
tion, about  3.8  to  5  cm.  (1^  to  2  inches)  above  the  zygoma . 


LIGATION  OF  TEMPORAL  BRANCH  OF  EXTERNAL  CAROTID 

JUST   ABOVE  ZYGOMA. 

Position. — Patient  supine;  shoulders  raised;  head  to  opposite  side. 
Surgeon  on  side  of  operation,  cutting  from  above  downward  on  right,  and 
vice  versa  (or  on  right  for  both  operations,  cutting  from  above  downward). 

Landmarks. — Tragus  of  ear;  condyle  of  jaw;  zygoma. 


44 


OPERATIONS    UPON    THE    ARTERIES. 


Incision. — Vertical,  about  2.5  to  3.8  cm.  (1  to  i\  inches)  in  length,  over 
line  of  artery,  with  center  over  zygoma,  and  extending  downward  in  the 
interval  between  the  tragus  of  the  ear  and  the  condyle  of  the  lower  jaw 
(Fig.  10,  O). 

Operation. — Incise  skin  and  dense  subcutaneous  tissue  and  parotid 
fascia — when  the  artery  will  be  exposed  lying  quite  superficial  as  it  crosses 
the  zygoma.  Avoid  the  accompanying  vein  posteriorly — also  avoid  the 
branches  of  the  temporofacial  division  of  the  facial  nerve  and  the  auriculo- 
temporal nerve  (Fig.  19). 


Fig.  19. — Ligation  ok  Right  Temporal  Just  above  Zygoma  :— A,  Temporal  artery,  with  its 
anterior  and  posterior  bifurcations,  and  its  transverse  facial,  middle  temporal,  and  anterior  auricular 
branches;  B,  Temporal  vein,  with  branches  corresponding  to  those  of  artery  ;  C,  Temporal  branches 
of  auriculotemporal  nerve  ;  D,  Branch  of  temporofacial  division  of  facial  nerve  ;  E,  Temporal  fascia. 


SURGICAL  ANATOMY  OF  MIDDLE  MENINGEAL  BRANCH  OF  INTERNAL 
MAXILLARY  BRANCH  OF  EXTERNAL  CAROTID. 

Description. — The  largest  branch  of  the  first  or  Maxillary  Portion  of 
the  internal  maxillary.  Arises  between  internal  lateral  ligament  and  neck 
of  inferior  maxilla — and,  under  cover  of  external  pterygoid,  passes  upward 
between  the  two  roots  of  the  auriculotemporal  nerve  to  the  foramen  spinosum, 
being  crossed  by  the  chorda  tympani  nerve.  It  enters  the  skull  through 
this  foramen  and  ascends  in  the  groove  on  the  great  wing  of  the  sphenoid, 
where  it  divides  into  anterior  and  posterior  branches  which  ramify  between 
the  bone  and  the  dura.  The  point  of  bifurcation  is  generally  given  by  anato- 
mists as  corresponding,  on  the  exterior  of  the  skull,  with  a  point  3.8  cm.  (1^ 
inches)  behind  the  external  angular  process  of  the  frontal  bone,  and  3.8  to 
4.5  cm.  (1^  to  if  inches)  above  the  zygoma.  The  Anterior  Branch  runs  in 
a  groove  on  the  great  ala  of  the  sphenoid  and  the  anterior  inferior  angle  of 
the  parietal.  The  Posterior  Branch  crosses  the  squamous  portion  of  the 
temporal  and  then  enters  the  groove  on  the  posterior  inferior  angle  of  the 
parietal  bone.     In  the  young  these  measurements  are  less. 

Indications  for  Ligation. — Intracranial  hemorrhage. 

Sites  of  Ligation. — The  common  trunk,  or  the  anterior  or  posterior 
branch,  as  indicated  (Fig.  10,  P,  Q,  R). 

Note. — Because  of  the  practical  surgical  bearing  of  the  middle  meningeal 
artery  and  its  branches,  and  because  of  the  wide  variations  from  each  other 


SURGICAL    ANATOMY    OF    MIDDLE    MENINGEAL    ARTERY.  45 

in  the  descriptions  of  the  intracranial  portion  of  the  middle  meningeal  artery 
and  its  branches  in  various  anatomies,  and  because  of  the  equally  wide 
variations  of  the  artery  and  its  branches,  as  actually  found  in  the  skull, 
from  the  text-book  descriptions, — the  following  summary  is  given  of  the  out- 
come of  special  research  upon  the  subject  made  upon  fifty  dried  skulls  and 
thirty  cadavera  (representing  160,  upon  the  two  sides)  by  S.  C.  Plummer. 
In  the  following  data  it  is  to  be  remembered  that,  owing  to  beveling,  the 
lower  part  of  the  coronal  suture  is  5  mm.  to  1  cm.  (y3^-  to  f  inch)  more  pos- 
terior on  the  inner  than  outer  side  of  skull,  and  that  the  squamoparietal 
suture  is  from  1  to  1.5  cm.  (f  to  §  inch)  lower  on  the  inner  than  the  outer 
side. 

Covering  of  Artery. — Instead  of  lying  between  dura  and  bone  (as 
generally  understood)  the  artery  is  really  covered  by  a  thin  process  of  dura 
on  its  outer  surface;  hence  its  adherence  to  the  dura  in  separation  of  the 
latter  from  the  bone. 

Trunk  of  Middle  Meningeal  Artery, — (1)  Present  in  95  per  cent.  In 
50  per  cent.,  anterior  and  posterior  branches  entered  separately,  or  the  trunk 
divided  at  the  foramen  spinosum.  (2)  Point  of  Division  into  Anterior  and 
Posterior  Branches: — 2  mm.  to  5.5  cm.  (little  more  than  y1^  to  2^  inches)  from 
foramen  spinosum  in  a  direct  line — (less  than  1  cm.  or  T7g-  inch)  in  16  cases — 
between  1  and  3  cm.  (y7^  and  iy\  inches)  in  60  cases — over  3  cm.  (iy\;-  inches) 
in  19  cases.  Bifurcation  was  58  times  upon  squamous  part  of  temporal — 21 
upon  sphenoid — 15  upon  squamosphenoidal  suture — once  on  sphenoparietal 
suture.  (Steiner,  another  investigator,  found  a  common  trunk  present  in 
only  43  per  cent. — and  found  that  bifurcation  occurred  in  57  per  cent,  at  the 
foramen  spinosum.)  (3)  Length: — corresponds  with  point  of  bifurcation, 
when  point  of  bifurcation  is  not  more  than  2  cm.  (f  inch)  above  the  foramen 
spinosum, — and  from  1  mm.  to  1.2  cm.  (-^  to  ^  inch)  greater  when  the  point 
of  bifurcation  is  more  than  2  cm.  (f  inch)  above  the  foramen  spinosum  (due 
to  curve  in  artery).  (In  Steiner's  cases  the  length  was  from  1  to  3.5  cm.,  or 
§  to  if  inches,  in  43  cases — and  from  3.5  to  5  cm.,  or  if  to  2  inches,  in  8  cases.) 
(4)  Direction: — almost  invariably  outward — and  more  frequently  outward 
and  forward  than  outward  and  backward.  Generallv  runs  outward  for  2  mm. 
to  1.7  cm.  (little  more  than  TXg-  to  J  inch)  and  thence  outward  and  forward — 
running  in  a  gentle  curve.  (5)  Location: — almost  always  runs  from  foramen 
spinosum  onto  the  temporal  (sometimes  first  runs  onto  the  sphenoid,  or 
squamosphenoidal  suture) — generally  running  from  5  mm.  to  1  cm.  (T3g-  to  § 
inch)  posterior  to  the  squamosphenoidal  suture;  thence  a  long  trunk  generally 
runs  onto  the  squamosphenoidal  suture — and  then  onto  the  great  wing  of  the 
sphenoid. 

Anterior  Branch  of  Middle  Meningeal  Artery. — (1)  Relative  Size: — 
Generally  the  main  branch  and  larger  than  the  posterior.  (2)  Direction 
and  Location: — Beginning  at  point  at  which  lowest  bifurcation  occurs  (v.  s.), 
the  anterior  branch,  after  bifurcating  on  the  squamous,  squamosphenoidal 
suture,  sphenoid,  or  on  the  sphenoparietal  suture,  as  the  case  may  be,  passes 
forward  and  upward  across  the  anterior  and  lower  part  of  the  squamous; — 
thence  almost  invariably  crosses  the  upper  part  of  the  great  wing  of  the 
sphenoid; — thence  passes  backward  across  the  sphenoparietal  suture  onto  the 
parietal — and  runs  thence  generally  upward  and  backward  about  parallel 
with  the  coronal  suture,  and  generally  within  2  mm.  to  3  cm.  (little 
more  than  y1^  to  iy3^  inches)  of  it.  Practically,  the  most  constant  position 
of  the  anterior  branch  is  where  it  crosses  the  sphenoparietal  suture — the  cross- 


46  OPERATIONS    UPON    THE    ARTERIES. 

ing  may  be  at  any  part  of  its  1.5  cm.  (nearly  §  inch)  length,  but  is  usually 
on  its  anterior  half.  (3)  As  to  Branches  of  Anterior  Branch: — The  anterior 
branch  did  not  divide  in  44  per  cent.  In  the  56  per  cent,  in  which  it  did 
divide,  it  divided  25  times  on  the  right  and  31  on  the  left.  There  were  2 
branches  in  49  cases — 3  branches  in  5  cases — 4  branches  in  2  cases; — and  these 
divisions  occurred  51  times  on  the  parietal,  3  times  on  the  sphenoparietal 
suture,  and  2  times  on  the  sphenoid.  Kroenlein  considers  that  the  anterior 
branch,  in  the  average  case,  divides  into  two  branches,  one  of  which  runs 
up  in  front  and  one  behind  the  rolandic  fissure.  Where  the  anterior  branch 
divides  into  branches,  one  branch  generally  runs  parallel  with  and  within 
2  cm.  (f  inch)  of  the  coronal  suture.  (4)  Bony  Canal: — In  from  38  per  cent. 
(Steiner)  to  60  per  cent.  (Plummer),  the  anterior  branch  was  found  to  run 
through  a  bony  canal  upon  the  anterior  inferior  angle  of  the  parietal  bone — 
the  canal  sometimes  beginning  upon  the  sphenoid — being  from  3  mm.  to 
2.S  cm.  (|  to  i£  incr.es)  Ions;. 

Posterior  Branch  of  Middle  Meningeal  Artery. — (1)  Much  less  con- 
stant in  size  and  position  than  anterior  branch.  Generally  smaller — often 
appearing  as,  and  mistaken  for,  a  branch  of  the  anterior  branch.  Some- 
times appears  to  be  a  continuation  of  the  trunk  and  larger  than  the  anterior — 
and  sometimes  is  larger  without  appearing  to  be  main  trunk.  (2)  Direction: — 
At  first  outward  and  backward,  or  upward  and  backward — rarely  directly 
backward.  Subsequently,  in  majority  of  cases,  it  passes  horizontally  backward 
— exceptionally,  downward  and  backward.  (3)  Location: — (a)  In  Majority 
of  Cases: — it  runs  approximately  parallel  with  squamoparietal  suture,  gener- 
ally within  1  cm.  (f  inch),  never  more  than  2  cm.  (f  inch)  from  it — gradually 
approaching  it — crossing  it  (unless  its  terminal  branches  are  given  off  on  the 
temporal  bone)  generally  within  2  cm.  (f  inch)  of  its  posterior  end,  passing 
thence  onto  the  parietal  bone — its  small  branches  running  onto  the  occipital, 
(It  may  at  first  run  parallel  with  the  squamosphenoidal  suture.  It  may 
cross  the  squamoparietal  suture  onto  the  parietal  bone  at  any  point.)  (b) 
In  Other  Cases: — sometimes  it  runs  outward  and  backward  over  the  squamo- 
petrosal  suture,  or  upon  the  squamous  parallel  with  and  generally  within 
1  cm.  of  the  squamopetrosal  suture — passing  back  over  the  base  of  the  petrous 
bone,  crossing  the  squamoparietal  suture  near  its  posterior  end — thence  back 
onto  the  parietal  bone,  superiorly  to  and  parallel  with  the  mastoparietal 
suture.  (4)  Branches  of  Posterior  Branch : — In  majority  of  cases  the  posterior 
branch  divides  into  two  branches — on  the  temporal  bone,  most  frequently 
— on  the  parietal  bone,  next  most  frequently — and  on  the  squamoparietal 
suture,  least  frequently. 

Summary. — (1)  That  no  parts  of  the  middle  meningeal  artery  or  its 
anterior  or  posterior  branches  have  fixed  relations,  except  the  main  trunk 
at  its  exit  from  the  foramen  spinosum,  and  the  anterior  branch  where  it 
crosses  the  sphenoparietal  suture  to  reach  anterior  inferior  angle  of  parietal. 
(2)  That  the  common  trunk  is  generally  present.  (3)  That  the  anterior  branch 
may  be  given  off  from  the  orbital  branch  of  the  lachrymal  branch  of  the 
ophthalmic.  (4)  That  a  tendency  to  symmetry  exists  upon  the  two  sides 
of  the  skull,  but  is  not  constant.  (5)  That  the  anterior  branch  runs  through 
a  bony  canal  in  the  anterior  inferior  angle  of  the  parietal  bone  in  the  majority 
of  cases. 


LIGATION    OF    TRUNK    OF    MIDDLE    MENINGEAL    ARTERY. 


47 


LIGATION  OF  TRUNK  OF  MIDDLE  MENINGEAL  ARTERY  IN  THE 

CRANIUM 

THROUGH   TREPHINE-OPENING   EXPOSED  BY   CURVED   OBLIQUE   INCISION. 

Position. — Patient  supine;  head  supported,  shaved  and  turned  to  oppo- 
site side;  surgeon  on  side  of  operation. 

Landmarks. — A  point  is  selected  as  the  center  of  the  trephine-opening 
which  will  fall  over  the  trunk  of  the  artery  proximal  to  its  bifurcation, — and 
which  is  taken  to  be  about  3.8  cm.  (i4  inches)  behind  the  external  angular 
process  of  the  frontal  bone  and  2.5  cm.  (1  inch)  above  the  zygoma. 

Incision. — Begins  at  external  angular  process  of  frontal  bone — passes 
obliquely  downward  and  backward  to  the  posterior  end  of  the  zygoma — and 
from  this  point  upward  and  backward  above  the  auricle  (Fig.  10,  P). 


Fig.  20. — Ligation  of  Trunk  of  Right  Middle  Meningeal  through  Trephine- 
opening  in  Temporal  Fossa  by  Curved  Oblique  Incision: — A,  Temporal  muscle  (iis 
posterior  border  retracted  upward  and  forward);  B,  Zygomatic  arch,  and  temporal  fossa  'ust 
above;  C,  Main  trunk  and  anterior  and  posterior  branches  of  midd'e  meningeal,  exposed  through 
trephine-open  ng  1  which  is  here  shown  somewhat  too  high);  D,  Deep  temporal  artery;  E,  Super- 
ficial temporal  artery  and  vein;  F,  Auriculotemporal  nerve  (retracted  backward);  G,  Branches 
of  facial  nerve  (retracted  downward  and  backward). 


Operation. — (1)  Having  incised  skin  and  temporal  fascia,  ligate  the 
superficial  temporal  artery  and  vein,  guarding  the  auriculotemporal  nerve 
and  branches  of  the  facial  (Fig.  20).  Then  carry  the  incision  along  the 
posterior  border  of  the  temporal  muscle  through  the  periosteum  to  the  bone. 
Detach  the  temporal  muscle  forward  subperiosteal!}',  baring  parts  of  the 
squamous,  parietal,  and  sphenoid  bones — guarding  the  deep  temporal  arteries. 
Firmly  retract  the  soft  parts  thus  freed  upward  and  forward.  (2)  Using  a 
trephine  about  3.8  cm.  (ih  inches)  in  diameter,  place  its  center  over  a  point 
about  3.8  cm.  (i^  inches)  behind  the  external  angular  process  and  2.5  cm. 
(1  inch)  above  the  zygoma.  Having  removed  the  disc  of  bone  (which  is 
here  thin),  expose  the  artery — and  pass  the  needle  carefully,  to  avoid  wounding 
the  brain.     (3)  In  completing  the  operation,  the  disc  of  bone  may  be  replaced, 


48  OPERATIONS    UPON    THE    ARTERIES. 

or  not,  according  to  the  individual  ideas  of  the  surgeon.  Allow  the  perios- 
teum and  soft  parts  to  re-occupy  their  normal  positions.  Suture  the  margins 
of  severed  periosteum  with  buried  catgut.  Repair  by  gut-suturing  any 
muscle  tissue  which  may  have  been  cut  and  close  the  skin  incision. 

Comment. — (i)  This  incision  of  Kocher,  together  with  the  subsequent 
retraction  of  the  soft  parts,  involves  less  injury  to  the  parts  than  the  turning 
downward  or  upward  of  a  semilunar  or  horseshoe  flap,  which  is  the  method 
of  approach  most  frequently  adopted.  (2)  According  to  the  researches  of 
Plummer  (v.  s.),  the  osteoplastic  flap  operation  of  Hartley-Krause  furnishes 
the  best  method  of  exposing  the  main  trunk  of  the  middle  meningeal  artery 
and  its  branches.  (3)  If  the  above  trephine-opening  expose  the  artery 
inconveniently  near  its  circumference,  the  opening  may  be  enlarged  in  the 
direction  of  the  artery  with  rongeur  forceps. 


LIGATION  OF  ANTERIOR  BRANCH  OF  MIDDLE  MENINGEAL  ARTERY 

IN  THE  CRANIUM 

THROUGH    TREPHINE-OPENING   EXPOSED.  BV   A   HORSESHOE  INCISION. 

Position. — As  for  ligation  of  main  trunk. 

Landmarks. — A  point  is  selected  as  the  center  of  the  trephine-opening 
which  will  fall  over  the  anterior  branch  just  beyond  its  bifurcation — and  is 
taken  to  be  about  3.8  cm.  (ih  inches)  behind  the  external  angular  process 
of  the  frontal  bone,  and  from  3.8  to  4.5  cm.  (1^  to  if  inches)  above  the  zygoma. 

Incision. — A  horseshoe  incision  with  its  center  over  the  above  point 
and  its  convexity  upward  is  outlined — its  anterior  limb  being  just  behind 
the  external  angular  process,  and  the  posterior  limb  corresponding  with  a 
line  extending  vertically  upward  from  the  auditory  meatus  (Fig.  10,  Q). 

Operation. — The  incision  is  carried,  throughout,  through  skin,  temporal 
fascia,  temporal  muscle,  and  periosteum  to  bone.  These  soft  parts  are 
raised  subperiosteally  and  turned  downward.  A  trephine  of  about  3.8  cm. 
(1^  inches)  diameter  is  applied  with  its  center  over  the  above  point.  The 
steps  of  the  operation  are,  henceforth,  the  same,  practically,  as  those  for 
the  main  trunk  (page  47). 

Comment. — (1)  See  the  surgical  anatomy  of  the  middle  meningeal 
artery  and  its  branches  for  variations  in  the  course  of  the  anterior  branch. 
(2)  According  to  Chipault's  method  of  cranio-cerebral  localization  (page  546), 
the  anterior  branch  of  the  middle  meningeal  crosses  the  second  tenths  of  the 
three  primary  lines.  In  following  which  method,  therefore,  the  trephine 
should  have  its  center  placed  over  a  line  which  will  cross  these  tenths  at 
about  their  middle.  (3)  According  to  the  researches  of  Plummer  (page  45), 
who  recommends  Kroenlein's  method  of  locating  the  anterior  branch  as  the 
best  of  several,  the  following  points  are  of  practical  value: — (A)  That  site 
should  be  chosen — (a)  Which  is  high  enough  to  avoid  missing  the  anterior 
branch  in  case  it  originates  from  the  orbital  branch; — (b)  which  is  high  enough 
to  be  above  the  orbital  branch  when  that  branch  is  only  a  communicating 
branch; — (c)  which  is  least  apt  to  fall  over  the  bony  canal  in  the  anterior  inferior 
angle  of  the  parietal,  and  over  the  bony  ridge  along  the  lower  portion  of  the 
coronal  suture: — (B)  That  a  2.5  cm.  (1  inch)  trephine-opening  placed  just 
behind  any  portion  of  the  coronal  suture  will  almost  certainly  strike  the  ante- 
rior branch,  or  a  branch  of  the  anterior  branch.  (4)  According  to  Kroenlein's 
method,  Reid's  base  line  (page  551)  is  first  drawn — then  a  higher  line  is  drawn 
parallel  with  it  and  on  a  level  with  the  supraorbital  border.  On  the  latter 
line  a  point  is  taken  3  or  4  cm.  (iy F  to  iT9g-  inches)  behind  the  external  angular 


SURGICAL  ANATOMY  OF  INTERNAL  CAROTID  ARTERY.      49 

process.  The  center  of  the  trephine  will  rest  on  the  sphenoid  in  the  majority 
of  cases.  (This  corresponds,  practically,  with  the  data  often  given,  of  fixing 
upon  a  point  from  3.2  to  3.8  cm.  (i|  to  1^  inches),  according  to  the  size  of 
the  head,  behind  the  external  angular  process — and  from  3.8  to  4.5  cm.  (i£ 
to  if  inches)  above  the  zygoma. 


LIGATION  OF  POSTERIOR  BRANCH  OF  MIDDLE  MENINGEAL  ARTERY 

IN  THE  CRANIUM 

THROUGH    TREPHINE-OPENING   EXPOSED    BY  A    HORSESHOE   INCISION. 

Position. — As  in  ligating  the  main  trunk. 

Landmarks. — A  point  is  selected  as  the  center  of  the  trephine-opening 
which  will  fall  over  the  posterior  branch  in  the  groove  of  the  parietal  bone — 
and  is  taken  to  be  at  the  intersection  of  a  line  drawn  horizontally  backward 
on  a  level  with  the  roof  of  the  orbit,  and  one  drawn  vertically  upward  from 
directly  behind  the  mastoid  process — which  point  of  intersection  lies  just 
below  the  parietal  eminence  (Jacobson). 

Incision. — A  horseshoe  incision  with  its  center  over  the  above  point, 
its  convexity  upward,  and  its  limbs  being  from  5  to  5.7  cm.  (2  to  i\  inches) 
apart  (Fig.  10,  R). 

Operation. — Performed  in  the  same  general  manner  as  for  ligation  of 
the  anterior  branch  (page  48). 

Comment. — (i)  According  to  the  researches  of  Plummer  (page  45), 
who  recommends  Steiner's  method  as  the  best  of  several  for  locating  the 
posterior  branch,  the  following  points  are  of  practical  value : — (A)  The  posterior 
branch  is  incapable  of  being  located  with  as  much  certainty  as  the  anterior 
branch: — (B)  The  lateral  sinus  is  to  be  guarded  in  exposing  the  posterior 
branch.  (2)  According  to  Steiner's  method,  Reid's  base-line  is  first  drawn — 
then  a  second  higher  line  is  drawn  parallel  with  it  and  on  a  level  with  the 
supraorbital  border.  A  third  line  is  drawn  vertically  upward  along  the 
anterior  border  of  the  mastoid  (drawing  the  ear  forward).  The  intersection 
of  the  third  with  the  second  line  marks  a  convenient  site  for  reaching  the 
posterior  branch.  The  trephine-pin  rests  on  the  squamoparietal  suture. 
When  the  posterior  branch  itself  is  not  encountered,  its  two  branches  usu- 
ally are. 


SURGICAL  ANATOMY  OF  INTERNAL  CAROTID  ARTERY. 

Description. — The  larger  of  the  two  branches  of  the  common  carotid. 
Arises  opposite  upper  border  of  thyroid  cartilage  (on  level  with  fourth  cervical 
vertebra)  —  at  first  comparatively  superficial,  and  lies  slightly  external  to 
external  carotid,  then  sinks  more  deeply  in  neck  and  passes  posteriorly  to 
that  vessel — ascending  neck  in  front  of  transverse  processes  of  upper  cervical 
vertebra.'  to  enter  the  carotid  canal.  The  relations  of  its  different  portions 
are  as  follows: 

Relations. — (i)  First  or  Cervical  Portion  :—  Anteriorly  (from  below 
upward) — skin;  superficial  fascia;  platysma;  deep  fascia;  sternomastoid; 
posterior  belly  of  digastric;  stylohyoid;  hypoglossal;  occipital  artery;  posterior 
auricular  artery;  external  carotid;  styloglossus;  stylopharyngeus;  glosso- 
pharyngeal nerve;  pharyngeal  branch  of  pneumogastric;  stylohyoid  ligament. 
Posteriorly — rectus    capitis   anticus    major;    transverse    processes  of  three 


5° 


OPERATIONS    UPON    THE    ARTERIES. 


upper  cervical  vertebra-;  superior  cervical  ganglion;  pneumogastric  nerve; 
hypoglossal  nerve;  glossopharyngeal  nerve;  spinal  accessory  nerve;  internal 
jugular  vein.  Externally— internal  jugular  vein;  pneumogastric  nerve. 
Internally— pharynx;  superior  constrictor;  tonsil;  ascending  pharyngeal 
artery;  ascending  palatine  artery;  eustachian  tube;  levator  palati.  (2) 
Second  or  Petrous  Portion  :— Within  carotid  canal  in  petrous  portion  of 
temporal  bone.  (3)  Third  or  Cavernous  Portion  :— Between  layers  of  dura 
mater,  forming  cavernous  sinus.  (4)  Fourth  or  Cerebral  Portion  : — Enters 
inner  extremity  of  fissure  of  Sylvius  and  gives  off  its  branches. 

Branches.'— From  cervical  portion— none.  From  petrous  portion— 
tympanic;  vidian.  From  cavernous  portion — arteria  receptaculi;  pituitary; 
gasserian;  anterior  meningeal;  ophthalmic.  From  cerebral  portion— anterior 
cerebral;  middle  cerebral;  posterior  communicating;  anterior  choroid. 

Line.— Same,  practically,  as  for  the  external  carotid.,— or  possibly  a  little 
to  the  outer  side  of  that  line  at  its  lower  part. 

Indications  for  Ligation. — Wounds;  aneurism. 

Site  of  Ligation. — Near  origin  (Fig.  10,  S). 


LIGATION  OF  INTERNAL  CAROTID  ARTERY 

NEAR   ORIGIN. 

Position— Landmarks. — As  for  ligation  of  external  carotid  below  the 
digastric  (page  37). 

Incision.— Slightly  posterior  to  the  incision  lor  the  external  carotid 
artery— that  is,  along'  the  anterior  border  of  the  sternomastoid.  instead  of 
just  in  front  of  it — with  the  center  of  the  incision  about  1.3  cm.  (h  inch)  above 
the  upper  border  of  the  thyroid  cartilage  (Fig.  10,  S). 

Operation. — The  steps  are,  at  first,  the  same  as  those  for  exposing  the 
external  carotid  below  the  digastric.  This  artery  (external  carotid)  is  first 
sought  (all  the  structures  mentioned  in  that  operation  being  encountered) 
and  traced  to  its  bifurcation,  and  thus  the  internal  carotid  is  exposed — the 
external  carotid  being  drawn  inward  and  the  digastric  upward.  In  opening 
the  sheath  special  care  must  be  taken  to  guard  the  internal  jugular  vein, 
pneumogastric  nerve,  cervical  sympathetic,  ascending  pharyngeal  artery — ■ 
the  needle  being  passed  from  the  vagus  and  internal  jugular  vein  (Fig.  15). 

Collateral  Circulation. — Circle  of  Willis. 


SURGICAL  ANATOMY  OF  SUBCLAVIAN  ARTERY. 

Description. — Subclavian  artery  on  right  side,  about  7.5  cm.  (3  inches) 
in  length,  arises  from  the  innominate;  and,  on  the  left,  about  10  cm.  (4  inches) 
in  length,  arises  from  arch  of  aorta — arching,  in  both  cases,  across  the  root 
of  neck,  over  the  dome  of  the  lung  and  pleura,  to  the  lower  border  of  the 
first  rib,  where  it  becomes  the  axillary  artery.  That  portion  of  the  subclavian 
internal  to  inner  border  of  scalenus  anticus  being  the  first  part — that  portion 
behind  this  muscle  being  the  second  part — and  that  portion  external  to  the 
outer  border  of  scalenus  anticus  being  the  third  part.  The  subclavian  vein 
lies  below  and  anterior  to  artery,  the  scalenus  anticus  intervening.  The 
posterior  border  of  the  sternomastoid  corresponds  with  the  external  border 
of  the  scalenus  anticus. 

Relations.— (a)  First  Portion  of  Right  Subclavian: — About  3  cm. 


SURGICAL  ANATOMY  OF  SUBCLAVIAN  ARTERY.  5 1 

(i\  inches)  in  length' — arises  from  bifurcation  of  innominate,  behind  upper 
border  of  right  sternoclavicular  articulation — curves  upward  and  outward 
(with  convexity  upward)  at  a  variable  distance  above  clavicle,  over  apex 
of  right  lung  and  pleura,  to  inner  border  of  right  scalenus  anticus,  hav- 
ing following  relations: — Anteriorly — skin;  superficial  fascia;  platysma;  an- 
terior laver  of  deep  fascia;  clavicular  origin  of  sternomastoid;  sternohyoid; 
sternothvroid;  deep  cervical  fascia;  right  innominate  vein;  internal 
jugular  vein;  vertebral  vein;  pneumogastric  nerve;  phrenic  nerve;  superior 
cardiac  branches  of  sympathetic  nerve: — Posteriorly — areolar  tissue;  longus 
colli;  transverse  process  of  seventh  cervical  and  first  dorsal  vertebra;  sym- 
pathetic nerve;  inferior  cardiac  nerves;  recurrent  laryngeal  nerve;  apex  of 
right  lung  and  pleura;  neck  of  first  rib: — Inferiorly — pleura  and  lung; 
recurrent  laryngeal  nerve;  subclavian  vein,  (b)  First  Portion  of  Left 
Subclavian: — Much  longer  than  that  of  right — arises  from  distal  end  of 
transverse  part  of  arch  of  aorta,  opposite  fourth  dorsal  vertebra,  to  left  and 
slightly  posterior  to  left  common  carotid — ascending,  at  first,  almost  vertically 
— then  arching  further  upward  and  outward  over  apex  of  left  lung  and  pleura 
to  inner  border  of  left  scalenus  anticus — having  following  relations: — Ante- 
riorly— left  pleura  and  lung;  sternothyroid;  sternohyoid;  sternomastoid;  left 
innominate  vein;  internal  jugular  vein;  vertebral  vein;  subclavian  vein;  phrenic 
nerve;  pneumogastric  nerve;  left  cervical  cardiac  nerves  of  sympathetic; 
left  common  carotid;  thoracic  duct: — Posteriorly — esophagus;  thoracic  duct; 
inferior  cervical  sympathetic  ganglion;  longus  colli;  vertebral  column;  left 
pleura  and  lung: — Externally — left  pleura  and  lung: — Internally— trachea; 
recurrent  laryngeal  nerve;  esophagus;  thoracic  duct,  (c)  Second  Portions 
of  Both  Subclavian  Arteries : — Highest  part  of  the  vessel — about  2  cm. 
(f  inch)  in  length — lies  behind  scalenus  anticus,  which  separates  the  artery 
from  the  subclavian  vein — and  has  following  relations: — Anteriorly — skin; 
superficial  fascia;  platysma;  anterior  layer  of  deep  fascia;  clavicular  origin 
of  sternomastoid;  deep  layer  of  deep  fascia;  phrenic  nerve;  subclavian  vein; 
scalenus  anticus: — Posteriorly — apex  of  lung  and  pleura;  scalenus  medius: — 
Superiorly— brachial  plexus: — Inferiorly— lung  and  pleura,  (d)  Third 
Portions  of  Both  Subclavians  : — Lie  in  subclavian  triangle  (of  sternomastoid, 
omohvoid,  and  clavicle).  Extend  from  outer  border  of  scalenus  anticus 
downward  and  outward  to  lower  border  of  first  rib,  and  have  following  rela- 
tions:— Anteriorly — skin;  superficial  fascia;  platysma;  clavicular  branches 
of  descending  portion  of  cervical  plexus;  anterior  layer  of  deep  fascia  (from 
omohyoid  to  clavicle) ;  posterior  layer  of  deep  fascia  (from  omohyoid  to  first 
rib);  fatty  areolar  tissue  between  layers  of  deep  cervical  fascia;  suprascapular 
artery;  external  jugular  vein;  suprascapular  vein;  transversalis  colli  vein; 
other  tributary  veins  to  external  jugular;  nerve  to  subclavius  muscle;  sterno- 
mastoid (sometimes);  clavicle;  subclavius  muscle: — Posteriorly— scalenus 
medius;  cord  of  brachial  plexus  formed  by  eighth  cervical  and  first  dorsal: 
— Superiorly— brachial  plexus;  posterior  belly  of  omohyoid: — Inferiorly 
— first  rib. 

Branches.— From  First  Portion : — vertebral,  thyroid  axis  (inferior  thyroid, 
transversalis  colli,  suprascapular),  internal  mammary.  From  Second  Portion: 
— superior  intercostal.     From  Third  Portion: — no  branches,  ordinarily. 

Line.— A  curve,  with  convexity  upward,  at  base  of  posterior  triangle- 
beginning  at  sternoclavicular  articulation  and  ending  at  center  of  inferior 
border  of  clavicle— its  mid-point  being  about  1.3  cm.  (h  inch)  above  the 
superior  border  of  clavicle. 

Indications  for  Ligation.— Wounds;  aneurism;  preliminary  to  extensive 
operations  about  the  shoulder  and  upper  extremity. 


52  OPERATIONS  UPON  THE  ARTERIES. 

Sites  of  Ligation.— But  few  successful  cases  of  ligation  of  the  first  portion 
of  the  right  subclavian  are  recorded  and  fewer  of  the  left — the  ligation  being 
particularly  hazardous,  especially  upon  the  latter  side.  Nor  is  ligature  of  the 
second  portion  to  be  recommended,  owing  to  the  depth  and  relations  of  the 
artery.  The  third  portion  is  the  part  of  the  artery  usually  selected  for  ligation 
(Fig.  10,  T).  Ligation  of  the  first  portion  of  the  subclavian  differs  slightly 
upon  the  two  sides,  owing  to  anatomical  relations. 


LIGATION  OF  FIRST  PORTION  OF  RIGHT   SUBCLAVIAN 

BY  ANGULAR   INCISION. 

Position — Landmarks — Incision. — As  for  ligation  of  innominate  by 
angular  incision  (page  27). 

Operation. — Having  incised  skin  and  superficial  fascia,  this  triangular 
flap  is  dissected  up,  as  in  ligation  of  the  innominate.  The  anterior  jugular 
vein  is  doubly  ligated  and  divided,  and  the  external  jugular  similarly  treated, 
if  in  the  way.  Divide  the  deep  fascia.  Expose  and  sever  the  sternal  and 
clavicular  heads  of  the  sternomastoid.  Divide  the  sternohyoid  and  sterno- 
thyroid either  in  whole  or  in  part.  Expose  the  common  carotid,  carefully 
retracting  the  internal  jugular  vein  and  pneumogastric  nerve  outward  and 
displacing  or  doubly  ligating  any  overlying  veins.  Identify  the  subclavian 
vein  by  following  down  the  common  carotid  on  its  postero-external  aspect 
to  the  bifurcation.  Clear  the  subclavian  artery,  carefully  guarding  the 
recurrent  laryngeal  and  phrenic  nerves  and  vertebral  artery.  Displace  the 
pleura  downward  and  outward  with  tip  of  finger,  and  pass. the  needle  from 
below  (from  the  pleura).  The  vertebral  should  also  be  secured  at  the  same 
time  and  through  the  same  incision — to  accomplish  which,  the  internal 
jugular  and  pneumogastric  nerve  are  now  retracted  inward  and  the  vertebral 
exposed  by  a  few  strokes  of  the  knife  as  it  lies  between  the  longus  colli  and 
scalenus,  guarding  the  phrenic  and  recurrent  laryngeal  nerves  and  the  inferior 
thyroid  artery.   (Also  see  Fig.  12.) 

Comment. — Excision  of  the  right  sternoclavicular  articulation  may  be 
done  when  necessary,  as  in  the  ligation  of  the  innominate  by  partial  bony 
resection. 

Collateral  Circulation. — Superior  thyroid,  with  inferior  thyroid;  one 
vertebral,  with  opposite  vertebral.  Internal  mammary,  with  deep  epigastric 
and  aortic  intercostals.  Superior  intercostal,  with  aortic  intercostals.  Pro- 
funda cervicis,  with  princeps  cervicis.  Scapular  branches  of  thyroid  axis, 
with  branches  of  axillary.  Thoracic  branches  of  axillary,  with  aortic  inter- 
costals. 


LIGATION  OF  FIRST  PORTION  OF  LEFT  SUBCLAVIAN 

BY   ANGULAR  INCISION. 

Position — Landmarks — Incision. — As  for  ligation  of  innominate  by 
angular  incision,  except  that  the  operation  is  placed  upon  the  left  side. 

Operation. — The  steps  of  the  operation  are  similar  to  those  for  ligation 
of  the  first  portion  of  the  right  subclavian — up  to  the  exposure  of  the  common 
carotid  and  internal  jugular.  Here  the  common  carotid  and  pneumogastric 
are  retracted  inward,  the  internal  jugular  is  drawn  outward  and  downward, 
and,  with  it,  the  left  innominate  vein.     At  this  stage  the  head  is  bent  forward 


LIGATION    OF    THIRD    PORTION    OF    THE    SUBCLAVIAN.  53 

to  relax  the  parts.  Special  care  is  here  given  to  identifying  the  thoracic 
duct  before  proceeding — the  duct  arching  from  the  seventh  cervical  vertebra 
forward  and  downward  over  the  subclavian  artery  in  front  of  the  scalenus 
anticus,  and  emptying  into  the  left  subclavian  vein  at  the  junction  with  it 
of  the  left  internal  jugular,  being  embedded  in  the  loose  areolar  tissue  of  the 
part,  making  it  often  difficult  to  find,  and  sometimes  dividing  into  several 
branches.  Having  safeguarded  the  important  neighboring  structures,  follow 
down  the  common  carotid  with  the  finger  until  the  subclavian  is  identified, 
on  a  plane  posterior  and  external  to  that  of  the  former  vessel.  The  artery 
is  then  to  be  freed,  carefully  guarding  the  pleura;  the  sheath  is  opened  and 
the  needle  passed  from  the  pleura. 

Comment. — If  more  room  be  required  than  given  by  the  above  incision, 
or  if  it  be  required  to  ligate  the  vessel  nearer  the  arch,  an  excision  of  the 
sternoclavicular  articulation   can  be   done. 

Collateral  Circulation. — See  Ligation  of  First  Part  of  Right  Subclavian. 


LIGATION  OF  SECOND  PORTION  OF  SUBCLAVIAN  ARTERY. 

Position — Landmarks — Incision. — As  for  ligation  of  third  portion  of 
subclavian. 

Operation. — The  steps  of  this  operation,  up  to  the  division  of  the  deep 
cervical  fascia  and  the  recognition  of  the  outer  border  of  the  scalenus  anticus 
(which  lies  directly  under  the  outer  border  of  the  sternomastoid),  are  identical 
with  those  for  the  exposure  of  the  third  part  of  the  subclavian.  The  further 
steps  consist  in  the  inward  retraction  of  the  scalenus  anticus  (and  overlying 
sternomastoid),  with  the  division  of  as  many  of  their  fibers  as  necessary,  when 
the  artery  will  be  exposed  and  may  be  ligated.  Especial  care  is  taken  to 
guard  the  phrenic  nerve,  which  crosses  obliquely  the  lower  anterior  surface 
of  the  scalenus  anticus, — as  well  as  the  transversalis  colli  and  suprascapular 
arteries,  which  cross  the  scalenus  anticus  transversely, — and  the  external 
jugular  vein,  running  parallel  with  the  anterior  scalene  muscle. 

Comment. — This  operation  is  often  merely  a  proximal  continuation  of 
the  operation  for  the  exposure  of  the  third  part  of  the  subclavian,  when  the 
application  of  a  ligature  to  the  third  part  is  impracticable. 


LIGATION  OF  THIRD  PORTION  OF  THE  SUBCLAVIAN. 

Position. — Patient  supine;  shoulders  raised;  head  thrown  back  and  to 
opposite  side;  operated  shoulder  depressed  by  arm  drawn  downward  and 
placed  under  the  back  (to  open  out  the  posterior  cervical  triangle).  Surgeon 
in  front  of  shoulder. 

Landmarks. — Posterior  border  of  sternomastoid  (which  corresponds 
with  the  outer  border  of  the  scalenus  anticus);  anterior  border  of  trapezius; 
middle  of  clavicle. 

Incision. — With  the  skin  of  the  posterior  cervical  triangle  drawn  down 
over  the  clavicle  by  the  left  hand,  an  incision  about  7.5  cm.  (3  inches)  is 
made  transversely  over  the  clavicle  down  to  the  bone,  from  the  posterior 
border  of  the  sternomastoid  to  the  anterior  border  of  the  trapezius,  and  with 
its  center  about  2.5  cm.  (1  inch)  internal  to  the  center  of  the  superior  border 
of  the  clavicle  (Fig.  10,  T). 

Operation. — (i)   This    incision   will  divide   the   skin,    fascia,   platysma, 


54 


OPERATIONS    UPON    THE    ARTERIES. 


some  supraclavicular  nerves,  and  maybe  a  connecting  vein  between  the 
cephalic  and  internal  jugular— but  will  avoid  the  external  jugular,  which 
passes  through  the  deep  fascia  above  the  clavicle.  The  incision  will  lie 
about  2.5  cm.  (£  inch)  above  the  clavicle  when  the  tension  upon  the  skin  is 
relaxed  (Fig.  21).  (2)  The  margins  of  the  sternomastoid  and  trapezius  will 
be  exposed,&and,  if  more  room  be  needed,  may  be  divided  along  the  clavicle 
as  far  as  necessary.  (3)  The  deep  cervical  fascia  is  next  incised,  the  external 
jugular  vein  being  carefully  exposed  and  retracted,  or  divided  between  double 
ligatures.  Tributary  vein's  of  the  external  jugular  are  to  be  similarly  treated, 
especially  the  transv'ersalis  colli  and  suprascapular.  (4)  Generally  the  trans- 
versaiis  colli  artery  lies  transversely  above  the  incision,  and  the  suprascap- 
ular transversely  below  it,  under  the  clavicle  and  out  of  the  way;  but  one  or 


Fig.  21. — Ligation  of  Third  Part  of  Right  Subclavian: — A,  Platysma;  B,  Trapezius;  C 
Sternomastoid  (posterior  border  incised);  D,  Scalenus  amicus;  E,  Posterior  belly  of  omohyoid  (re- 
tracted upward);  F,  Clavicle ;  G,  Third  part  of  subclavian  ;  H,  Transversalis  colli  A.;  I,  Suprascapu- 
lar A.;  J,  Subclavian  vein;  K,  Upper  end  of  external  jugular  V.  (divided  and  retracted),  with 
transversalis  colli  V.  and  communicating  branch  to  anterior  jugular  ;  L,  Lower  end  of  external  jugu- 
lar (divided  and  retracted),  with  suprascapular  branch  ;  M,  Brachial  plexus;  N,  N,  N,  Supraclavicu- 
lar nerves  ;  O,  Deep  cervical  fascia. 


both  may  present  in  the  field,  and  are  to  be  carefully  preserved  for  collateral 
circulation.  Retract  the  posterior  belly  of  the  omohyoid  upward  if  in  the 
way.  Identify  the  outer  margin  of  the  scalenus  (just  under  the  outer  margin 
of  the  sternomastoid)  as  a  guide  to  the  artery,  and  follow  its  outer  border 
downward  until  the  finger  reaches  the  tubercle  on  the  upper  border  of  the 
first  rib,  which  lies  between  the  subclavian  vein  in  front,  and  the  subclavian 
artery  behind — when  the  artery  will  be  recognized  and  may  be  traced  upward. 
(5)  Expose  the  lowest  cord  of  the  brachial  plexus — for  the  purpose  of  hence- 
forth avoiding  it  (as  it  has  been  mistaken  and  ligated  for  the  artery).  The 
subclavian  vein  will  lie  anteriorly  and  inferiorly  to  the  artery.  (6)  Open 
the  sheath — clear  the  artery — and  pass  the  needle  from  the  brachial  plexus, 
guarding  the  subclavian  vein  and  the  pleura. 


LIGATION    OF    VERTEBRAL    BRANCH    OF    SUBCLAVIAN.  55 

Collateral  Circulation. — (When  the  second  or  third  part  is  tied) : — Supra- 
scapular and  posterior  scapular  above,  with  acromiothoracic,  infrascapular, 
subscapular,  and  dorsalis  scapuke  below;  internal  mammary,  superior  inter- 
costals,  aortic  intercostals  above,  with  long  thoracic  and  scapular  arteries 
below;  plexiform  vessels  from  branches  of  subclavian  above,  with  branches 
of  axillary  below. 


SURGICAL  ANATOMY  OF  VERTEBRAL  ARTERY. 

Description. — Largest  and  generally  first  branch  of  subclavian.  Arises 
from  upper  and  posterior  portion  of  first  part  of  subclavian,  near  inner  border 
of  scalenus  anticus — ascends  upward,  backward,  and  outward,  in  interval 
between  scalenus  anticus  and  longus  colli,  to  foramen  in  transverse  process 
of  sixth  cervical  vertebra — passes  through  foramina  in  all  vertebrae  above 
this — emerging  from  foramen  in  transverse  process  of  atlas,  it  runs  in  groove 
on  posterior  arch  of  atlas,  lying  in  the  suboccipital  triangle,  and  pierces  the 
occipito-atloid  ligament  and  dura  mater — and  passes  into  cranium  through 
foramen  magnum — upward  upon  lateral  aspect  of  medulla  to  its  anterior 
aspect,  where  it  unites  with  its  fellow  to  form  the  basilar. 

Relations. — (a)  First  or  Cervical  Part : — from  origin  to  transverse 
process  of  sixth  cervical  vertebra,  lying  between  scalenus  anticus  and  longus 
colli.  Anteriorly — vertebral  vein;  internal  jugular  vein;  inferior  thyroid 
artery;  thoracic  duct  (left  side).  Posteriorly — transverse  process  of  seventh 
cervical  vertebra;  sympathetic  nerve.  Externally — scalenus  anticus.  In- 
ternally— longus  colli,  (b)  Second  or  Vertebral  Portion  : — runs  in  osseo- 
muscular  canal  formed  by  intervertebral  foramina  and  intertransverse  muscles, 
surrounded  by  plexus  of  veins  and  branches  of  sympathetic  nerve,  (c) 
Third  or  Occipital  Portion  : — lies  in  suboccipital  triangle,  which  is  formed, 
superiorly  and  internally,  by  rectus  capitis  posticus  major;  superiorly  and 
externally,  by  obliquus  capitis  superior;  inferiorly  and  externally,  by  obliquus 
capitis  inferior;  covered  by  complexus  muscle;  and  floor  formed  by  posterior 
occipito-atlantal  ligament,  posterior  arch  of  atlas  and  posterior  atlanto- 
axial ligament; — the  triangle  containing  the  vertebral  artery  and  suboccipital 
nerve,  the  latter  passing  between  the  artery  and  arch  of  the  atlas.  Ante- 
riorly— rectus  capitis  lateralis;  articular  process  of  atlas;  occipito-atloid 
ligament.  Posteriorly — superior  oblique;  rectus  capitis  posticus  major; 
complexus.  (d)  Fourth  or  Intracranial  Portion: — from  opening  in  dura 
to  lower  border  of  pons,  where  it  unites  with  its  fellow  to  form  basilar 
artery. 

Indications  for  Ligation. — Wounds;  traumatic  aneurism;  in  connection 
with  ligation  of  innominate  (to  prevent  secondary  hemorrhage). 

Sites  of  Ligation. — In  the  first  or  cervical  portion  (usual  site);  in  third 
or  occipital  portion  (rarely). 


LIGATION  OF  VERTEBRAL  BRANCH  OF  SUBCLAVIAN 

NEAR   ITS  ORIGIN. 

Position. — Patient  supine;  shoulders  raised;  neck  prominent;  head  to 
opposite  side;  surgeon  on  right,  in  operating  on  either  vertebral. 
Landmarks. — Anterior  border  of  sternomastoid. 


56  OPERATIONS    UPON    THE    ARTERIES. 

Incision.- — About  7.5  cm.  (3  inches)  in  length,  extending  along  the  ante- 
rior border  of  the  sternomastoid,  ending  below  at  the  clavicle.  (As  for  ligation 
of  the  common  carotid  below  the  omohyoid.) 

Operation. — (1)  Having  divided  skin,  superficial  fascia,  and  the  anterior 
portion  of  the  platysma,  branches  of  the  superficial  cervical  nerve,  and  com- 
municating veins  between  the  anterior  and  external  jugular  veins,  are  en- 
countered and  are  treated  as  indicated.  (2)  Incise  the  deep  cervical  fascia, 
exposing  the  anterior  border  of  the  sternomastoid,  which  is  to  be  drawn 
outward;  and  the  omohyoid,  which  is  to  be  retracted  downward  and  inward; 
and  also  the  sternohyoid,  which  is  drawn  inward.  (3)  Having  freed  the 
attachment  of  the  inner  aspect  of  the  common  sheath,  the  carotid,  internal 
jugular,  and  pneumogastric  are  drawn  outward  from  over  the  vertebral 
artery.  The  prevertebral  fascia  is  then  incised  vertically  between  the  carotid 
tubercle  (transverse  process  of  sixth  cervical  vertebra)  and  the  arch  of  the 
inferior  thyroid  artery  (where  it  turns  inward  to  the  posterior  surface  of  the 
thyroid  gland) — where  the  vertebral  artery  will  be  found  ascending,  partly 
covered  by  the  longus  colli,  to  the  foramen  in  the  transverse  process  of  the 
sixth  cervical  vertebra,  having  the  anterior  scalenus  muscle  and  phrenic 
nerve  to  its  outer  side,  and  the  longus  colli  muscle  and  recurrent  laryngeal 
nerve  to  its  inner  side,  and  the  inferior  thyroid  artery  and  vein  and  the  vertebral 
vein  lying  over  it.  All  these  structures,  therefore,  are  to  be  displaced  in  the 
most  convenient  directions,  as  the  finger  seeks  the  vertebral  artery  in  the 
above  triangular  space.  The  pleura  lies  below  and  internally.  The  thoracic 
duct,  on  the  left,  crosses  the  artery  from  within  outward.  (4)  The  artery  is 
to  be  exposed,  and  the  ligature  passed  with  especial  care,  in  order  to  avoid, 
as  far  as  possible,  the  fibers  of  the  sympathetic,  some  of  which  are  apt  to  be 
included  in  the  ligature.     (Also  see  Fig.  12,  M.) 

Comment. — The  vertebral  artery  may  also  be  ligated  bv  an  incision 
made  along  the  posterior  border  of  the  sternomastoid,  followed  by  the  inward 
retraction  of  that  muscle  (with  or  without  a  partial  division  of  its  clavicular 
attachment),  but  is  less  simple  than  the  above.  The  artery  may  also  be 
ligated  in  the  suboccipital  triangle. 


SURGICAL  ANATOMY  OF  INFERIOR  THYROID  BRANCH  OF  THYROID 
AXIS  OF  SUBCLAVIAN  ARTERY. 

Description  and  Relations. — Largest  branch  of  thyroid  axis  (which 
latter  arises  from  first  part  of  subclavian).  Ascends  upward  and  inward 
to  posterior  surface  of  thyroid  gland — passing  behind  common  carotid,  internal 
jugular,  pneumogastric  nerve,  and  sympathetic  nerve  (middle  cervical  gan- 
glion usually  resting  upon  it) — and  in  front  of  vertebral  artery,  recurrent 
laryngeal  nerve  (sometimes  posterior  to  it),  longus  colli  muscle.  The  thoracic 
duct  passes  in  front  of  commencement  of  left  vertebral  artery. 

Indications  for  Ligation. — Preliminary  to  thyreoidectomy;  and  to 
diminish  goiter. 

Sites  of  Ligation. — Just  beyond  the  ascending  cervical  branch  (which 
arises  shortly  before  the  vertebral  passes  behind  the  carotid). 


SURGICAL    ANATOMY    OF    INTERNAL    MAMMARY.  57 

LIGATION  OF  INFERIOR  THYROID  BRANCH  OF  THYROID  AXIS  OF 

SUBCLAVIAN. 

Position. — Patient  supine;  shoulders  elevated;  neck  prominent;  head  to 
opposite  side.     Surgeon  to  right  side,  in  either  case. 

Landmarks. — Anterior  border  of  sternomastoid. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  along  the  anterior  margin 
of  the  sternomastoid  (as  for  the  common  carotid). 

Operation. — Divide  skin,  superficial  fascia,  and  the  platysma,  when 
branches  of  the  superficiaiis  colli  nerve  and  tributaries  between  the  anterior 
and  external  jugular  veins  are  met,  and  are  to  be  dealt  with  as  indicated. 
Incise  the  deep  cervical  fascia  and  define  the  anterior  border  of  the  sterno- 
mastoid, and  retract  that  muscle  outward — the  omohyoid  is  drawn  downward 
and  inward,  and  the  sternohyoid  inward.  After  freeing  the  inner  attachment 
of  the  common  sheath,  the  carotid,  internal  jugular,  and  pneumogastric  are 
drawn  outward  from  over  the  inferior  thyroid  artery.  The  artery  is  then 
sought  by  continuing  the  dissection  toward  the  .vertebra?,  lying  a  little  way 
below  the  carotid  tubercle,  in  the  interval  covered  by  the  sternothyroid  muscle, 
between  the  inner  border  of  the  retracted  carotid  sheath  and  the  outer  border 
of  the  thyroid  gland.  The  gland  is  raised  and  displaced  inward.  The 
artery  is  exposed  where  it  arches  inward,  and  where  the  ascending  cervical 
branch  arises.  The  ligature  is  applied  just  beyond  this  branch — thus  avoid- 
ing the  recurrent  laryngeal  nerve,  which  runs  along  the  trachea  and  behind 
the  thyroid  gland;  and  the  vertebral  artery,  nearly  parallel  with  it  below 
and  passing  behind  the  inferior  thyroid  as  the  latter  bends  inward.  The 
sympathetic  nerve,  which  sometimes  embraces  the  artery,  and  the  phrenic, 
which  lies  to  its  outer  side,  are  to  be  guarded  against  injury. 

SURGICAL    ANATOMY    OF    INTERNAL    MAMMARY    BRANCH    OF    SUB- 
CLAVIAN. 

Description. — Arises  from  lower  aspect  of  first  part  of  subclavian,  near 
to  inner  margin  of  scalenus  anticus — descends  forward  and  inward,  passing 
behind  clavicle  to  enter  thorax  posterior  to  cartilage  of  first  rib — thence 
runs  downward  parallel  with  and  about  1.3  cm.  (h  inch)  external  to  margin 
of  sternum,  to  interspace  between  sixth  and  seventh  costal  cartilages,  where 
it  divides  into  superior  epigastric  and  musculophrenic.  Its  two  vena?  comites 
unite  to  form  one  trunk  in  first  intercostal  space  and  empty  into  the  innominate 
vein.  The  internal  mammary  artery,  above,  is  0.5  to  1.5  cm.  (i-  to  f  inch) 
from  border  of  sternum — and,  below,  from  1  to  2  cm.  (f-  to  A  inch)  from  the 
sternal  margin.  In  its  upper  part  it  lies  between  the  internal  intercostal 
muscle  and  costal  cartilages,  in  front;  and  pleura  behind.  In  its  lower  part 
it  lies  between  the  costal  cartilages  in  front;  and  triangularis  sterni  behind 
(the  latter  structure  intervening  between  it  and  the  pleura). 

Relations. — (a)  Cervical  Part : — Covered  by  sternomastoid,  subclavian 
vein,  internal  jugular  vein,  phrenic  nerve.  Rests  on  pleura,  innominate 
vein,  (b)  Thoracic  Part : — Covered  by  cartilages  of  first  to  sixth  ribs,  pecto- 
ralis  major,  internal  intercostal  muscles,  anterior  intercostal  membrane. 
Rests  on  pleura  (above),  and  triangularis  sterni  (below). 

Arterial  Supply  of  the  Antero-lateral  Thoracic  Wall. — (a)  As  the 
internal  mammary  artery  crosses  the  upper  intercostal  spaces  two  branches 
(superior  and  inferior  anterior  intercostal  arteries,  or  superior  and  inferior 
branches  of  the  anterior  intercostal  arteries,  where  they  arise  from  a  common 
trunk)  are  given  off  in  each  of  the  five  or  six  upper  interspaces — which  pass 
outward  between  the  pleura  and  the  internal  intercostal  muscles,  and  then 


58 


OPERATIONS    UPON    THE    ARTERIES. 


between  the  internal  and  external  intercostal  muscles,  running  along  the 
lower  border  of  the  superior,  and  the  upper  border  of  the  inferior  rib — to 
anastomose  with  the  superior  and  inferior  branches  of  the  aortic  intercostals. 
(b)  In  each  of  the  same  upper  five  or  six  spaces  a  single  branch,  the  perforating, 
or  the  anterior  perforating,  is  given  off  between  the  upper  and  lower  anterior 
intercostal  arteries — which  pierce  the  internal  intercostal  muscles,  between 
the  costal  cartilages,  and  supply  the  pectoralis  major,  mammary  gland  (sec- 
ond, third,  and  fourth  branches),  and  skin,  (c)  The  anterior  intercostal 
branches  for  the  five  or  six  lower  interspaces  are  given  off  by  the  mus- 
culophrenic branch,  which  passes  down  behind  the  costal  cartilages,  pierc- 
ing the  diaphragm  opposite  the  ninth  rib,  and  ending  at  the  tenth  or  eleventh 
interspace  by  anastomosing  with  the  ascending  branch  of  the  deep  circumflex 
iliac.  The  anterior  intercostals  anastomose  with  the  lower  aortic  intercostals. 
(See  Surgical  Anatomy  of  Aortic  Intercostal  Arteries,  page  76.) 

Indications  for  Ligation. — Rare,  except  for  wound,  when  it  is  usually 
ligated  at  the  site  of  injury.  If  the  artery  have  retracted  out  of  reach,  it  is 
ligated  in  the  interspace  above  or  below. 

Sites  of  Ligations. — Reached  most  readily  in  first,  second,  or  third 
interspaces — especially  in  the  second. 


A  CFG 

Fig.  22.— Ligation  of  Right  Internal  Mammary  in  Second  Intercostal  Space:— A,  Pec- 
toralis major;  B,  External  intercostal  muscle,  continued  to  sternum  by  anterior  intercostal  mem- 
brane; C,  Internal  intercostal  muscle;  D,  Margin  of  sternum;  E,  Endothoracic  fascia;  F,  Pleura; 
G,  Internal  mammary  artery  and  venae  comites. 


LIGATION  OF  INTERNAL  MAMMARY  BRANCH  OF  SUBCLAVIAN 

IN   SECOND   INTERCOSTAL  SPACE. 

Position. — Patient  supine;  chest  supported  from  behind  (to  increase 
width  of  intercostal  spaces).     Surgeon  on  side  of  operation. 

Landmarks. — Outer  border  of  sternum;  lower  border  of  second  and 
upper  border  of  third  costal  cartilages. 


SURGICAL    ANATOMY    OF    AXILLARY    ARTERY. 


59 


Incision. — Transverse  in  direction  and  about  6.3  cm.  (2J  inches)  in 
length — beginning  over  center  of  sternum  and  passing  outward  over  center 
of  interspace  between  second  and  third  costal  cartilages  (Fig.  10,  V). 

Operation. — Divide  skin,  fascia,  pectoralis  major,  anterior  intercostal 
membrane  (running  downward  and  inward),  internal  intercostal  muscle 
(running  downward  and  outward),  and  endothoracic  fascia — when  the  artery 
is  found  lying  upon  the  pleura,  with  the  venae  comites  to  either  side.  Separate 
the  artery  and  pass  the  needle  with  especial  care,  to  avoid  the  pleura  (Fig.  58). 


W  « 


Fig. 23. — Incisions  for  Ligating  Right  Axillary  and  Brachial  Arteries: — A,  Junction 
of  anterior  and  middle  thirds  of  outer  axillary  wall  ;  B,  Center  of  bend  of  elbow  ;  C,  Ligation  of  third 
part  of  axillary  ;  D,  Of  brachial  in  middle  of  arm  ;  E,  Of  brachial  at  bend  of  elbow. 


SURGICAL  ANATOMY  OF  AXILLARY  ARTERY. 

Description  and  Relations. — Continuation  of  subclavian — extending 
through  axilla,  from  lower  border  of  first  rib,  on  to  the  arm,  at  the  lower 
border  of  the  tendon  of  teres  major  muscle,  where  it  becomes  the  brachial. 
It  is  divided  into  three  parts:  (a)  First  Part : — About  2.5  cm.  (1  inch)  in  length 
— extending  from  lower  border  of  first  rib  to  upper  border  of  pectoralis 
minor,  having  following  relations:  Anteriorly — skin;  superficial  fascia; 
origin  of  platysma;  deep  fascia;  pectoralis  major;  clavicle  (when  shoulder  is 
depressed) ;  subclavius  muscle  (when  shoulder  is  depressed) ;  costocoracoid 
membrane;  layer  of  areolar  fatty  tissue;  cephalic  vein;  acromiothoracic  vein; 
anterior  external  thoracic  nerve;  axillary  lymphatic  trunk.  Posteriorly — 
first  intercostal  space;  first  intercostal  muscle;  second  (and  sometimes  third) 
serrations  of  serratus  magnus;  part  of  second  rib;  posterior  thoracic  nerve. 
Externally — brachial  plexus.  Internally — axillary  vein;  anterior  internal 
thoracic  nerve,  (b)  Second  Part : — about  3  cm.  (i|  inches)  in  length — 
lying  behind  pectoralis  minor  muscle,  and  having  following  relations:  Ante- 


60  OPERATIONS    UPON    THE    ARTERIES. 

riorly — integuments;  superficial  fascia;  pectoralis  major;  pectoralis  minor. 
Posteriorly — posterior  cord  of  brachial  plexus;  areolar  tissue  and  fat;  sub- 
scapularis.  Externally — external  cord  of  brachial  plexus;  coracoid  process 
(somewhat  removed).  Internally — internal  cord  of  brachial  plexus;  axillary 
vein,  (c)  Third  Part: — about  7.5  cm.  (3  inches)  in  length — extending  from 
lower  border  of  pectoralis  minor  to  lower  border  of  tendon  of  teres  major 
(the  upper  half  being  in  axilla,  the  lower  half  on  arm),  and  having  following 
relations:  Anteriorly — integument;  superficial  fascia;  pectoralis  major;  deep 
fascia  of  arm;  internal  root  of  median  nerve;  external  brachial  vena  comes. 
Posteriorly — musculospiral  nerve;  circumflex  nerve;  fatty  areolar  tissue; 
subscapulars ;  latissimus  dorsi;  teres  major.  Externally — external  root  of 
median  nerve;  musculocutaneous  nerve;  coracobrachialis.  Internally — in- 
ternal root  of  median  nerve;  ulnar  nerve;  internal  cutaneous  nerve;  lesser 
internal  cutaneous  nerve;  axillary  vein. 

Branches. — From  first  part — superior  thoracic,  acromial  thoracic. 
From  second  part — long  thoracic,  alar  thoracic.  From  third  part — sub- 
scapular, anterior  circumflex,  posterior  circumflex. 

Line  of  Artery. — (With  arm  at  right  angle  to  trunk  and  hand  supine) — 
from  middle  of  clavicle  to  junction  of  anterior  and  middle  thirds  of  the 
outer  axillary  wall,  between  the  anterior  and  posterior  folds  of  the  axilla. 

Sites  of  Ligation. — Third  part,  by  preference; — first  part,  if  third  part 
not  available.  Ligation  of  third  portion  of  subclavian  is  usually  considered 
preferable  to  that  of  first  part  of  axillary  (Figs.  23,  C,  and  10,  W). 

Comment. — (1)  When  the  arm  is  at  a  right  angle  to  the  body,  the  axillary 
vein  is  drawn  across  the  first  part  of  the  artery.  (2)  The  upper  and  lower 
borders  of  the  pectoralis  minor  correspond,  respectively,  with  lines  drawn 
from  the  junction  of  the  third  rib  and  its  cartilage  to  the  coracoid  process; 
and  from  the  junction  of  the  fifth  rib  and  its  cartilage  to  the  coracoid  process. 
(3)  Two  brachial  venae  comites  are  generally  found  at  the  lower  part  of  the 
artery — and  also  the  basilic  vein,  unless  it  have  already  joined  the  internal 
vena  comes. 

LIGATION  OF  FIRST  PART  OF  AXILLARY  ARTERY 

PA'  CURVED  TRANSVERSE  INCISION  BELOW  CLAVICLE. 

Position. — Patient  on  back,  at  edge  of  table;  upper  thorax  raised;  shoulder 
backward.  Surgeon  near  thorax  on  left,  for  left  operation;  near  head  on 
right,  for  right  operation — (or  between  abducted  limb  and  body  on  each 
side). 

Landmarks. — Clavicle;  sternoclavicular  articulation;  coracoid  process. 

Incision. — Curved  incision  in  infraclavicular  fossa — beginning  just  ex- 
ternal to  the  sternoclavicular  joint — dipping,  at  lowest  point,  about  1.3  cm. 
(^inch)  below  clavicle — and  ending  at  the  coracoid  process  (Fig.  10,  W). 

Operation. — Incise  skin,  platysma,  supraclavicular  nerves,  and  fascia. 
Carefully  guard  the  cephalic  vein  and  branches  of  acromial  thoracic  artery 
at  outer  part  of  wound,  on  account  of  collateral  circulation.  Divide  the  clavic- 
ular origin  of  the  pectoralis  major  throughout  the  wound.  Clear  the  areolar 
tissue  beneath  the  pectoralis  major.  Expose  the  upper  border  of  the  pectoralis 
minor  and  draw  it  downward.  Divide  obliquely  downward  and  outward,  near 
the  coracoid  process,  the  costocoracoid  membrane — through  which  pass  the 
cephalic  vein,  branches  of  the  acromiothoracic  artery,  and  the  anterior  thoracic 
nerves — and  displace  it  upward  and  outward.  The  cephalic  vein,  indicating 
the  position  of  the  axillary  vein,  is  generally  closely  adherent  to  the  costocora- 


LIGATION    OF    FIRST    PART    OF    AXILLARY    ARTERY. 


6l 


coid  membrane.  Expose  the  sheath  and  clear  the  artery — which  lies  between 
the  axillary  vein  on  the  inner  side  and  the  brachial  plexus  on  the  outer,  aided 
in  the  exposure  by  bringing  the  arm  nearer  the  body,  when  the  axillary  vein 
will  be  carried  from  over  the  artery  to  its  inner  side.  The  ligature  is  placed 
above  the  acromiothoracic  branch.  The  incised  pectoralis  major  muscle 
is  repaired  by  gut  suturing. 

Comment. — This  is  the  easiest  and  most  frequent  ligation  of  the  first  part 
in  the  rare  cases  in  which  a  ligation  at  this  site  is  done — a  ligation  of  the  third 
portion  of  the  subclavian  being  considered  preferable.  The  first  part  may  also 
be  exposed  by  an  oblique  incision  in  the  groove  between  the  pectoralis  major 
and  deltoid. 

Collateral  Circulation. — When  ligated  between  the  superior  thoracic 
and  acromial  thoracic: — Suprascapular  and  posterior  scapular;  with  acromial 
thoracic  and  subscapular.  Internal  mammary,  aortic  intercostals,  superior 
intercostal;  with  long  thoracic  and  subscapular.  Plexiform  vessels  from 
subclavian;  with  plexiform  vessels  from  axillary. 


Fig.  24. — Ligation  of  Third  Part  of  Right  Axillary: — A,  Coracobrachial  (retracted 
outward);  B,  Pectoralis  major;  C,  Teres  major;  D,  Triceps;  E,  Axillary  artery;  F,  Basilic  vein, 
becoming  axillarv  vein  after  receiving  two  brachial  venae  comites;  G,  Right  brachial  vena 
comes;  H,  Musculocutaneous  nerve;  1,  Median  X.;  S,  Internal  cutaneous  X.;   K,  K,  Ulnar  N. 


62 


OPERATIONS    UPON    THE    ARTERIES. 


LIGATION  OF  THIRD  PART  OF  AXILLARY  ARTERY. 

Position. — Patient  supine  at  edge  of  table;  shoulders  raised;  arm  at 
right  angle  to  body,  and  slightly  rotated  outward.  Surgeon  between  arm 
and  chest,  on  either  side.     Axilla  to  be  shaved. 

Landmarks. — Junction  of  anterior  and  middle  thirds  of  external  axillary 
wall;  coracobrachialis. 

Incision. — About  7.5  cm.  (3  inches)  in  length — beginning  at  the  middle 
of  the  outlet  of  the  axilla,  at  the  junction  of  the  anterior  and  middle  thirds 
of  its  outer  wall,  and  passing  downward  along  the  inner  border  of  the  coraco- 
brachialis (Fig.  23,  C). 


Fig.  25. — Cross-section  of  the  Right  Arm  at  the  Axillary  Level: — A,  Axillary 
artery  and  vein;  B,  Ulnar  nerve;  C,  Musculospiral  nerve;  D,  Median  nerve;  E,  Internal  cutaneous 
nerve;  F,  Musculocutaneous  nerve;  G,  Coracobrachialis  muscle;  H,  Biceps;  I,  Pectoralis  major 
muscle  and  biceps  tendon;  J,  Deltoid;  K,  Triceps;  L,  L,  Latissimus  dorsi.  (The  cross-section 
modified  from  Esmarch.) 

Operation. — Having  incised  integument  and  fascia,  expose  the  inner 
border  of  the  coracobrachialis  (Fig.  24).  Draw  this  muscle  and  the  musculo- 
cutaneous nerve  outward.  The  median  nerve  is  exposed  and  also  drawn 
outward.  The  internal  cutaneous  and  ulnar  nerves  are  drawn  inward.  Venae 
comites  are  generally  present  at  the  lower  part  of  the  axilla  and  sometimes 
the  basilic  vein,  which  have  to  be  guarded.  Again,  the  axillary  vein  alone 
may  be  present  to  the  inner  side  of  the  artery.  Pass  the  needle  from  the  vein, 
ligating  the  artery  as  far  from  a  large  branch  as  possible  (Fig.  25). 


SURGICAL  ANATOMY  OF  BRACHIAL  ARTERY. 


63 


Collateral  Circulation. — (a)  If  tied  below  the  circumflex  arteries: — the 
posterior  circumflex  above,  with  the  superior  profunda  below,  (b)  If  tied 
between  subscapular  above  and  two  circumflex  branches  below: — the  supra- 
scapular and  acromial  thoracic  above,  with  posterior  circumflex  below. 


SURGICAL  ANATOMY  OF  BRACHIAL  ARTERY. 

Description. — Continuation  of  axillary  artery.  Extends  down  inner 
and  anterior  aspect  of  arm,  from  lower  border  of  tendon  of  teres  major  to 
about  1.3  cm.  (^  inch)  below  center  of  crease  at  bend  of  elbow,  and  divides, 
opposite  junction  of  head  with  neck  of  radius,  into  radial  and  ulnar  arteries. 
The  artery  lies  in  the  depression  at  the  inner  borders  of  the  coracobrachialis 
and  biceps,  and  then  in  the  groove  between  the  supinator  longus  and  pronator 
radii  teres,  passing  under  the  bicipital  fascia  below.  It  lies  to  the  inner  side 
of  humerus  above,  and  in  front  of  it  below. 


Fig.  26.— Ligation  of  Right  Brachial  at  Middle  of  Arm  :— A,  Biceps;  B,  Coracobrachi- 
alis (retracted  outward)  :  C,  Triceps;  D,  Brachial  artery  and  branches;  E,  Brachial  venae  comites 
and  communicating  branches  ;  F,  Basilic  vein  ;  G.  Branch  from  basilic  to  cephalic  vein  ;  H,  Median 
nerve;  I,  Ulnar  X.  ;  J,  Internal  cutaneous  N. 

Relations. — Anteriorly:  integument;  superficial  and  deep  fascia; 
median  nerve  (in  middle);  median  basilic  vein  and  bicipital  fascia  (at  elbow). 
Posteriorly  :  lies,  in  order,  upon — long  head  of  triceps  (musculospiral  nerve 
and  superior  profunda  artery  intervening);  inner  head  of  triceps;  insertion 
of  coracobrachialis;  brachialis  anticus.  Externally:  in  order — coraco- 
brachialis; belly  of  biceps  (both  slightly  overlapping  the  artery);  tendon  of 


64 


OPKRATIONS    UPON    THE    ARTERIES. 


biceps;  median  nerve,  above  (crossing  artery  at  middle);  external  vena  comes. 
Internally:  internal  cutaneous  and  ulnar  nerves  (above);  median  nerve 
(below);   internal  vena  comes;  basilic  vein. 

Branches. — Superior  profunda;  inferior  profunda;  anastomotica  magna; 
nutrient;  muscular. 

Line  of  Artery. — (Arm  extended  and  abducted,  hand  supine.)  From 
junction  of  anterior  and  middle  thirds  of  outer  wall  of  axilla  to  center  of 
bend  of  elbow  (Fig.  23,  A  and  B). 

Sites  of  Ligation. — Middle  of  arm  (preferably);  bend  of  elbow. 


Fig.  27. — Cross-section  of  the  Middle  of  the  Right  Arm: — A,  Brachial  artery  and 
veins  and  inferior  profunda  artery  and  median  and  ulnar  nerves;  B,  Musculospiral  nerve  and 
superior  profunda  artery;  C,  Nutrient  vessels;  D,  Biceps  muscle;  E,  Triceps;  F,  Brachialis  anticus 
muscle.     (Cross-section  modified  from  Braune.) 


LIGATION   OF  BRACHIAL   ARTERY 

IN    MIDDLE    OF    ARM. 

Position. — Limb  extended,  abducted,  and  hand  supine.  Surgeon  to 
outer  side  of  limb,  cutting  from  above  downward  on  right,  and  from  below 
upward  on  left. 

Landmarks. — Inner  border  of  coracobrachialis  and  biceps;  line  of 
artery. 

Incision. — About  5  to  7.5  cm.  (2  to  3  inches)  in  length,  extending  along 
inner  border  of  biceps,  in  line  of  artery,  opposite  middle  of  arm  (Fig.  23,  D). 

Operation. — The  skin  and  fascia  having  been  divided,  the  inner  border 
of  the  biceps  must  be  clearly  recognized  and  retracted  outward — when  the 
arterv  is  generally  found  under  its  inner  margin — the  median  nerve  usually 
crossing  the  front  of  the  arterv  at  its  middle — the  internal  cutaneous  nerve 


LIGATION    OF    BRACHIAL    ARTERY. 


65 


lying  to  the  inner  side  (Fig.  26).  The  venae  comites  and  basilic  vein  are  to 
be  separated  from  the  artery.  The  needle  is  passed  from  the  nerve  (Fig.  27). 
Comment. — (1)  The  artery  is  not  as  easily  found  in  this  situation  as 
the  superficial  position  would  suggest.  Its  exposure  is  made  easier  by  an 
assistant's  holding  the  limb  by  the  wrist,  so  that  it  cannot  rest  on  the  table, 
where  the  triceps  is  apt  to  be  pushed  upward  and  may  protrude  the  inferior 
profunda  artery  and  ulnar  nerve,  instead  of  the  brachial  artery  and  median 
nerve  (Heath).  (2)  In  ligating  higher  than  the  middle  third,  the  artery 
lies  to  the  inner  side  of  the  coracobrachialis,  the  median  nerve  to  the  outer 
side,  and  the  ulnar  nerve  to  the  inner. 


Fig.  28. — Ligation  of  the  Right  Brachial  at  the  Bend  of  the  Elbow: — A,  A,  Median 
basilic  vein;  B,  Median  cephalic  vein;  C,  Internal  cutaneous  nerve  and  branches;  D,  Biceps; 
E,  E,  Bicipital  fascia;  F,  Brachial  artery;  G,  Brachial  venae  comites  and  communicating  branch; 
H,  Median  nerve;  I,  Brachialis  anticus  muscle. 


LIGATION  OF  BRACHIAL  ARTERY 

AT    BEND    OF    ELBOW. 

Position. — Limb  extended  (not  overextended)  and  abducted.  Surgeon 
to  outer  side  of  limb,  cutting  from  above  on  right,  and  from  below  on  left. 

Landmarks. — Inner  border  of  biceps  tendon. 

Incision. — About  5  cm.  (2  inches)  in  length — in  the  internal  bicipital 
fossa,  along  the  inner  border  of  the  biceps  tendon — its  center  corresponding 
to  the  "  fold  of  the  elbow."  This  incision  will  be  oblique  and  its  upper  end 
will  commence  opposite  the  tip  of  the  internal  condyle  of  the  humerus.  It  is 
well  to  compress  the  veins  above,  to  get  an  idea  of  their  position  at  the  elbow, 


66 


OPERATIONS    UPON    THE    ARTERIES. 


and  thus  avoid  them,  if  possible.     Ordinarily  the  incision  will  lie  above  and 
to  the  outer  side  of  the  median  basilic  (Fig.  23,  E). 

Operation. — Having  incised  skin  and  superficial  fascia,  isolate  the  median 
basilic  vein  and  accompanying  internal  cutaneous  nerve  and  retract  them 
inward  (Fig.  28).  Incise,  in  the  direction  of  the  original  wound,  the  deep 
fascia  and  the  bicipital  fascia — the  latter  (passing  inward  and  downward) 
is  to  be  incised  to  as  limited  an  extent  as  possible.  Beneath  the  bicipital  fascia 
lies  the  artery,  with  its  vense  comites — the  median  nerve  generally  lying  out 
of  the  way  and  to  the  inner  side,  nearer  the  upper  than  the  lower  part  of  the 


Fig.  20  — Cross-section  of  Right  Arm  just  below  the  Elbow-joint  : — A,  Brachial 
artery  dividing  into  radial  and  ulnar,  with  vena;  comites;  B,  Median  basilic  vein;  C,  Radial 
recurrent  artery  and  radial  and  interosseous  nerves;  D,  Ulnar  nerve  and  posterior  ulnar  recurrent 
artery;  E,  Median  nerve  and  anterior  ulnar  recurrent  artery;  F,  Biceps  tendon;  G,  Supinator 
longus  muscle;  H,  Extensor  carpi  radialis  longior;  I,  Extensor  carpi  radialis  brevior;  J,  Extensor 
carpi  ulnaris;  K,  Anconeus;  L,  Pronator  radii  teres;  M,  Flexor  sublimis  digitorum;  N,  Flexor 
carpi  ulnaris  (a  fascial  line  is  seen  between  its  two  parts).  The  brachialis  anticus  muscle  lies 
just  below  the  brachial  artery.  The  flexor  carpi  radialis  lies  just  to  the  right  of  the  pronator 
radii  teres.     (The  cross-section  modified  from  Braune.) 


wound.     Pass  the  needle  from  the  side  of  the  ulnar  nerve, 
bicipital  fascia  with  gut  (Fig.  29). 


Resuture  the 


SURGICAL  ANATOMY  OF  RADIAL  ARTERY. 

Description. — Smaller  but  more  direct  of  two  divisions  of  brachial. 
Begins  at  bifurcation  of  brachial,  about  1.3  cm.  (J  inch)  below  bend  of  elbow 
— runs  outward  and  downward  along  radial  side  of  forearm  to  styloid  process 
of  radius — thence  passes  around  outer  side  of  carpus  over  external  lateral 
ligament  and  beneath  extensor  tendons  of  thumb,  to  back  of  wrist — and 
enters  palm  between  first  and  second  metacarpal  bones,  passing  between 
the  two  heads  of  first  dorsal  interosseous  muscle — thence  crosses  metacarpal 


SURGICAL    ANATOMY    OF    RADIAL    ARTERY.  67 

bones  and  interossei  muscles,  anastomosing  at  ulnar  side  of  hand  with  deep 
branch  of  ulnar,  to  form  deep  palmar  arch.  The  artery  is  accompanied  by 
two  vena?  comites. 

Relations. — (a)  In  Forearm  : — The  artery  runs  in  outermost  intermuscu- 
lar space,  lying  between  supinator  longus  and  pronator  radii  teres  above,  and 
between  supinator  longus  and  tendon  of  flexor  carpi  radialis  below.  Ante- 
riorly— skin;  fascia;  supinator  longus  (above).  Skin;  fascia;  cutaneous 
vessels  and  nerves  (below).  Posteriorly — (from  above  downward)  tendon 
of  biceps;  supinator  brevis;  insertion  of  pronator  radii  teres;  radial  origin 
of  flexor  sublimis  digitorum;  flexor  longus  pollicis;  pronator  quadratus; 
anterior  surface  of  lower  end  of  radius.  Externally — supinator  longus 
(guide  to  arterv)  and  external  vena  comes  (throughout) ;  radial  nerve  (middle 
third).  Internally — pronator  radii  teres  (upper  third);  tendon  flexor  carpi 
radialis  (lower  third);  internal  vena  comes  (throughout),  (b)  At  Wrist: — 
The  artery  winds  over  outer  side  of  carpus,  from  a  point  just  below  and 
internal  to  stvloid  process  of  radius,  to  base  of  first  interosseous  space,  entering 
the  palm  between  the  two  heads  of  the  first  dorsal  interosseous  muscle  (ab- 
ductor indicis)  to  form  the  deep  palmar  arch.  It  is  covered,  successively, 
by  extensor  ossis  metacarpi  pollicis;  extensor  brevis  pollicis;  branches  of 
radial  nerve;  superficial  radial  veins;  extensor  longus  pollicis; — and  rests,  in 
order,  upon  external  lateral  ligament;  scaphoid;  trapezium;  base  of  first 
metacarpal;  dorsal  carpal  ligaments.  It  is  accompanied  by  two  vena?  comites 
and  branches  of  musculocutaneous  nerve,  (c)  In  the  Palm  : — Enters  palm 
in  upper  part  of  interval  between  first  and  second  metacarpals,  passing 
between  two  heads  of  first  dorsal  interosseous  muscle  (abductor  indicis) — 
runs  inward  between  adductor  obliquus  pollicis  and  adductor  transversus 
pollicis — crossing  the  palm  transversely,  with  slight  downward  curve,  to 
base  of  metacarpal  of  little  finger,  and  there  anastomoses  with  deep  branch 
of  ulnar,  forming  the  deep  palmar  arch.  The  deep  palmar  arch,  therefore, 
extends  from  base  of  first  interosseous  space  to  base  of  metacarpal  of  little 
finger,  and  is  about  2  cm.  (f  inch)  nearer  the  wrist  than  is  the  superficial 
palmar  arch.  It  is  covered  by  the  superficial  and  deep  flexor  tendons;  ad- 
ductor obliquus  pollicis;  part  of  flexor  brevis  minimi  digiti;  part  of  opponens 
minimi  digiti;  lumbricales.  It  rests  upon  adductor  transversus  pollicis; 
carpal  extremities  of  metacarpal  bones;  interossei  muscles.  It  is  accom- 
panied by  two  vena?  comites  and  the  deep  branch  of  the  ulnar  nerve  (running 
in  opposite  direction). 

Branches. — (a)  In  Forearm — radial  recurrent;  muscular;  anterior  radial 
carpal;  superficialis  vola?.  (b)  At  Wrist — posterior  radial  carpal;  metacarpal 
(first  dorsal  interosseous);  dorsalis  pollicis;  dorsalis  indicis.  (c)  In  Palm 
— princeps  pollicis;  radialis  indicis;  palmar  interosseous;  recurrent;  per- 
forating. 

Line  of  Artery. — (a)  In  Forearm  (with  hand  supine) — from  center  of 
bend  of  elbow,  to  inner  side  of  forepart  of  stvloid  process  of  radius  (Fig. 
30,  H  and  I),  (b)  At  Wrist — from  inner  side  of  forepart  of  styloid  process 
to  base  of  first  interosseous  space,  (c)  In  Palm — runs  about  2  cm.  (f 
inch)  nearer  wrist  than  does  superficial  palmar  arch  (which  corresponds 
with  a  line  continued  across  on  level  with  lower  border  of  outstretched 
thumb). 

Sites  for  Ligature. — Upper  forearm  (rarely);  middle  forearm;  lower 
forearm  (preferably);  back  of  hand  (rarely).  In  palm — the  arch  may  be 
tied  in  case  of  wounds,  under  which  circumstances  it  may  be  ligated  at  any 
site  (Fig.  30,  A,  B,  C,  D). 

Anatomy   of    the   "  Tabatiere,"    or    "  Snuff-box." — The    triangular 


68 


OPERATIONS    UPON    THE    ARTERIES. 


space  on  back  of  hand — bounded,  on  radial  side,  by  extensor  ossis  metacarpi 
pollicis,  and  extensor  brevis  pollicis; — on  ulnar  side,  by  extensor  longus  polli- 
cis; — above,  by  lower  edge  of  posterior  annular  ligament.  Its  floor  is 
formed  by  trapezium,  part  of  scaphoid,  base  of  first  metacarpal.  It  con- 
tains radial  artery,  cephalic  vein  of  thumb,  branch  of  internal  division  of 
radial  nerve,  branch  of  musculocutaneous  nerve. 


Fig.  30.— Incisions  for  Ligating  Right  Radial  and  Ulnar  Arteries,  and  Superficial 
and  Deep  Palmar  Arches  :— A,  Ligation  of  radial  in  upper  third  of  forearm  ;  B,  of  radial  in  middle 
third;  C,  of  radial  in  lower  third;  D,  of  deep  palmar  arch  ;  E,  Ligation  of  ulnar  in  middle  third  of 
forearm;  F,  of  ulnar  in  lower  third  ;  G,  of  superficial  palmar  arch;  H,  Center  of  bend  of  elbow  ;  I, 
Antero-internal  aspect  of  styloid  process  of  radius;  J,  Radial  sideof  pisiform  bone;  K,  Anterior  aspect 
of  inner  condyle  of  humerus;  L,  Point  on  inner  aspect  of  forearm  at  junction  of  upper  and  middle, 
thirds. 


LIGATION    OF    RADIAL    ARTERY. 


69 


Fig.  31. — Ligation  of  the  Right  Radial  Artery  in  the  Upper  Part  of  the  Forearm: 
— A,  Radial  artery;  B,  Radial  vena?  comites;  C,  Radial  nerve;  D,  Supinator  longus  muscle; 
E,  Pronator  radii  teres  muscle;  F,  Flexor  carpi  radialis  muscle.      (Modified  from  Deaver.) 


LIGATION  OF  RADIAL  ARTERY 

IN  UPPER  THIRD  OP"  FOREARM. 

Position. — Hand  supine;  wrist  extended.  Surgeon  stands  outside  of 
limb,  cutting  downward  on  right  and  upward  on  left.  Assistant  holds  fingers 
with  one  hand  and  grasps  forearm  with  other. 

Landmarks. — Line  of  artery;  inner  border  of  supinator  longus. 

Incision. — From  5  to  7.5  cm.  (2  to  3  inches),  in  line  of  artery — with 
center  over  the  point  to  be  tied  (Fig.  30,  A). 

Operation. — Having  incised  skin  and  superficial  fascia,  the  radial  or 
median  vein  may  be  met.  Divide  the  deep  fascia  and  open  up  the  space 
between  the  supinator  longus  (fibers  running  directly  downward)  and  the 
pronator  radii  teres  (fibers  running  downward  and  outward)  (Fig.  31).  The 
artery  lies  under  the  edge  of  the  supinator  longus  and  upon  the  inser- 
tion of  the  pronator  radii  teres.  The  radial  nerve  lies  well  to  the  outer 
side. 

Comment. — Unless  one  recognize  the  inner  margin  of  the  supinator 
longus,  there  is  possibility  of  hitting  off  the  wrong  intermuscular  septum  and 
getting  too  near  the  middle  of  the  forearm.  The  anterior  surface  of  the 
supinator  longus  (and  not  its.  inner  border)  appears  at  first,  in  operating  upon 


7o 


OPERATIONS    UPON    THE    ARTERIES. 


the  muscular — and  this  must  be  well  retracted  outward.  Note. — Ligation 
of  the  middle  third  of  the  radial  amounts  to  a  downward  extension  of  the  follow- 
ing operation  {v.  s.),  or  an  upward  extension  of  the  following  operation 
(v.  i.).  The  vessel  is  found  at  the  inner  margin  of  the  supinator  longus, 
resting  upon  the  flexor  sublimis  digitorum  and  tlexor  longus  pollicis. 


Fig.  32. — Cross-section  of  the  Upper  Third  of  the  Right  Forearm: — A,  Radial 
artery  and  branches,  veins,  and  nerve;  B,  Ulnar  and  interosseous  arteries,  veins,  and  median 
nerve;  C,  Ulnar  nerve;  D,  Pronator  radii  teres  muscle;  E,  Flexor  carpi  radialis;  F,  Subcutaneous 
vein  and  nerve,  G,  Flexor  profundus  digitorum;  H,  Flexor  carpi  ulnaris;  I,  Anconeus;  J,  Supinator 
longus;  K,  Extensor  carpi  radialis  longior;  L,  Supinator  brevis;  M,  Extensor  carpi  radialis 
brevior;  N,  Extensor  communis  digitorum;  O,  Extensor  carpi  ulnaris.  (Cross-section  modified 
from  Braune.) 


LIGATION  OF  RADIAL  ARTERY 

IN    LOWER    THIRD    OF   FOREARM. 

Position. — As  for  upper  third. 

Landmarks. — Tendons  of  supinator  longus  and  flexor  carpi  radialis. 

Incision. — From  2.5  to  5  cm.  (1  to  2  inches),  vertically,  in  center  of  interval 
between  tendons  of  supinator  longus  and  flexor  carpi  radialis  (Fig.  30,  C). 

Operation. — Having  incised  skin  and  superficial  fascia,  the  radial  vein, 
or  a  large  branch,  and  often  the  superficialis  volse  artery,  are  met  and  are 
displaced  to  one  side  (Fig.  33).  The  deep  fascia  is  divided,  and  the  interval 
between  the  tendon  of  the  supinator  longus,  externally,  and  the  tendon  of  the 
flexor  carpi  radialis,  internally,  is  opened  up  and  the  artery  and  its  venae 
comites  are  found  between  them,  accompanied  by  the  anterior  branch  of 
the  musculocutaneous  nerve. 


LIGATION    OF    RADIAL    ARTERY. 


71 


Fig. 33.— Ligation  ok  Lower  Third  of  Right  Radial  (Jtst  above  Wrist)  :— A,  Radial 
vein;  B,  Anterior  branch  of  musculocutaneous  nerve;  C,  Supinator  longus  tendon  ;  D,  Flexor  carpi 
radialis  tendon  ;  E,  Pronator  quadratus  ;  F,  Radial  artery  ;  G,  Superficialis  volae  artery  ;  H,  H,  Radial 
venae  comites. 


Fig.  34. — Cross-section  of  the  Lower  Third  of  the  Right  Forearm: — A,  Radial 
artery  and  veins;  B,  Ulnar  artery,  veins,  and  nerve;  C,  Anterior  interosseous  artery;  D,  Posterior 
interosseous  artery;  E,  Median  nerve;  F,  Flexor  sublimis  digitorum  muscle;  H,  Flexor  digitorum 
profundus;  I,  Flexor  longus  pollicis;  J,  Pronator  quadratus;  K,  Extensor  indicis  pollicis;  L, 
Extensor  proprius  pollicis;  M,  Extensor  indicis;  X,  Extensor  communis  digitorum;  O,  Supinator 
longus  tendon;  P,  Flexor  carpi  radialis.      (The  cross-section  modified  from  Braune.) 


72 


OPERATIONS    UPON   THE    ARTERIES. 


r 


F'g-  35- — Ligation  of  Left  Superficial  and  Deep  Palmar  Arches: — A,  Annular  liga- 
ment; B,  Flexor  brevis  pollicis  (part  of  its  origin  from  annular  ligament  incised)  ;  C,  Tendons  of 
flexor  sublimis  digitorum  and  outer  lumbrical  (drawn  inward);  1),  Adductor  obliquus  pollicis;  E, 
Adductor  transversus  pollicis;  F,  F,  Branches  of  median  nerve  ;  H,  H,  Superficial  palmar  arch  ;  G, 
Deep  palmar  arch  and  its  vena;  comites  ;  I,  I,  Superficial  vein. 


LIGATION  OF  DEEP  PALMAR  ARCH  OF  RADIAL  ARTERY. 

Position. — Limb  supine;  hand  extended.  Assistant  steadying  fingers 
and  wrist.     Surgeon  cuts  from  above  downward  on  both  sides. 

Landmarks. — Oblique  crease  running  downward  and  outward  from 
junction  of  thenar  and  hypothenar  eminences  and  partially  circumscribing 
the  thenar  eminence. 

Incision. — From  junction  of  the  thenar  and  hypothenar  eminences — and 
running  along  the  thenar  crease  toward  the  metacarpo-phalangeal  joint  of 
the  index-finger — with  the  center  of  the  incision  opposite  the  center  of  the 
ball  of  the  thumb  (Fig.  30,  D). 


SURGICAL  ANATOMY  OF  ULNAR  ARTERY.  73 

Operation. — Having  incised  skin  and  superficial  fascia,  expose  and 
ligate  the  superficial  palmar  arch  (crossing  the  palm  on  a  level  with  the  lower 
border  of  the  outstretched  thumb)  (Fig.  35).  The  muscles  of  the  thenar 
eminence  are  now  exposed,  and  these,  with  the  annular  ligament,  are  incised 
at  the  upper  part  of  the  wound  to  as  limited  an  extent  as  possible.  The 
interval  between  the  flexor  tendon  of  the  index-finger  and  its  accompanying 
lumbrical  muscle,  on  the  one  hand,  and  the  muscles  of  the  thumb,  on  the 
other,  is  made  out  and  opened  up  by  deep  retraction,  guarding  the  branches 
of  the  median  nerve.  In  the  interval  thus  exposed  by  retraction  is  seen 
the  adductor  obliquus  pollicis,  which  is  to  be  divided  vertically,  w  hen  the 
arch  will  be  found  under  it,  running  transversely  from  between  the  adductor 
obliquus  pollicis  and  adductor  transversus  pollicis  onto  the  deep  fascia  covering 
the  interossei,  and  about  2  cm.  (f  inch)  nearer  the  wrist  than  does  the  super- 
ficial arch.  The  needle  is  to  be  carefully  passed  in  the  deep  wound,  to  avoid 
the  nerves  and  veins. 

Comment. — The  position  for  ligating  can  be  located  by  feeling  for  the 
apex  of  the  first  interosseous  space  on  the  back  of  the  hand. 


SURGICAL  ANATOMY  OF  ULNAR  ARTERY. 

Description. — Larger  of  two  divisions  of  brachial  artery.  Begins  at 
bifurcation  of  brachial,  about  1.3  cm.  (J  inch)  below  bend  of  elbow,  and  in 
middle  of  forearm — runs  through  upper  half  of  forearm,  with  slight  curve 
(convexity  to  ulnar  side),  to  ulnar  aspect  of  limb,  passing  beneath  the  pronator 
radii  teres  and  superficial  flexors — thence  vertically  down  the  lower  half 
of  the  forearm,  along  its  ulnar  border  to  the  wrist,  being  slightly  overlapped 
by  the  flexor  carpi  ulnaris.  It  crosses  the  annular  ligament  immediately 
to  the  radial  side  of  the  pisiform  bone,  and,  entering  the  palm,  divides  into 
superficial  and  deep  palmar  branches,  to  help  form  superficial  and  deep 
palmar  arches.  It  is  accompanied  by  two  vena?  comites.  The  ulnar 
nerve  comes  into  contact  with  the  artery  at  the  junction  of  its  upper  and 
middle  thirds,  and  remains  in  relation  with  it  to  the  palm,  being  upon  its 
ulnar  side. 

Relations. — (A)  In  Forearm: — Anteriorly — (a)  Above — skin;  fascia; 
superficial  flexors  (pronator  radii  teres,  flexor  carpi  radialis,  palmaris  longus, 
flexor  sublimis  digitorum) ;  median  nerve  (separated  from  artery  by  deep 
head  of  pronator  radii  teres),  (b)  Upper  part  of  lower  half — skin;  fascia; 
and  overlapped  by  tendon  of  flexor  carpi  ulnaris.  (c)  Lower  part  of  lower 
half — skin;  superficial  fascia;  deep  fascia;  palmar  cutaneous  branch  of  ulnar 
nerve.  Posteriorly — brachialis  anticus;  flexor  profundus  digitorum.  Ex- 
ternally— flexor  sublimis  digitorum  (in  lower  two-thirds  of  artery's  course). 
Internally — flexor  carpi  ulnaris  (in  lower  two-thirds) ;  ulnar  nerve  (in  lower 
two-thirds).  (B)  At  Wrist : — This  part  of  the  artery  extends  from  the  upper 
to  the  lower  part  of  the  annular  ligament,  running  in  a  channel  formed  by 
the  pisiform  and  unciform  process  of  unciform  bone  and  by  expansion  of 
flexor  carpi  ulnaris  extending  from  pisiform  to  unciform  process.  Ante- 
riorly— skin;  fascia;  expansion  of  flexor  carpi  ulnaris  from  pisiform  to  unci- 
form process  of  unciform.  Posteriorly — anterior  annular  ligament.  Ex- 
ternally— unciform  process  of  unciform  bone.  Internally — pisiform  bone; 
ulnar  nerve.  (C)  In  Palm : — On  entering  the  palm,  the  ulnar  divides  into 
superficial  branch  and  deep  branch: — (1)  Superficial  branch  of  ulnar — 
direct   continuation   of   ulnar  artery — descends  short  distance  toward  gap 


74  OPERATIONS    UPON    THE    ARTERIES. 

between  fourth  and  fifth  fingers,  thence  curves  outward  (with  convexity 
toward  fingers)  and  anastomoses  opposite  gap  between  index  and  middle 
finger,  and  at  junction  of  upper  and  middle  thirds  of  hand,  with  superficialis 
vola?  of  radial  (sometimes  with  branch  from  radialis  indicis  of  radial)  to 
form  superficial  palmar  arch — having  following  relations:  Anteriorly — 
skin;  fascia;  and,  from  ulnar  to  radial  side,  by  palmaris  brevis,  palmar  branch 
of  ulnar  nerve,  palmar  fascia,  palmar  branch  of  median  nerve.  Posteriorly 
— in  order,  from  ulnar  to  radial  side — annular  ligament;  short  muscles  of 
little  finger;  digital  branches  of  ulnar  nerve;  superficial  flexor  tendons;  digital 
branches  of  median  nerve.  (2)  Deep  (communicating)  branch  of  ulnar 
artery — runs  deeply  inward,  between  abductor  minimi  digiti  and  flexor 
brevis  minimi  digiti — anastomosing  with  termination  of  radial  to  form  deep 
palmar  arch. 

Branches. — (a)  In  Forearm — anterior  ulnar  recurrent;  posterior  ulnar 
recurrent;  common  interosseous  (anterior  and  posterior  interosseous);  mus- 
cular, (b)  At  Wrist — anterior  ulnar  carpal;  posterior  ulnar  carpal,  (c) 
In  Palm — superficial  palmar  arch;  deep  (communicating)  palmar. 

Line  of  Artery. — Upper  third  of  artery  corresponds  with  line  from  a 
point  about  1.3  cm.  (h  inch)  below  center  of  bend  of  elbow,  passing  to  inner 
side  with  gentle  curve  (convexity  to  ulnar  side),  to  a  point  at  junction  of 
upper  and  middle  thirds  of  following  line.  Lower  two-thirds  corresponds 
with  line  from  anterior  surface  of  internal  condyle  of  humerus  to  radial 
side  of  pisiform  bone  (Fig.  30,  H,  L,  and  K,  J). 

Sites  for  Ligation. — Upper  third  of  forearm  (rarely) ;  middle  third;  lower 
third  (commonly);  superficial  palmar  arch  (for  wounds  at  that  site).  (Fig. 
3°-) 


LIGATION  OF  ULNAR  ARTERY 

IN  MIDDLE  THIRD  OF  FOREARM. 

Position. — As  for  the  radial  artery. 

Landmarks. — Line  of  artery.  The  muscular  landmarks  at  the  middle 
of  the  forearm  are  generally  difficult  to  recognize. 

Incision. — About  7.5  cm.  (3  inches),  in  line  of  artery,  with  its  center 
corresponding  with  the  center  of  the  forearm  (Fig.  30,  E). 

Operation. — Incise  skin  and  superficial  fascia.  The  anterior  ulnar  vein 
and  anterior  branch  of  internal  cutaneous  nerve  are  likely  to  be  encountered 
(Fig.  36).  Divide  the  deep  fascia  somewhat  to  the  outer  side  of  the  skin 
incision,  as  the  flexor  sublimis  digitorum  is  generally  slightly  overlapped  by 
the  flexor  carpi  ulnaris.  In  this  deep  fascia  the  intermuscular  plane  between 
the  flexor  carpi  ulnaris  and  flexor  sublimis  digitorum  is  sought  by  exposure 
and  by  the  sense  of  touch.  A  muscular  branch  will  often  lead  to  it.  These 
muscles  are  retracted  well  apart,  when  the  ulnar  nerve  is  first  encountered 
between  them — and,  following  inward  on  the  same  plane,  the  artery  will  be 
found  upon  the  flexor  profundus,  surrounded  by  the  venae  comites,  and  with 
the  ulnar  nerve  to  the  ulnar  side. 

Comment. — It  is  sometimes  exceedingly  difficult  to  hit  off  the  intermuscular 
space,  and  even  to  find  the  artery  when  once  in  it.  Remember  that  the  anterior 
margin  of  the  flexor  carpi  ulnaris  slightly  overlaps  the  flexor  sublimis  digitorum 
at  this  level.  Also  remember,  when  once  in  the  intermuscular  space,  not  to 
pass  below  the  ulnar  nerve,  and  thus  go  too  deeply  on  the  ulnar  side  of  the 
forearm,  but  rather  work  inward  from  the  level  of  the  nerve. 


LIGATION    OF    ULNAR    ARTERY. 


75 


Fig.  36. — Ligation  of  Right  Ulnar  in  Upper  Part  of  Middle  Third: — A,  Anterior 
ulnar  vein;  B,  Anterior  branch  of  internal  cutaneous  nerve;  C,  Flexor  carpi  ulnaris;  D,  Flexor 
sublimis  digitorum;  E,  Flexor  profundus  digitorum;  F,  Ulnar  nerve;  G,  Ulnar  artery;  H,  Vena? 
comites. 


Fig-  37- — Ligation  of  Lower  Third  of  Right  Ulnar  (Just  above  the  Wrist): — A, 
Anterior  ulnar  vein;  C,  Tendon  of  flexor  carpi  ulnaris;  D,  Tendon  of  flexor  sublimis  digitorum: 
E,  Ulnar  artery;  G,  Ulnar  vena;  comites;  H,  Ulnar  nerve. 


76  OPERATIONS    UPON    THE    ARTERIES. 

LIGATION  OF  ULNAR  ARTERY 

IN    LOWER   THIRD   OF    FOREARM. 

Position. — As  for  radial. 

Landmarks. — Outer  border  of  flexor  carpi  ulnaris. 

Incision. — About  5  cm.  (2  inches)  in  length— ending  about  2.5  cm. 
(1  inch)  above  the  pisiform  bone — and  placed  between  the  tendon  of  the 
flexor  carpi  ulnaris  and  the  innermost  tendon  of  the  flexor  sublimis  digitorum. 
(As  the  innermost  tendon  of  the  flexor  sublimis  digitorum  is  not  always 
recognizable,  the  incision  is  generally  placed  to  the  outer  side  of  the  tendon 
of  the  flexor  carpi  ulnaris.)     (Fig.  30,  F.) 

Operation. — Having  incised  skin  and  superficial  fascia,  avoid  the  anterior 
ulnar  vein  or  its  branches  (Fig.  37).  Divide  the  deep  fascia.  Partly  flex 
the  wrist  to  relax  the  structures,  and  retract  the  flexor  carpi  ulnaris  to  the  ulnar 
side.  The  artery  will  be  found  upon  the  flexor  profoundus  digitorum,  with 
the  venae  comites  closely  surrounding  it,  and  the  ulnar  nerve  lying  closely  to 
the  ulnar  side. 

SURGICAL    ANATOMY    OF    INTERCOSTAL    BRANCHES    OF    THORACIC 

AORTA. 

Description. — The  ten  aortic  intercostals  generally  supply  from  the 
third  to  eleventh  intercostal  spaces  inclusive— the  first  space  being  supplied 
by  superior  intercostal  alone — and  the  second  space  also  by  superior  inter- 
costal alone,  or  conjointly  by  it  and  the  first  aortic  intercostal.  The  tenth 
aortic  intercostal  runs  below  the  twelfth  rib  (subcostal  artery),  (a)  The  Ver- 
tebral Portions  of  the  Intercostal  Arteries,  arising  in  pairs  from  the  posterior 
part  of  the  thoracic  aorta,  pass  around  the  vertebne — the  right  being  covered 
by  thoracic  duct,  vena  azygos  major,  pleura,  lung,  esophagus— the  left, 
by  vena  azygos  minor,  left  superior  intercostal  vein,  third  vena  azygos 
pleura,  lung.  The  arteries  here  divide  into  posterior  or  dorsal,  and  anterior 
or  intercostal  branches,  (b)  The  Intercostal  Portions  run  forward  and 
obliquely  upward  in  the  intercostal  space  to  the  lower  border  of  the  superior 
rib,  and  divide  near  the  angle  of  the  rib  into  upper  (larger)  and  lower  (smaller) 
branches — the  former,  to  run  in  the  groove  along  the  lower  border  of  the 
upper  rib  and  anastomose  with  the  superior  intercostal  branch  of  the  internal 
mammary  in  the  upper  spaces,  and  of  the  musculophrenic  in  the  lower — the 
latter,  to  run  along  the  upper  border  of  the  lower  rib  and  anastomose  with 
the  inferior  branch  of  the  internal  mammary  in  the  upper  spaces,  and  of  the 
musculophrenic  in  the  lower.  At  first  these  arteries  lie  between  pleurae, 
lungs,  endothoracic  fascia,  and  infracostals  internally — and  external  inter- 
costal muscles  externally — then  (from  the  angles  of  the  ribs)  between  the 
external  and  internal  intercostal  muscles.  The  sympathetic  nerve  crosses 
them  opposite  the  head  of  the  ribs.  The  intercostal  vein  lies  above  and 
the  intercostal  nerve  below  the  intercostal  arteries — except  in  the  upper 
spaces.  The  arteries  of  the  tenth  and  eleventh  spaces  run  outward  between 
the  abdominal  muscles. 

LIGATION  OF  AN  INTERCOSTAL  ARTERY 

BY  AN    INTERCOSTAL    INCISION. 

Position. — Patient  supine,  and  so  turned  as  to  render  site  of  operation 
prominent,  and  chest  supported  below,  so  as  to  increase  width  of  intercostal 
spaces.     Surgeon  stands  on  side  of  operation.     Assistant  opposite. 


LIGATION    OF   AN   INTERCOSTAL   ARTERY. 


77 


Landmarks. — Lower  border  of  rib  in  the  groove  of  which  the  special 
artery  runs;  or  the  upper  border,  in  case  it  be  the  lower  branch  of  the  inter- 
costal artery. 

Incision. — About  5  cm.  (2  inches),  parallel  with  and  just  below  the 
lower  border  of  the  indicated  rib;  or  just  above  the  upper  border,  as  the 
case  may  be. 

Operation. — Incise  skin  and  superficial  fascia.  As  to  what  muscle,  and 
as  to  what  amount  of  muscle  tissue,  as  well  as  fascia,  will  have  to  be  further 
incised  in  the  line  of  the  original  incision,  before  the  intercostal  muscles  are 
reached,  will  depend  upon  the  site  at  which  the  artery  is  to  be  exposed.  Having 
passed  through  the  overlying  muscle-covering  of  the  thoracic  wall,  the  inter- 
costal fascia  is  met  and  incised,  then  the  external  intercostal  muscle  (if  operat- 
ing anywhere  between  the  tubercles  of  the  ribs  behind,  and  the  costal  car- 
tilages in  front).  The  two  cut  margins  of  the  external  intercostals  are  then 
drawn  upward  and  downward  and  the  artery  sought  as  it  lies  partially  or 
entirely  concealed  in  the  inferior  intercostal  groove,  with  intercostal  nerve 
below  and  vein  above.  The  artery  may  be  drawn  out  of  its  groove  and  down 
into  view  by  the  curved  tip  of  the  aneurism-needle.  The  vessel  should  be 
doubly  ligated  (its  supply  coming  from  both  directions).  The  incised  inter- 
costal muscle  and  fascia  may  be  sutured  with  gut  in  closing  the  wound. 

Comment. — (1)  If  difficulty  in  exposing  the  artery  be  experienced,  the  rib 
may  be  exposed  subperiosteally,  as  in  the  following  operation.  (2)  It  is  to  be 
remembered,  in  operating  posterior  to  the  angle  of  the  rib,  that  the  intercostal 
artery  has  not  yet  reached  the  inferior  groove  of  the  upper  rib,  but  lies  between 
the  two  ribs,  and  has  not  divided  into  its  upper  and  lower  branches.  (3)  If  it 
be  desired  to  ligate  the  upper  and  lower  branches  of  the  intercostal  (anywhere 
between  the  angle  and  costal  cartilages),  the  incision  is  made  midway  between 
the  ribs,  and,  after  retracting  the  cut  external  intercostal  muscle,  the  upper 
branch  is  sought  as  above,  and  the  lower  branch  is  found  along  the  upper 
border  of  the  lower  rib.  Both  are  doubly  ligated.  The  upper  intercostal 
artery  is  often  so  small  as  to  be  difficult  or  impossible  to  find. 


Fig.  38. — Ligation  of  Left  Intercostal  Artery,  in  Lower  Anterior  Thoracic  Region, 
by  Partial  Excision  of  a  Rib: — A,  Thoracic  muscles;  B,  External  intercostal  muscle;  C,  Rib, 
with  half-button  of  bone  bitten  out  with  rongeur  forceps;  D,  Periosteum,  incised  over  center  of 
rib;  E,  Lower  half  of  anterior  layer  of  periosteum  retracted  downward  ;  F,  F,  Posterior  layer  oi  peri- 
osteum incised  and  retracted  upward  and  downward,  showing  intercostal  vessels  beneath;  G,  Inter- 
costal artery  ;  H,  Intercostal  vein  ;  I,  Intercostal  nerve.     (Hartley's  method.) 


78  OPERATIONS    UPON   THE   ARTERIES. 

LIGATION  OF  AN  INTERCOSTAL  ARTERY 

BY   PARTIAL,   SUBPERIOSTEAL    EXCISION    OF    RIB   (HARTLEY'S   METHOD.) 

Position — Landmarks. — As  in  the  preceding  operation. 

Incision.- — About  6  cm.  (2^  inches),  parallel  with  and  directly  over 
center  of  rib. 

Operation. — The  above  incision  passes  through  skin,  superficial  fascia, 
any  overlying  thoracic  muscles  (according  to  site  of  operation),  deep  fascia  and 
periosteum  (Fig.  38).  With  periosteal  elevator,  free  the  lower  half  of  the 
anterior  surface,  the  inferior  groove,  and  the  lower  half  of  the  posterior  sur- 
face of  the  rib,  all  subperiosteally.  Then,  with  rongeur  bone-forceps,  bite 
out  a  "half -button"  of  bone  from  the  bared  lower  half  of  the  rib,  being 
careful  to  insert  the  lower  blade  of  the  rongeur  between  the  detached  peri- 
osteum and  the  rib.  After  the  half-button  of  bone  is  removed,  the  position 
of  the  artery  is  plainly  evident— and  the  vessel  is  exposed  by  incising 
through  the  periosteal  membrane,  directly  over  it. 

Comment. — The  artery  may  also  be  exposed  by  the  ordinary  method  of 
subperiosteal  excision  of  about  4  cm.  (ij  inches)  of  rib  throughout  its  entire 
thickness. 


SURGICAL  ANATOMY  OF  ABDOMINAL  AORTA. 

Description. — Continuation  of  thoracic  aorta.  Commences  at  aortic 
opening  of  diaphragm,  opposite  lower  border  of  twelfth  dorsal  vertebra — and 
passes  down  between  pillars  of  diaphragm,  in  front  of  lumbar  vertebrae,  at 
first  in  median  line,  but  deviating  to  left  as  it  descends,  until  it  lies  a  little 
to  left  of  spine  at  its  point  of  bifurcation,  opposite  lower  border  of  fourth 
lumbar  vertebra,  where  it  divides  into  right  and  left  common  iliac  arteries. 
Its  point  of  bifurcation  is  represented  externally,  roughly,  by  a  point  about 
1.3  cm.  (^  inch)  below  and  a  little  to  left  of  umbilicus — and,  more  accurately, 
by  a  line  crossing  the  abdomen  on  a  level  with  the  highest  points  of  the  iliac 
crests.  The  accompanying  vena  cava  is  separated  from  the  aorta  above 
by  the  right  crus  of  the  diaphragm,  and  is  on  a  plane  anterior  to  it.  Below, 
the  vein  lies  in  contact  with  the  artery,  and  on  a  somewhat  posterior  plane. 
The  artery  is  covered  only  by  peritoneum  at  the  site  indicated  for  ligation, 
but  between  the  serous  covering  and  the  artery  lie  important  sympathetic 
nerve-cords  from  the  aortic  plexus  (lying  along  the  aorta  between  the  superior 
and  inferior  mesenteric  arteries)  to  the  hypogastric  plexus  (lying  between 
the  common  iliacs). 

Relations. — Anteriorly  (from  above  downward,  in  order) :  right  lobe 
of  liver;  solar  plexus;  lesser  omentum;  termination  of  esophagus  in  stomach; 
ascending  layer  of  transverse  mesocolon;  splenic  vein  (or  beginning  of  vena 
portae);  pancreas;  left  renal  vein;  third  part  of  duodenum;  mesentery;  aortic 
plexus  of  sympathetic;  spermatic  (or  ovarian)  arteries;  inferior  mesenteric 
artery;  median  lumbar  lymphatic  glands  and  vessels;  small  intestines.  Pos- 
teriorly: bodies  of  lumbar  vertebrae;  intervening  intervertebral  cartilages; 
anterior  common  ligament;  left  crus  of  diaphragm;  left  lumbar  veins.  To 
right:  right  crus  of  diaphragm;  great  splanchnic  nerve;  spigelian  lobe  of 
liver;  receptaculum  chyli  (on  a  posterior  plane);  thoracic  duct  (on  a  posterior 
plane);  right  semilunar  ganglion;  inferior  vena  cava;  vena  azygos  major. 
To  left:  left  crus  of  diaphragm;  left  splanchnic  nerve;  left  semilunar  gan- 
glion; tail  of  pancreas;  small  intestines. 


LIGATION    OF    ABDOMINAL    AORTA. 


79 


Branches. — (From  above  downward.)  Phrenic,  coeliac  axis  (gastric, 
hepatic,  splenic);  suprarenals;  first  lumbars,  superior  mesenteric;  renals; 
spermatics  (ovarians) ;  second  lumbars;  inferior  mesenteric;  third  lumbars; 
fourth  lumbars;  common  iliacs;  middle  sacral. 

Line  of  Artery. — From  a  point  in  the  anterior  median  line,  on  a  level 
with  the  lower  border  of  twelfth  dorsal  vertebra,  to  a  point  a  little  to  left  of 
umbilicus,  on  a  level  with  the  highest  points  of  the  iliac  crests. 

Indications  for  Ligation. — Iliac  and  inguinal  aneurisms  and  primary 
and  secondary  hemorrhage — in  cases  where  no  other  means  are  possible. 
More  than  a  dozen  cases  have  been  reported — one  case  living  ten  days. 

Sites  for  Ligation. — Between  the  origin  of  the  inferior  mesenteric  (be- 
tween 2.5  and  5  cm.,  or  1  and  2  inches,  above  the  bifurcation)  and  the  bifurca- 
tion (Fig.  39). 


Fig-  39- — Incisions  for  Ligations  in  the  Abdomino-pelvic  Region:— A,  Exposure  of 
abdominal  aorta  by  transperitoneal  route,  through  median  incision  over  umbilicus;  B,  Exposure  of 
internal  iliac,  common  iliac,  and  abdominal  aorta  by  retroperitoneal  route,  through  oblique  incision 
parallel  with  Poupart's  ligament ;  C,  Exposure  of  external,  internal,  and  common  iliacs  by  transperi- 
toneal route,  through  median  incision  below  umbilicus  ;  D,  of  external  and  deep  epigastric,  retro- 
peritoneally,  through  oblique  incision  parallel  with  Poupart's  ligament  ;  E,  of  common,  internal,  and 
external  iliacs,  transperitoneally,  through  vertical  incision  in  linea  semilunaris;  F,  of  external  iliac, 
transperitoneally,  through  intramuscular  incision  ;  G,  G,  Anterior  superior  iliac  spines;  H,  Symphysis 
pubis. 


LIGATION  OF  ABDOMINAL  AORTA 

BV   TRANSPERITONEAL    .METHOD. 

Description. — The  abdomen  is  opened  in  the  median  line,  the  intestines 
displaced,  and  the  posterior  parietal  peritoneum  opened  over  the  artery. 

Position. — Patient  supine;  shoulders  raised;  knees  slightly  flexed.  Surgeon 
on  right.     Assistant  opposite. 


80  OPERATIONS    UPON    THE    ARTERIES. 

Landmarks. — Median,  vertical  abdominal  line;  transverse  line  on  level 
with  highest  points  of  iliac  crests. 

Incision. — About  10  cm.  (4  inches)  in  length,  in  linca  alba,  with  its 
center  corresponding  with  the  umbilicus — the  incision  passing  slightly  to 
left  of  the  navel,  to  avoid  the  round  ligament  of  the  liver  and  the  urachus 

(Fig.  39,  A). 

Operation. — The  peritoneal  cavity  having  been  opened  in  the  usual 
manner,  the  small  intestines  and.  mesentery  are  well  retracted  upward  and 
to  the  sides.  Guided  to  the  artery  by  its  known  position  and  by  its  pulsation, 
the  peritoneum  covering  the  vessel  is  carefully  divided  between  the  inferior 
mesenteric  and  its  bifurcation  in  the  iliacs.  The  clearing  of  the  artery  should 
be  done  with  especial  care,  as  inclusion  of  the  sympathetic  nerve-fibers  (see 
Surgical  Anatomy)  is  otherwise  apt  to  take  place — and  is  supposed  to  have 
been  done  in  one  case,  which  quickly  ended  fatally.  A  flat  ligature  should 
be  used  (kangaroo  tendon,  chromicized  gut  and  silk,  flat  and  round,  have 
been  used).  The  needle  should  be  of  special  make  and  shape,  and  should 
be  passed  from  the  inferior  vena  cava. 

Comment. — This  is  the  more  desirable  form  of  operation,  though  the 
case  which  survived  longest  was  done  through  a  posterior  retroperitoneal 
incision. 

Collateral  Circulation. — Internal  mammary,  above;  with  deep  epi- 
gastric, below.  Inferior  mesenteric,  above;  with  internal  pudic,  below. 
Possibly  by  lumbar  arteries,  above;  with  branches  of  internal  iliac,  below. 
And,  if  above  the  inferior  mesenteric,  by  superior  mesenteric,  above;  with 
inferior  mesenteric,  below. 


LIGATION  OF  ABDOMINAL  AORTA 

BY  RETROPERITONEAL  OPERATION. 

Description. — The  artery  is  here  approached  from  the  anterolateral 
abdominal  region,  the  peritoneum  being  pushed  back  from  the  iliac  vessels 
until  the  aorta  is  reached  and  exposed. 

Position — Landmarks — Incision — Operation. — The  operation  is  prac- 
tically similar  to  that  for  the  exposure  and  ligation  of  the  common  iliac  extra- 
peritoneally,  the  site  being  reached  by  an  extension  of  those  steps  (Fig.  39,  B, 
except  on  left  side,  and  Fig.  40).  The  patient  is  placed  so  as  to  be  tilted  toward 
the  right  side,  the  surgeon  standing  behind  the  patient,  upon  the  side  of  the 
operation  (the  left).  An  extension  of  the  incision  employed  for  the  common 
iliac  is  carried  further  upward  to  give  the  necessary  room;  and,  if  still  required, 
additional  room  may  be  gotten  by  a  second  incision  running  parallel  with  the 
ribs,  at  a  right  angle  to  the  main  incision.  The  incision  is  made  upon  the 
left  side — its  general  direction  being  from  just  within  the  anterior  superior 
iliac  spine  toward  the  tip  of  the  tenth  rib — and  the  aorta  is  reached  by  following 
up  the  common  iliac  in  the  peeling  back  of  the  peritoneum  from  the  iliac  fascia 
The  separation  of  the  parts  and  exposure  of  the  common  iliac  are,  otherwise, 
the  same  as  for  the  ligation  of  that  vessel.  The  vessel  is  thus  less  satis- 
factorily exposed  than  by  the  intra-abdominal  operation,  and  there  is  greater 
difficulty  in  avoiding  the  sympathetic  nerve-cords  that  surround  the  vessel. 
The  ligature  is  placed  upon  the  same  site  as  in  the  intra-abdominal  operation, 
and  the  inferior  vena  cava  is  guarded  in  passing  the  needle. 


LIGATION    OF    COMMON    ILIAC    ARTERY.  8 1 

SURGICAL  ANATOMY  OF  COMMON  ILIAC  ARTERIES. 

Description. — Arise  from  bifurcation  of  the  abdominal  aorta,  opposite 
lower  border  of  left  side  of  body  of  fourth  lumbar  vertebra  (corresponding, 
approximately,  to  a  point  about  1.3  cm.  [h  inch]  below  and  a  little  to  left  of 
umbilicus — or,  more  accurately,  on  a  level  with  a  line  passing  transversely 
through  the  highest  points  of  the  iliac  crests) — and  pass  thence  downward 
and  outward  over  the  body  of  the  fifth  lumbar  vertebra  to  margin  of  pelvis, 
bifurcating  opposite  upper  border  of  sacro-iliac  synchondrosis,  into  external 
and  internal  iliac  arteries.  The  relations  of  right  and  left  common  iliacs 
differ  slightly. 

Relations  of  Right  Common  Iliac  Artery. — Anteriorly:  peritoneum; 
right  ureter  (a  little  above  its  bifurcation) ;  ovaries  (in  female) ;  termination  of 
ileum;  terminal  branches  of  superior  mesenteric;  branches  of  sympathetic 
to  hypogastric  plexus.  Posteriorly:  right  common  iliac  vein;  end  of  left 
common  iliac  vein;  beginning  of  inferior  vena  cava;  and,  in  less  immediate 
relationship,  the  following — psoas  magnus;  sympathetic  nerve;  lumbosacral 
cord;  obturator  nerve;  iliolumbar  artery.  Externally:  beginning  of  inferior 
vena  cava;  end  of  right  common  iliac  vein;  psoas  magnus.  Internally: 
right  common  iliac  vein;  end  of  left  common  iliac  vein;  hypogastric  plexus. 

Relations  of  Left  Common  Iliac  Artery.— Anteriorly :  peritoneum; 
small  intestines;  ureter;  ovarian  artery  (in  female);  branches  of  sympathetic 
to  hypogastric  plexus;  termination  of  inferior  mesenteric  artery;  sigmoid 
flexure;  sigmoid  mesocolon;  superior  hemorrhoidal  artery.  Posteriorly: 
lower  part  of  body  of  fourth  lumbar  vertebra;  fifth  lumbar  vertebra;  inter- 
vertebral discs;  left  common  iliac  vein;  and,  in  less  immediate  relationship, 
the  following — psoas  muscle;  obturator  nerve;  lumbosacral  cord;  iliolumbar 
artery.  Externally:  psoas  muscle.  Internally:  left  common  iliac  vein; 
hypogastric  plexus;  middle  sacral  artery. 

Branches. — Peritoneal;  subperitoneal;  ureteric;  internal  iliac;  external 
iliac. 

Line  of  Artery. — Draw  a  line  transversely  across  the  abdomen,  on 
level  with  highest  points  of  iliac  crests,  which  will  cross  the  abdominal  aorta 
at  its  bifurcation — draw  a  second  line  transversely  across  the  abdomen  on  a 
level  with  the  anterior  superior  iliac  spines,  which  will  cross  the  common 
iliacs  at  their  bifurcation — draw  a  third  line  from  a  point  on  the  first  line  about 
1.3  cm.  (h  inch)  to  the  left  of  its  center  (which  is  the  linea  alba),  to  a  point 
midway  between  the  anttrior  superior  iliac  spine  and  symphysis  pubis. 
That  portion  of  the  third  line  between  the  two  zones  represents  the  common 
iliac—  and  that  portion  below  the  lower  zone,  the  external  iliac.  The  right 
common  iliac  is  about  5  cm.  (2  inches)  in  length;  and  the  left,  about  4.5  cm. 
(if  inches). 

Site  for  Ligation. — As  nearly  midway  of  its  length  as  possible. 


LIGATION  OF  COMMON  ILIAC  ARTERY 

BV  RETROPERITONEAL  OPERATION. 

Position. — Patient  supine,  or  slightly  turned  to  one  side.  The  intes- 
tines are  more  easily  displaced  from  the  field  of  operation  if  the  patient  be 
in  the  Trendelenburg  position.  Surgeon  stands  upon  side  of  operation. 
Assistant  opposite. 

Landmarks. — Line  of  external  iliac  (v.  s.);  Poupart's  ligament;  anterior 
superior  spine  of  ilium;  eleventh  rib. 
6 


82 


OPERATIONS    UPON    THE    ARTERIES. 


Incision. — Begun  as  for  exposure  of  external  iliac  (page  89)  and  con- 
tinued in  the  cleavage  line  of  the  external  oblique  as  far  upward  toward 
the  eleventh  rib  as  necessary  to  furnish  sufficient  room  (Fig.  39,  B). 

Operation. — The  steps  of  the  operation  are  identical  with  those  for 
exposure  of  the  external  iliac  (page  89),  with  an  extension  upward,  in  the 
present  operation,  of  the  separation  of  the  fibers  of  the  external  oblique 
and  a  division  of  the  fibers  of  the  internal  oblique  and  transversalis  as  far 


Fig.  40. — Ligation  of  Right  Common  and  Internal  Iliacs,  Retroperitoneally  : — A,  A, 
External  oblique  muscle  and  aponeurosis;  B,  Internal  oblique;  C,  Transversalis;  D,  Conjoint  ten- 
don ;  E,  E,  Peritoneum  retracted  ;  F,  Ureter,  retracted. ;  G.  Common  iliac  artery  (sheath  incised)  ;  H, 
Internal  iliac  artery  (sheath  incised)  ;  I,  External  iliac  artery  ;  J,  External  and  internal  iliac  veins; 
K,  K,  Deep  epigastric  artery  ;  L,  Deep  circumflex  iliac  artery;  M,  Lumbar  artery ;  N,  Iliolumbar 
artery;  O,  Spermatic  artery;  P,  Anterior  crural  nerve;  Q,  Ilio-inguinal  nerve;  R,  Genitocrural 
nerve;  S,  External  cutaneous  nerve;  T,  Iliac  fascia;  M,  Lumbar  artery  and  iliohypogastric  (or 
dorsal)  nerve. 


up  toward  the  eleventh  rib  as  necessary — the  incision  of  the  two  latter  muscles 
corresponding  in  direction  with  the  separation  of  the  fibers  of  the  external 
oblique  (Fig.  40).  In  this  higher  part  of  the  wound  the  last  dorsal  and 
other  dorsal  nerves  are  apt  to  be  encountered  between  the  internal  oblique 
and  transversalis,  and  are  to  be  carefully  preserved.  The  deep  circumflex 
iliac  artery  and  the  lumbar  arteries  are  apt  to  be  met  here  above  the  crest 
of  the  ilium.  Having  divided  the  transversalis  fascia  and  separated  the 
peritoneum  from  the  iliac  fascia  (which  overlies  the  iliacus  muscle),  detaching 
it  downward  and  backward  to  the  psoas  muscle  and  then  upward  to  the 


SURGICAL    ANATOMY    OF    INTERNAL    ILIAC    ARTERY.  83 

sacral  promontory,  the  structures  in  the  floor  of  the  iliac  fossa  are  exposed. 
The  external  iliac  artery  is  first  found,  and  this  is  followed  up  to  the  common 
iliac,  guarding  the  deep  epigastric.  The  genitocrural,  external  cutaneous, 
and  anterior  crural  nerves,  branch  of  the  iliolumbar,  and  the  spermatic 
arteries  cross  this  area.  The  ureter  crosses  either  the  common  iliac,  or  the 
external  iliac,  obliquely,  opposite  the  first  piece  of  the  sacrum,  having  the 
ileum  in  front  of  it  on  the  right,  and  the  sigmoid  flexure  of  the  colon  in  front 
of  it  on  the  left;  but  in  the  peeling  back  of  the  peritoneum  the  ureter  usually 
adheres  to  the  peritoneum,  and  is  thus  removed  from  the  area  of  operation 
without  trouble.  The  artery  having  been  reached  and  bared  of  peritoneum, 
the  needle  is  passed  from  the  iliac  vein. 

Comment. — The  line  of  incision  may  begin  further  to  the  outer  side 
of  the  external  iliac  than  for  the  typical  operation  upon  that  artery,  though 
that  vessel  is  then  a  little  less  easily  encountered.  As  to  a  choice  between 
the  extraperitoneal  and  intraperitoneal  operations,  the  former  is  to  be  pre- 
ferred wherever  the  relations  of  the  parts  are  not  too  much  disturbed  by 
disease  or  injury. 

Collateral  Circulation. — Internal  mammary  and  lower  intercostals 
above,  with  deep  epigastric  below.  Lumbar  above,  with  deep  circumflex 
iliac  and  iliolumbar  below.  Superior  hemorrhoidal  above,  with  middle  and 
inferior  hemorrhoidal  below.  Aliddle  sacral  above,  with  lateral  sacral  below. 
Pudic,  epigastric,  obturator  and  epigastric  branches  of  one  side,  with  corre- 
sponding arteries  of  other  side. 


LIGATION  OF  COMMON  ILIAC  ARTERY 

BY   TRANSPERITONEAL  OPERATION. 

Position — Landmarks — Incision — Operation. — The  steps  are  prac- 
tically the  same  as  for  the  transperitoneal  ligation  of  the  abdominal  aorta, 
though  somewhat  less  extensive,  and  with  the  slight  modifications  necessitated 
by  the  anatomy  of  the  parts  (Fig.  39,  C).  Especial  care  is  taken  to  recognize 
the  position  of  the  ureter  before  incising  the  peritoneum. 


SURGICAL  ANATOMY  OF  INTERNAL  ILIAC  ARTERY. 

Description. — About  4  cm.  (1^  inches)  in  length — arising  from  bifurca- 
tion of  common  iliac,  opposite  upper  border  of  sacro  iliac  synchondrosis. 
Descends  in  pelvis  to  upper  margin  of  great  sacrosciatic  foramen,  where  it 
divides  into  anterior  and  posterior  branches. 

Relations. — Anteriorly:  peritoneum;  ureter.  Posteriorly:  termina- 
tion of  external  iliac  vein;  internal  iliac  vein;  inner  border  of  psoas;  lumbo- 
sacral cord;  obturator  nerve;  sacrum.  Externally:  psoas.  Internally: 
internal  iliac  vein;  peritoneum. 

Branches. — From  Anterior  Trunk: — Hypogastric;  superior,  middle,  and 
inferior  vesical;  middle  hemorrhoidal;  obturator;  sciatic;  internal  pudic; 
uterine;  vaginal.  From  Posterior  Trunk: — Iliolumbar;  lateral  sacral;  glu- 
teal. 

Line  of  Artery. — See  under  Line  of  Common  Iliac. 

Indications  for  Ligation. — Gluteal  and  sciatic  aneurism;  hemorrhage; 
to  cause  atrophy  of  prostate  gland. 

Sites  for  Ligation. — Midway  between  its  origin  and  its  bifurcation. 


84  OPERATIONS    UPON   THE   ARTERIES. 

LIGATION  OF   INTERNAL   ILIAC  ARTERY 

BY  RETROPERITONEAL  OPERATION. 

Position — Landmarks — Incision — Operation. — Same  as  for  the  retro- 
peritoneal ligation  of  the  external  iliac— which,  having  been  exposed,  is 
followed  up  to  the  bifurcation  of  the  common  iliac   (Fig.  39,  B,  and  Fig. 

44)- 

Collateral  Circulation. — Sciatic  above,  with  superior  branch  of  profunda 
below.  Inferior  mesenteric  above,  with  hemorrhoidal  arteries  below.  Pubic 
branch  of  obturator  of  one  side,  with  same  of  opposite.  Branches  of  pudic 
of  one  side,  with  same  of  opposite.  Circumflex  and  perforating  of  profunda 
above,  with  sciatic  and  gluteal  below.  Middle  sacral  above,  with  lateral 
sacral  below.     Circumflex  iliac  above,  with  iliolumbar  and  gluteal  below. 


LIGATION  OF  INTERNAL  ILIAC  ARTERY 

BY    TRANSPERITONEAL   OPERATION. 

Position— Landmarks— Incision— Operation.  Same  as  for  the  trans- 
peritoneal ligation  of  the  abdominal  aorta,  with  the  modifications  necessitated 
by  the  anatomy  of  the  parts  (Fig.  39,  C,  and  page  80).  Recognize  the 
position  of  the  ureter  before  incising  the  peritoneum. 


SURGICAL  ANATOMY  OF  SCIATIC  BRANCH  OF  ANTERIOR  DIVISION 
OF  INTERNAL  ILIAC. 

Description  and  Relations. — Larger  of  two  terminal  branches  of 
anterior  trunk.  Descends  over  sacral  plexus  and  pyriformis  muscle  to  lower 
part  of  great  sacrosciatic  foramen,  whence  it  passes  out  of  pelvis  between 
pyriformis  and  coccygeus  muscles,  with  pudic  artery  anterior  and  internal 
to  it.  Emerging  through  great  sciatic  foramen  upon  buttock,  beneath  the 
gluteus  maximus,  it  descends  the  thigh  midway  between  trochanter  major 
and  tuberosity  of  ischium,  resting  upon  gemellus  superior,  obturator  internus, 
gemellus  inferior,  quadratus  femoris  and  adductor  magnus — being  to  inner 
side  of  great  sciatic  nerve  and  accompanied  by  small  sciatic  nerve. 

Line  of  Artery. — Having  rotated  the  thigh  inward  and  slightly  flexed 
it,  draw  a  line  from  the  posterior  superior  iliac  spine  to  the  outer  border 
of  the  tuberosity  of  the  ischium.  A  point  on  this  line,  at  the  junction  of  its 
middle  and  lower  thirds,  will  represent  the  site  at  which  the  sciatic  and  pudic 
arteries  emerge  from  the  lower  part  of  the  sciatic  foramen  upon  the  gluteal 
region  (Fig.  41,  A,  C,  E). 

Indications  for  Ligation. — Wounds. 

Site  for  Ligation. — At  its  emergence  onto  the  gluteal  region,  just  below 
the  pyriformis  muscle  (Fig.  41). 


LIGATION  OF  SCIATIC  BRANCH  OF  INTERNAL  ILIAC 

UPON  THE   BUTTOCK. 

Position. — Patient  upon  uninvolved  side,  rolled  nearly  onto  chest,  with 
knee  flexed  and  thigh  rotated  in.  Surgeon  on  side  of  operation;  assistant 
opposite. 


SURGICAL    ANATOMY    OF    INTERNAL    PUDIC    ARTERY. 


85 


Landmarks. — Posterior  superior  iliac  spine;  tuberosity  of  ischium. 

Incision. — Having  drawn  the  line  given  under  Anatomy,  make  an  in- 
cision about  10  cm.  (4  inches)  in  length,  obliquely  across  this  line,  in  the 
direction  of  the  fibers  of  the  gluteus  maximus  (which  run  from  above  and 
behind,  downward  and  forward) — with  its  center  corresponding  to  the  junc- 
tion of  the  middle  and  lower  thirds  of  the  line  (Fig.  41,  E). 

Operation. — Having  incised  skin  and  thick  fatty  areolar  tissue,  divide 


9^\ 

y 
m 


, 


Fig.  41. — Incisions  for  Ligations  about  the  Buttock  : — A,  Posterior  superior  iliac  spine  ;  B, 
Great  trochanter;  C,  Tuberosity  of  ischium;  D,  Incision  for  exposure  of  gluteal  branch  of  internal 
iliac  at  its  emergence  from  upper  part  of  great  sacrosciatic  notch  ;  E,  For  exposure  of  sciatic  and 
internal  pudic  branches  of  internal  iliac  at  their  emergence  from  lower  part  of  great  sacrosciatic  notch. 

the  fibers  of  the  gluteus  maximus  in  their  cleavage  line  (Fig.  42,  F).  Retract 
the  separated  margins  of  this  muscle  upward  and  downward,  respectively. 
Expose  the  lower  margin  of  the  pyriformis  muscle.  Follow  the  lesser  sacro- 
sciatic ligament  to  the  spine  of  the  ischium — when  the  sciatic  artery  will  be 
found  emerging  from  beneath  the  pyriformis  muscle — passing  out  of  the 
pelvis  above  the  spine  of  the  ischium,  and  the  lesser  sacrosciatic  ligament 
attached  to  it — and  lying  posterior  and  external  to  the  pudic  artery. 


SURGICAL  ANATOMY  OF  INTERNAL  PUDIC  BRANCH  OF  ANTERIOR 
DIVISION  OF  INTERNAL  ILIAC. 

Description. — Smaller  of  two  terminal  branches  of  anterior  trunk  of 
internal  iliac.  Descends  over  pyriformis  and  sacral  plexus  to  lower  border 
of  great  sacrosciatic  foramen,  lying  in  front  and  to  inner  side  of  sciatic  artery — ■ 
passes  thence  out  of  pelvis  between  pyriformis  and  coccygeus — crosses  over 


86  OPERATIONS    UPON    THE    ARTERIES. 

outer  surface  of  spine  of  ischium,  under  gluteus .  maximus,  and  re-enters 
pelvis  through  lesser  sciatic  notch — passing,  thence,  forward  over  obturator 
interims  muscle,  along  outer  wall  of  ischiorectal  fossa,  about  4  cm.  (i£  inches) 
above  the  lower  margin  of  the  tuberosity  of  ischium,  and  contained  in  a  canal 
of  the  obturator  fascia.  Gradually  approaching  the  border  of  the  ischial 
ramus,  it  runs  forward  and  upward — pierces  posterior  layer  of  deep  perineal 
fascia,  runs  forward  along  inner  margin  of  ramus  of  pubis,  giving  off  artery 
of  cms  penis  and  artery  of  bulb  between  layers  of  triangular  ligament — piercing 
anterior  layer  of  deep  perineal  fascia  as  the  dorsal  arterv  of  penis. 

Relations. — (a)  Within  Pelvis: — descends  over  pyriformis  muscle  and 
sacral  plexus  to  lower  border  of  great  sacrosciatic  notch,  whence  it  emerges 
between  pyriformis  and  coccygeus  muscles,  together  with  sciatic  artery, 
pudic  nerve,  greater  and  lesser  sciatic  nerves,  and  nerve  to  obturator  internus 


Fig. 42. — Ligation  of  Right  Internal  Pudic  and  Sciatic  Arteriks  upon  the  Buttock,  be- 
low the  Pyriformis: — A,  A,  Gluteus  maximus  (incised  and  retracted);  P>,  Pyriformis  (lower 
border  retracted  upward);  C,  Obturator  internus,  with  gemellus  superior  and  inferior,  above  and 
beli  iw  ;  D,  Pudic  artery  and  venae  comites  ;  E,  Internal  pudic  nerve ;  F,  Sciatic  artery  and  venae  com- 
ites  ;  G,  Small  sciatic  nerve  ;  H,  Great  sciatic  nerve. 

muscle,  (b)  Crossing  Spine  of  Ischium: — is  covered  by  gluteus  maximus  and 
edge  of  great  sacrosciatic  ligament.  A  vena  comes  is  on  either  side,  and  the 
nerve  to  the  obturator  internus  to  the  outer  side  and  the  pudic  nerve  to  the 
inner  side,  (c)  On  Obturator  Internus  Muscle: — bound  to  muscle  by  sheath 
of  obturator  layer  of  pelvic  fascia  (Alcock's  canal),  with  dorsal  nerve  of  penis 
above  and  superficial  perineal  nerve  below,  (d)  Between  Two  Layers  of 
Triangular  Ligament: — runs  near  to  ramus  of  pubis,  in  substance  of  com- 
pressor urethra?  muscle. 

Line  of  Artery. — See  Surgical  Anatomy  of  Sciatic  Artery. 

Indications  for  Ligation. — Wounds. 

Sites  for  Ligation. — Over  the  spine  of  the  ischium,  or  in  the  perineum. 
(Fig    41,  E.) 

Comment. — The  main  trunk  of  the  arterv  is  the  same  in  both  sexes. 


LIGATION    OF    GLUTEAL    BRANCH   OF   INTERNAL   ILIAC   ARTERY.       87 
LIGATION  OF  INTERNAL  PUDIC  BRANCH  OF  INTERNAL  ILIAC 

UPOX    THE    BUTTOCK. 

Position — Landmarks — Incision — Operation. — Same  as  for  Ligation 
of  Sciatic  Branch  of  Internal  Iliac  upon  the  Buttock — the  arteries  lying  side 
by  side  at  their  exit  from  the  pelvis,  below  the  lower  border  of  the  pyriformis 
(Fig.  41,  E,  and  Fig.  42,  D). 

LIGATION  OF  INTERNAL  PUDIC  BRANCH  OF  INTERNAL  ILIAC 

IN   THE    PERINEUM. 

Position. — Patient  in  lithotomy  position.     Surgeon  sits  facing  buttock. 

Landmarks. — Tuberosity  and  ascending  ramus  of  ischium. 

Incision. — Begins  about  7.5  cm.  (3  inches)  above  inner  border  of  tuber- 
osity of  ischium  and  passes  downward  along  the  margin  of  the  ascending 
ramus  of  the  ischium. 

Operation. — Divide  skin  and  fascia,  avoiding  inferior  pudendal  nerve 
beneath  the  superficial  fascia.  The  erector  penis  muscle  is  exposed  (in  the 
male).  The  transversus  perinan  is  either  cut  or  drawn  downward  and  in- 
ward. Divide  the  base  of  the  triangular  ligament  and  adjacent  parietal 
pelvic  fascia — when  the  artery  will  be  found  running  forward  above  the 
pudic  nerve,  upon  the  inner  surface  of  the  obturator  internus  muscle,  and 
above  the  attachment  of  the  great  sacrosciatic  ligament. 


SURGICAL    ANATOMY    OF    GLUTEAL    BRANCH    OF    POSTERIOR    DIVI- 
SION OF  INTERNAL  ILIAC. 

Description  and  Relations. — Largest  branch  of  posterior  division,  of 
which  it  is  the  continuation.  Passes  backward  and  downward  between 
first  sacral  nerve  and  lumbosacral  cord — leaving  pelvis  through  upper  part 
of  sacrosciatic  notch,  above  pyriformis,  in  osseotendinous  groove  formed  by 
margin  of  bone  and  pelvic  fascia,  accompanied  by  gluteal  vein  and  superior 
gluteal  nerve, — emerging  from  the  pelvis  under  the  gluteus  maximus,  where 
it  divides  into  its  branches  just  above  the  upper  border  of  the  pyriformis 
muscle. 

Line  of  Artery. — Having  rotated  inward  and  slightly  flexed  the  thigh, 
draw  a  line  from  the  posterior  superior  iliac  spine  to  the  top  of  the  great 
trochanter.  A  point  on  this  line  at  the  junction  of  the  upper  and  middle 
thirds  will  correspond  with  the  emergence  of  the  gluteal  artery  from  the 
sciatic  notch  (Fig.  41,  A,  B,  D). 

Indications  for  Ligation. — Wounds;  aneurism. 

Site  for  Ligation. — At  emergence  from  sciatic  notch,  at  upper  border 
of  pyriformis  muscle  (Fig.  41). 


LIGATION  OF  GLUTEAL  BRANCH  OF  INTERNAL  ILIAC  ARTERY 

ON   THE    BUTTOCK. 

Position. — Patient  on  involved  side,  rolled  nearly  onto  chest;  knee  flexed; 
thigh  rotated  inward.     Surgeon  on  side  of  operation. 

Landmarks. — Posterior  superior  iliac  spine;  top  of  great  trochanter. 


88  OPERATIONS    UPON    THE    ARTERIES. 

Incision. — Having  drawn  the  line  given  under  Surgical  Anatomy,  an 
incision  about  to  cm.  (4  inches)  in  length  is  drawn  along  this  line,  with  its 
center  corresponding  with  the  junction  of  its  upper  and  middle  thirds,  which 
will  be  over  the  site  at  which  the  gluteal  artery  leaves  the  sciatic  notch 
(Fig.  41,  D). 

Operation. — After  dividing  skin,  superficial  fascia,  some  superficial 
nerves,  and  the  fascia  of  the  gluteus  maximus,  the  muscle  itself  is  met,  its 
fibers  running  parallel  with  the  skin  incision  (Fig.  43).  Incise  the  muscle- 
fibers  of  the  gluteus  maximus  along  their  cleavage  line.  Having  passed 
through  the  thickness  of  the  gluteus  maximus,  a  branch  of  the  gluteal  artery 
will  generally  lead  to  the  interval  between  the  gluteus  medius  and  pyriformis 
(which  otherwise  is  sought  without  this  guide).  Having  divided  the  fascia 
over  the  lower  border  of  the  gluteus  medius,  separate  these  muscles  by  re- 
tractors and  expose  the  upper  margin  of  the  sciatic  notch  by  passing  the 


Fig.  43.— Ligation  of  Right  Gluteal  Artery  upon  the  Buttock,  above  the  Pyriformis: — 
A,  Deep  fascia  over  gluteus  maximus;  B,  B,  Gluteus  maximus,  incised  and  retracted;  C,  Gluteus 
medius  (retracted  upward)  ;  D,  Pyriformis  (retracted  downward  i  ;  E,  Fascia  between  gluteus  max- 
imus and  gluteus  medius  and  pyriformis;  F,  Gluteal  artery  and  vena;  comites  ;  G,  Superior  gluteal 
nerve  and  branches;  H,  Gluteus  minimus. 


finger  under  the  lower  border  of  the  gluteus  medius — and  through  the  upper 
portion  of  the  sciatic  notch,  between  the  lower  border  of  the  gluteus  medius 
and  upper  border  of  the  pyriformis,  emerge  the  gluteal  artery,  vein,  and 
superior  gluteal  nerve. 


SURGICAL  ANATOMY  OF  EXTERNAL  ILIAC  ARTERY. 

Description. — The  larger  (in  the  adult)  branch  of  common  iliac.  About 
9  to  10  cm.  (3^  to  4  inches)  in  length.  Arises  at  bifurcation  of  common 
iliac  at  sacro-iliac  synchondrosis — running  thence  obliquely  downward  and 
outward  along  brim  of  pelvis,  upon  inner  border  of  psoas  muscle — passing 
under  lower  border  of  Poupart's  ligament,  midway  between  anterior  superior 
iliac  spine  and  symphysis  pubis,  to  become  femoral.  The  external  iliac  vein 
lies  to  inner  side  of  artery  below,  and  to  inner  and  posterior  aspect  above. 


LIGATION    OF    EXTERNAL    ILIAC.  89 

The  deep  epigastric  artery  arises  about  6  mm.  (\  inch)  above  Poupart's 
ligament,  and  runs  between  transversalis  fascia  and  peritoneum  toward  the 
umbilicus.  The  deep  circumflex  iliac  arises  below  the  deep  epigastric,  and 
passes  behind  Poupart's  ligament  upon  the  iliacus  muscle.  The  internal 
abdominal  ring  is  situated  about  1.3  cm.  (%  inch)  above  Poupart's  ligament, 
and  midway  between  anterior  superior  iliac  spine  and  spine  of  os  pubis, 
and  hence  just  external  to  course  of  artery. 

Relations. — Anteriorly:  Parietal  peritoneum;  subperitoneal  fascia;  end 
of  ileum,  on  right;  sigmoid  flexure  of  colon,  on  left;  genital  branch  of  genito- 
crural  nerve  (over  its  lower  third);  circumflex  iliac  vein;  spermatic  artery 
and  vein;  ovarian  vessels  (in  female);  vas  deferens;  ureter  (sometimes);  ex- 
ternal iliac  lymphatic  vessels  and  glands.  Posteriorly  :  External  iliac  vein ; 
inner  border  of  psoas  magnus  and  its  tendon;  iliac  fascia.  Internally: 
External  iliac  vein;  peritoneum;  vas  deferens;  ovarian  vessels,  in  female. 
Externally:  Psoas  magnus;  iliac  fascia. 

Branches. — Deep  epigastric;  deep  circumflex  iliac;  several  branches  to 
psoas  magnus  and  lymphatic  glands. 

Line  of  Artery. — See  Surgical  Anatomy  of  Common  Iliac. 

Indications  for  Ligation. — Wounds;  secondary  hemorrhage;  femoral 
or  iliofemoral  aneurisms;  to  arrest  malignant  growths;  in  elephantiasis  arabum; 
as  a  distal  ligation  in  aneurism  of  common  iliac. 

Sites  of  Ligation. — Proximal  to  deep  epigastric  and  deep  circumflex  iliac 
branches  (Fig.  39,  D). 


LIGATION  OF  EXTERNAL  ILIAC 

BY   RETROPERITONEAL   ROUTE. 

Position. — Patient  supine,  near  edge  of  table.  Surgeon  on  side  of 
operation.' 

Landmarks. — Poupart's  ligament;  anterior  superior  iliac  spine;  line  of 
artery. 

Incision. — Begins  over  external  iliac  artery,  about  1.3  cm.  (h  inch) 
above  Poupart's  ligament,  and  passes  upward  and  outward  parallel  with 
the  ligament,  to  the  anterior  superior  iliac  spine — and  is  prolonged  upward  as 
far  as  necessary,  in  the  cleavage  line  of  the  external  oblique  (Fig.  39,  D). 

Operation. — (1)  Having  incised  skin,  superficial  fascia — together  with, 
possibly,  the  superficial  epigastric,  branches  of  superficial  circumflex  iliac, 
with  their  veins,  ligating  where  necessary,  expose  the  aponeurosis  of  the 
external  oblique  (Fig.  44).  (2)  Divide  this  aponeurosis  in  its  cleavage  line, 
without  cutting  its  fibers — and  continue  this  division,  or  separation,  in  the 
cleavage  line  as  far  toward  or  beyond  the  anterior  superior  iliac  spine  as 
indicated  to  give  free  room  for  manipulation.  (3)  Having  retracted  the  cut 
edges  of  the  external  oblique  well  apart,  separate  from  the  outer  half  of 
Poupart's  ligament  the  attachment  of  the  internal  oblique.  Carefully  retract 
the  cut  edges  of  the  internal  oblique,  being  on  the  watch  for  branches  of  the 
iliohvpogastric  and  ilio-inguinal  nerves  between  the  internal  oblique  and 
transversalis,  and,  if  encountered,  carefully  displace  them  above  or  below, 
but  avoid  cutting  them.  If  necessary  to  gain  more  room,  the  internal  oblique 
is  to  be  incised  in  the  line  of  the  separation  of  the  external  oblique  as  far  as 
the  upper  limit  of  the  separation  of  the  fibers  of  the  latter  muscle.  (4)  Having 
incised  the  internal  oblique  and  protected  the  nerves  encountered,  detach 
the  transversalis  from  the  outer  third  of  Poupart's  ligament,  and  as  far  beyond 


9° 


OPERATIONS    UPON    THE   ARTERIES. 


as  necessary,  incising  its  fibers  transversely  to  their  direction,  but  in  the 
direction  of  the  division  of  the  internal  oblique.  After  dividing  the  trans- 
versalis,  guard  the  deep  circumflex  iliac  artery  and  vein  and  the  genitocrural 
nerve,  both  lying  between  the  transversalis  fascia  and  peritoneum.  (5) 
Having  now  separated  the  fibers  of  the  aponeurosis  of  the  external  oblique, 
and  divided  the  fibers  of  the  internal  oblique  and  transversalis  in  the  same 
line  as  the  separation  of  the  external  oblique  aponeurosis,  and  having  safe- 
guarded the  important  nerves  encountered,  the  fascia  transversalis  is  then 
exposed  and  is  divided  over  the  artery  in  a  transverse  direction,  corresponding 


Fig.  44—  Ligation  of  Right  External  Iliac,  Retroperitoneally— through  Oblique  In- 
cision Parallel  with  Poupart's  Ligament: — A,  A,  Superficial  epigastric  artery;  B,  External 
oblique  muscle  ;  C,  C,  G,  External  oblique  aponeurosis  ;  D,  Internal  oblique;  E,  Ilioinguinal  nerve  ; 
F,  Transversalis  muscle;  H,  Deep  circumflex  iliac  artery  and  accompanying  vein;  I,  Deep  epigas- 
tric artery  and  venae  comites ;  J,  Genitocrural  nerve ;  K,  Peritoneum  (peeled  back  and  retracted  up- 
ward) ;  L,  Iliac  fascia  ;  M,  External  iliac  artery  (its  sheath  incisedj  ;  N,  External  iliac  vein  ;  O,  An- 
terior crural  nerve  (seen  through  fascial  ;  P,  Poupart's  ligament. 


with  the  preceding  separation  and  incision  lines.  The  artery  is  here  clearly 
defined,  and  the  deep  epigastric,  the  main  source  of  collateral  circulation, 
is  carefully  guarded.  (6)  As  soon  as  the  artery  is  clearly  located,  the  sub- 
peritoneal tissue  about  the  vessel  is  carefully  opened  up  and  the  artery  well 
exposed — as  well  as  the  deep  epigastric,  for  the  purpose  of  guarding  it.  The 
peritoneum  is  then  pushed  and  rolled  backward  and  upward  from  the  vessel 
with  the  fingers  and  held  out  of  the  way  by  retractors.  (7)  When  sufficiently 
exposed,  the  sheath  of  the  artery  is  opened  and  the  needle  passed  from  the 
vein  on  its  inner  side  guarding  the  anterior  crural  nerve  on  its  outer  side. 
The  ligature  should  be  about  3  cm.  (i\  inches)  above  Poupart's  ligament. 
(8)  In  concluding  the  operation,  the  cut  edges  of  the  transversalis  are  united 
by  buried  catgut  sutures  to  their  line  of  severance  from  Poupart's  ligament, 
and  as  far  beyond  as  they  may  have  been  divided.  The  cut  edges  of  the 
internal  oblique  are  similarly  sutured  to  their  former  attachment  to  Poupart's 
ligament,  and  to  their  opposite  cut  margin  as  far  beyond  as  divided.     And, 


SURGICAL    ANATOMY    OF    FEMORAL    ARTERY.  QI 

finally,  the  separated  margins  of  the  external  oblique  are  united  by  a  buried 
gut  suture.     The  skin  wound  is  then  closed. 

Comment. — The  incision  for  exposure  may,  if  thought  necessary,  begin 
about  3  cm.  (i|  inches)  to  the  outer  side  of  the  spine  of  the  os  pubis — being 
thus  begun  well  to  the  inner  side  of  the  artery,  as  in  the  modified  Astley 
Cooper  operation. 

Collateral  Circulation. — Internal  mammary,  lumbar,  lower  intercostals, 
above;  with  deep  epigastric,  below.  Iliolumbar,  lumbar,  gluteal,  above; 
with  deep  circumflex  iliac,  below.  Obturator  and  sciatic,  above;  with  internal 
circumflex  below.  Sciatic,  above;  with  superior  perforating,  below.  Gluteal, 
above;  with  external  and  internal  circumflex  and  first  perforating,  below. 
Internal  pudic,  above;  with  external  pudic,  below. 


LIGATION  OF  EXTERNAL  ILIAC 

BV   TRANSPERITONEAL    ROUTE. 

Position. — As  in  the  extraperitoneal  operation.  Or  in  the  Trendelen- 
burg position. 

Landmarks. — As  for  the  extraperitoneal  exposure. 

Incision. — The  incision  may  be  in  one  of  three  sites:  (a)  As  an  intra- 
muscular incision,  placed  over  the  site  of  the  artery  to  be  tied  (Fig.  39,  F); 
(b)  vertical,  in  the  linea  semilunaris  (Fig.  39,  E);  or  (c)  vertical,  in  the  linea 
alba  (Fig    39,  C). 

Operation. — The  steps  of  the  operation  and  the  manipulation  to  expose 
the  site  of  ligation  are,  practically,  similar  to  those  in  the  transperitoneal 
exposure  of  the  common  iliac,  or  the  internal  iliac. 


SURGICAL  ANATOMY  OF  FEMORAL  ARTERY. 

Description. — Continuation  of  external  iliac.  Begins  at  lower  border 
of  Poupart's  ligament,  midway  between  anterior  superior  iliac  spine  and 
symphysis  pubis — passes  down  anterior  and  inner  side  of  thigh  to  opening 
in  adductor  magnus,  at  junction  of  middle  and  lower  thirds  of  thigh,  through 
which  it  passes  into  popliteal  space,  becoming  popliteal  artery.  Above,  the 
artery  lies  near  the  antero-internal  aspect  of  head  of  femur.  Below,  it  is 
close  to  inner  side  of  bone.  Between,  it  is  some  distance  from  bone.  In 
its  upper  third  the  artery  passes  from  the  center  of  base  to  apex  of  Scarpa's 
triangle.  [Scarpa's  triangle  is  bounded,  externally,  by  sartorius;  internally, 
by  adductor  iongus;  its  base,  above,  being  formed  by  Poupart's  ligament; 
its  apex,  below,  at  junction  of  sartorius  and  adductor  Iongus.  Its  floor 
(from  without  inward)  is  formed  by  iliacus,  psoas,  pectineus,  small  part  of 
adductor  brevis,  and  small  part  of  adductor  Iongus.  It  contains  femoral 
artery  (in  its  center),  with  its  cutaneous  and  profunda  branches;  femoral  vein 
(toward  inner  side),  with  deep  femoral  vein  and  internal  saphenous  branches, 
passing  from  middle  of  base  to  apex;  anterior  crural  nerve  (to  outer  side): 
lymphatic  glands.]  In  its  lower  third  the  artery  passes  through  Hunter's 
canal.  [Hunter's  canal  is  an  aponeurotic  canal  extending  from  apex  of 
Scarpa's  triangle  to  femoral  opening  in  adductor  magnus,  and  formed,  ex- 
ternally, by  vastus  internus;  postero-internaily,  by  adductor  Iongus  and 
magnus;  antero-internally,  by  aponeurosis  stretching  from  vastus  internus 
over  femoral  vessels  to  adductor  Iongus  and  magnus,  the  sartorius  passing 
over  top  of  this  aponeurosis.     It  contains  femoral  artery,  femoral  vein  (each 


92 


OPERATIONS    UPON    THE    ARTERIES. 


in  its  own  sheath,  the  vein  being  behind  and  external  to  artery),  and  long 
saphenous  nerve  (external  to  vessels).] 

Divisions  of  Artery.— Common  Femoral— first  4  cm.  (i1  inches). 
Superficial  Femoral— made  up  by  remainder  (about  9  cm.— 3$  inches).  Deep 
Femoral — profunda  femoris  branch. 

Relations.— (a)  Common  Femoral :—  Anteriorly— skin;  superficial 
fascia;  superficial  inguinal  glands;  iliac  portion  of  fascia  lata;  continuation 
of  transversalis  fascia  into  femoral  sheath;  crural  branch  of  genitocrural 
nerve;  superficial  circumflex  iliac  vein;  superficial  epigastric  vein  (sometimes). 
Posteriorly — continuation  of  iliac  fascia  into  femoral  sheath;  pubic  portion 
of  fascia  lata;  nerve  to  pectineus;  psoas  muscle;  pectineus  muscle;  capsule 
of  hip-joint.  Externally— anterior  crural  nerves.  Internally— femoral 
vein,  (b)  Superficial  Femoral  Artery  in  Scarpa's  Triangle  :— Anteriorly 
—skin;  superficial  fascia;  crural  branch  of  genitocrural  nerve;  deep  fascia; 


Fig. 45. —Incisions  for  Ligation  of  Chief  Arteries  of  Thigh  :— A.  Anterior  superior  iliac 
spine  ;  B,  Symphysis  pubis  ;  C,  Adductor  tubercle  ;  D,  Mid-point  between  anterior  superior  iliac  spine 
and  symphysis  pubis  ;  E,  Ligation  of  common  femoral  at  baseof  Scarpa's  triangle,  by  incision  parallel 
with  artery;  F,  Same,  by  incision  parallel  with  and  just  below  Poupart's  ligament;  G,  Of  profunda 
femoris,  near  origin  ;  H,  Of  superficial  femoral  at  apex  of  Scarpa's  triangle  ;  I,  Of  superficial  femoral 
in  Hunter's  canal ;  J,  Of  popliteal  in  upper  part  of  popliteal  space,  from  inner  side  of  thigh. 


internal  cutaneous  nerve.  Posteriorly — femoral  vein;  profunda  vein;  pro- 
funda artery;  pectineus  muscle;  adductor  longus.  Externally — long  saphe- 
nous nerve;  nerve  to  vastus  internus.  Internally — femoral  vein  (getting 
behind  artery  at  apex  of  Scarpa's  triangle),  (c)  Superficial  Femoral 
Artery  in  Hunter's  Canal: — Anteriorly — skin;  superficial  fascia;  deep 
fascia;  sartorius;  aponeurotic  roof  of  Hunter's  canal;  internal  saphenous 
nerve.  Posteriorly — angle  of  junction  of  vastus  internus  and  adductors; 
femoral  vein  (lying,  in  middle  of  Hunter's  canal,  behind  and  becoming 
slightly  external  and  closely  adherent  to  artery).  Externally— vastus  internus, 
femoral  vein  (at  lower  part  of  Hunter's  canal).  Internally— adductor  longus 
(above) ;  adductor  magnus  (below) . 

Branches. — From  Common  Femoral — superficial  epigastric,  superficial 
circumflex  iliac,  superficial  external  pudic,  deep  external  pudic,  profunda. 
From    Superficial    Femoral    in    Scarpa's    Triangle— muscular,    saphenous. 


LIGATION    OF    COMMON    FEMORAL.  93 

From  Superficial  Femoral  in  Hunter's  Canal— muscular,  anastomotica 
magna. 

Line  of  Artery. — (With  hip  slightly  flexed,  thigh  abducted  and  rotated 
outward.)  From  a  point  midway  between  anterior  superior  iliac  spine 
and  symphysis  pubis,  to  adductor  tubercle  of  internal  femoral  condyle 
(Fig.  45,  D,  C).  (When  thigh  in  normal  position  and  parallel  with  its 
fellow — from  midway  between  anterior  superior  iliac  spine  and  symphysis 
pubis,  to  inner  border  of  patella.) 

Sites  for  Ligation. — Common  femoral  at  base  of  Scarpa's  triangle — 
rare  (on  account  of  proximity  of  large  vessels).  Superficial  femoral  at  apex 
of  Scarpa's  triangle — operation  of  election.  Superficial  femoral  in  Hunter's 
canal — not  common  (Fig.  45). 

Indications  for  Ligation.— As  for  ligation  of  External  Iliac  (page  89). 

Comment. — (i)  A  short  common  femoral  is  more  frequent  than  a  long 
one.  (2)  Apex  of  Scarpa's  triangle  is  from  7.5  to  9  cm.  (3  to  3$  inches) 
below  Poupart's  ligament.  (3)  Profunda  femoris  arises  about  4  cm.  (i£ 
inches)  below  Poupart's  ligament.  (4)  At  groin,  femoral  artery  and  vein 
are  on  same  plane — at  apex  of  Scarpa's  triangle,  vein  is  posterior — in  middle 
of  Hunter's  canal,  vein  is  posterior  and  slightly  external — at  lower  part  of 
Hunter's  canal,  vein  is  external.  (5)  Order  of  vessels  at  apex  of  Scarpa's 
triangle,  from  before  backward,  is  femoral  artery,  femoral  vein,  profunda 
vein,  profunda  artery.  (6)  Line  approximately  representing  course  of  long 
saphenous  vein  is  one  running  from  a  point  about  2  cm.  (f  inch)  internal  to 
mid-point  between  anterior  superior  iliac  spine  and  symphysis  pubis,  to 
posterior  border  of  sartorius  muscle  at  femoral  condyle. 

LIGATION  OF  COMMON  FEMORAL 

AT  BASE  OF  SCARPA'S  TRIANGLE— BY  INCISION  PARALLEL  WITH  ARTERY. 

Position. — Patient  supine;  hip  slightly  flexed;  thigh  abducted  and  rotated 
outward;  knee  bent  and  lying  upon  its  outer  aspect.  Surgeon  stands  on 
side  of  operated  limb,  cutting  from  above  downward  on  the  right,  and  vice 
versa. 

Landmarks. — Line  of  artery  (page  93) . 

Incision. — About  5  cm.  (2  inches),  beginning  just  a  little  above  Poupart's 
ligament  and  extending  downward  in  line  of  artery  (Fig.  45,  E). 

Operation. — Incise  skin  and  superficial  fascia.  Avoid  lymphatic  glands 
— also  the  superficial  circumflex  iliac,  superficial  epigastric,  and  superficial 
external  pudic  arteries  and  veins.  Divide  the  iliac  portion  of  the  fascia  lata 
(Fig.  46).  Avoid  the  crural  branch  of  the  genitocrural  nerve  on  the  femoral 
sheath,  a  little  external  to  the  artery.  Expose  and  open  the  sheath,  guarding 
the  femoral  vein,  which  lies  immediately  to  the  inner  side  of  the  artery  and 
within  the  sheath — and  the  anterior  crural  nerve  lying  further  to  the  outer 
side  of  the  artery  and  outside  of  the  sheath.     Pass  the  needle  from  the  vein 

(Fig.  47)- 

Comment. — (I)  Ligation  at  the  base  of  Scarpa's  triangle  is  rarely  done, 
owing  to  the  nearness  and  number  of  the  branches — except  in  such  cases 
as  wounds,  and  to  control  hemorrhage  at  the  hip-joint,  or  for  temporary 
control  in  operating  about  the  thigh.  Where  not  otherwise  indicated,  ligation 
of  the  external  iliac  is  the  better  operation.  (2)  The  artery  may  also  be 
exposed,  at  this  site,  by  an  incision  parallel  with  and  about  6  mm.  (^  inch) 
below  the  middle  third  of  Poupart's  ligament  (Fig.  45,  F). 

Collateral   Circulation. — Internal   pudic   of   internal   iliac;   with   pudic 


94 


OPERATIONS    UPON    THE    ARTERIES. 


of  femoral.  Gluteal;  with  external  and  internal  circumflex  and  superior 
perforating.  Superficial  circumflex  iliac;  with  external  circumflex.  Ob- 
turator;   with   internal   circumflex.     Sciatic;   with   superior   perforating   and 


Fig.  46. — Ligation  of  Right  Common  Femoral  at  Base  of  Scarpa's  Triangle: — A,  A> 
Superficial  fascia;  B,  B,  Fascia  lata;  D,  Pectineus;  E,  Psoas;  G,  G,  Poupart's  ligament  and  external 
oblique;  H,  Common  femoral  artery,  with  superficial  epigastric,  external  pudic,  and  circumflex 
iliac  branches;  I,  I,  Femoral  vein;  J,  Internal  saphenous,  with  superficial  epigastric,  external 
pudic,  and  circumflex  iliac  veins;  K,  Anterior  crural  nerve;  L,  Crural  branch  of  genitocrural. 

internal  circumflex.     Comes  nervi  ischiadici;  with  all  the  perforating  branches 
of  profunda  and  articular  of  popliteal. 


SURGICAL  ANATOMY  OF  PROFUNDA  FEMORIS  BRANCH  OF  COMMON 

FEMORAL  ARTERY. 

Description. — Largest  branch  of  femoral,  nearly  equaling  main  trunk. 
Arises  from  externo-posterior  aspect  of  common  femoral,  about  4  cm.  (ih 
inches)  below  Poupart's  ligament — passing  down  thigh,  at  first  external  to 


LIGATION    OF    PROFUNDA    FEMORIS. 


95 


superficial  femoral — thence  posterior  to  femoral  artery  and  vein  to  inner 
side  of  femur — thence  leaves  femur  and  runs  beneath  adductor  longus  and 
adductor  magnus. 

Relations. — Anteriorly:  (near  origin)  skin;  superficial  fascia;  deep 
fascia;  branches  of  anterior  crural  nerve;  (lower  down)  femoral  vein;  pro- 
funda vein;  (still  lower)  adductor  longus.  Posteriorly:  (in  order)  iliacus; 
pectineus;  adductor  brevis;  adductor  magnus.  Externally  :  vastus  internus. 
Internally:  pectineus;  angle  of  junction  of  adductor  brevis  and  adductor 
magnus. 

Branches. — External  circumflex;  internal  circumflex;  three  perforating. 

Site  of  Ligation. — At  origin. 

Indications  for  Ligation. — Wounds  of  itself  and  branches.     Aneurisms. 




Fig.  47. — Cross-section  of  the  Left  Thigh,  through  the  Head  of  the  Femur  (The 
skin  relations  of  this  section  erroneously  represent  a  lower  level.): — A,  Iliacus;  B,  Sartorius; 
C,  Femoral  artery,  vein,  and  crural  nerve;  D,  Pectineus;  E,  Psoas;  F,  Tensor  vaginas  femoris; 
G,  Gluteus  minimus;  H,  Gluteus  medius;  I,  Great  sciatic  artery,  vein,  and  nerve;  J,  Gluteus 
maximus;  K,  Obturator  internus;  L,  Obturator  externus;  M,  Adductor  brevis;  N,  Adductor 
longus.     (The  cross-section  from  Braune.j 


LIGATION  OF  PROFUNDA  FEMORIS 

NEAR   ORIGIN. 

Position. — Patient  supine;  limb  extended  and  parallel  with  fellow. 
Surgeon  on  outer  side  of  operated  limb,  cutting  from  above  downward  on 
the  right,  and  vice  versa. 

Landmarks. — Line  of  artery  (with  extended  limb — see  page  93) ;  Pou- 
part's  ligament. 


96 


OPERATION'S    UPON    THE    ARTERIES. 


Incision. — About  5  or  6  cm.  (2  or  2^  inches)  in  length,  in  line  of  artery 
— calculating  to  fall  over  its  outer  border,  with  the  center  of  incision  over  a 
point  in  the  course  of  the  artery  about  4  cm.  (ij  inches)  below  Poupart's 
ligament  (Fig.  45,  G). 

Operation. — Incise  skin,  superficial  fascia,  and  fascia  lata.  Expose  the 
inner  edge  of  the  sartorius  and  retract  it  outward.  Beneath  this  muscle 
lies  the  rectus,  with  branches  of  the  anterior  crural  nerve  in  close  relation — 
these  are  to  be  drawn  outward.  The  trunk  of  the  common  femoral  will 
then  be  exposed,  with  the  profunda  coming  off  from  its  postero-external 
aspect,  and  running  outward  and  downward,  with  the  external  circumflex 
arising  from  it  and  passing  under  the  rectus.  The  artery  is  then  freed  and 
the  ligature  passed. 


Fig.  48. —Ligation  of  Right  Femoral  at  Apex  of  Scarpa's  Triangle  :— A,  Sartorius;  B, 
Adductor  longus ;  C,  Femoral  artery  and  muscular  branches,  with  its  sheath  incised  and  retracted; 
D,  Femoral  vein  ;  E,  Branch  of  internal  saphenous  vein  ;  F,  Long  saphenous  nerve ;  G,  Internal  cuta- 
neous nerve. 


LIGATION  OF   SUPERFICIAL  FEMORAL 

AT  APEX  OF  SCARPA'S  TRIANGLE. 

Position. — Same  as  for  ligation  of  common  femoral  at  base  of  Scarpa's 
triangle. 

Landmarks. — Line  of  artery. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  in  line  of  artery — with  its 


LIGATION    OF    SUPERFICIAL    FEMORAL    ARTERY. 


97 


center  over  apex  of  Scarpa's  triangle,  that  is,  about  7.5  cm.  (3  inches)  below 
Poupart's  ligament  (Fig.  45,  H). 

Operation. — Incise  skin  and  superficial  fascia.  Draw  aside,  or  ligate, 
branches  of  internal  saphenous  vein  (Fig.  48).  Divide  fascia  lata.  Identify 
inner  margin  of  sartorius  (fibers  running  downward  and  inward)  and  retract 
outward.  Open  up  the  groove  between  the  sartorius  and  adductor  longus 
(fibers  of  latter  running  directly  downward,  or  downward  and  outward)  and 
retract  the  adductor  longus  internally,  if  necessary.  The  internal  cutaneous 
nerve  and  long  saphenous  nerve  are  encountered  anterior  to  the  artery,  and 
are  to  be  displaced  to  one  side.  Clearly  identify  the  femoral  sheath  and 
incise — guarding  the  femoral  vein,  which  lies  posteriorly  and  internally  to 
the  artery.     Pass  the  needle  from  the  vein. 

Collateral  Circulation. — External  circumflex;  with  lower  muscular 
branches  of  femoral,  anastomotica  magna,  superior  articular  of  popliteal, 
and  anterior  tibial  recurrent.  Perforating  and  terminating  of  profunda, 
with  muscular  branches  of  femoral  and  muscular  and  superior  articular 
branches  of  popliteal.  Comes  nervi  ischiadici;  with  perforating  of  profunda 
and  articular  of  popliteal. 


Fig    49. — Ligation  of  the  Right  Femoral  Artery  in  Hunter's  Canal: — A,  Internal 
cutaneous  nerve;  B,  Sartorius;  C,  Hunter's  canal,  the  roof  incised;  D,  Femoral  artery;  E,  Femoral 
vein:  F,  Internal  saphenous  nerve. 
7 


98 


OPERATIONS    UPON    THE    ARTERIES. 


Fitr.  50. — Cross-section  through  the  Middle  of  the  Left  Thigh: — A  Rectus  muscle; 
B,  Vastus  interims;  C,  Sartorius;  D,  Superficial  femoral  artery,  vein,  and  saphenous  nerve; 
E,  Adductor  longus;  F,  Adductor  magnus;  G,  Gracilis;  H,  Semimembranosus;  I,  Vastus  externus; 
J,  Descending  branch  of  external  circumflex;  K,  Terminal  branch  of  profunda  femoris;  L, 
Crureus;  M,  Great  sciatic  nerve  and  arteria  comes  nervi  ischiadici;  N,  Biceps;  O,  Semitendinosus. 
(The  cross  section  modified  from  Braune.) 


LIGATION  OF  SUPERFICIAL  FEMORAL 

IN  HUNTER'S  CANAL. 

Position. — Same  as  for  common  femoral  at  base  of  triangle. 

Landmarks. — Line  of  artery. 

Incision. — From  7.5  to  9  cm.  (3  to  3^  inches),  in  line  of  artery — over 
middle  third  of  thigh  (Fig.  45,  I). 

Operation. — Incise  skin  and  superficial  fascia.  The  anterior  branch  of 
the  internal  cutaneous  nerve,  to  the  outer  side,  and  the  long  saphenous  vein, 
to  the  inner  side,  are  likely  to  be  encountered.  Divide  the  fascia  lata.  Ex- 
pose the  outer  edge  of  the  sartorius  (its  fibers  running  downward  and  inward) 
and  retract  inward  from  its  position  over  the  roof  of  Hunter's  canal.  Hunter's 
canal  is  thereby  exposed  in  the  interval  between  the  vastus  internus  and  the 
adductor  magnus  (the  fibers  of  the  latter  running  obliquely  downward  and 
outward).  The  nerve  to  the  vastus  internus  may  be  here  exposed.  Incise 
the  roof  of  the  canal,  when  the  internal  saphenous  nerve  is  found  between 
the  aponeurotic  roof  and  the  sheath  of  the  vessels,  running  from  without 
inward.     Open  the  sheath  and  pass  the  needle  from  the  vein  (Fig.  50). 


SURGICAL  ANATOMY  OF  POPLITEAL  ARTERY. 


99 


Comment. —  Guard  against  taking 
the  vastus  internus  for  the  sartorius — 
the  fibers  of  the  former  running  down- 
ward and  outward. 

Collateral  Circulation. — Same  as 
for  the  superficial  femoral  at  the  apex  of 
Scarpa's  triangle. 


SURGICAL  ANATOMY  OF  POPLITEAL 
ARTERY. 

Description. — Continuation  of  fem- 
oral. Extends  from  aponeurotic  open- 
ing in  adductor  magnus,  at  junction  of 
middle  and  lower  thirds  of  thigh,  down- 
ward and  outward  through  the  popliteal 
space  to  its  center  behind  the  knee-joint 
— thence  vertically  downward  to  the  in- 
ferior border  of  the  popliteus  muscle,  op- 
posite the  lower  border  of  the  tubercle  of 
the  tibia,  where  it  divides  into  anterior 
and  posterior  tibial  arteries. 

Relations. — Anteriorly  :  (from  above 
downward)  popliteal  surface  of  femur; 
posterior  ligament  of  knee;  posterior 
articular  surface  of  tibia;  popliteus  mus- 
cle. Posteriorly :  (above)  semimem- 
branosus; (center)  skin,  superficial  fascia, 
deep  fascia;  (below)  internal  head  of  gas- 
trocnemius, aponeurotic  arch  of  soleus. 
Popliteal  vein  lies  behind  artery  through- 
out its  course,  crossing  obliquely  from 
outer  to  inner  side,  and  may  be  double 
below.  Internal  popliteal  nerve  lies  be- 
hind artery  and  vein  (immediately  pos- 
terior to  latter),  crossing  the  vessels  ob- 
liquely at  their  center,  from  outer  to 
inner  side.  Externally :  (above)  ex- 
ternal condyle,  biceps,  internal  popliteal 
nerve;  (below)  outer  head  of  gastroc- 
nemius, plantaris.  Internally :  (above) 
semimembranosus;  (below)  inner  head 
of  gastrocnemius,  internal  popliteal  nerve. 

Branches. —  Cutaneous;  muscular 
(superior  muscular,  inferior  muscular  or 
sural) ;  articular  (superior  external  artic- 
ular, superior  internal  articular,  inferior 
external  articular,  inferior  internal  artic- 
ular, azygos  articular);  terminal  (poste- 
rior tibial,  anterior  tibial). 


Fig.  51. — Ligation  of  Popliteal, 
Posterior  Tibial,  and  Peroneal  Ar- 
teries:— A,  Outer  border  of  semimem- 
branosus (at  junction  of  middle  and  lower 
thirds  of  thigh)  ;  B,  Middle  of  popliteal 
space  ;  C,  Center  of  posterior  aspect  of  leg 
on  level  with  tibial  tubercle;  D,  Point 
midway  between  convexity  of  heel  and  tip 
of  internal  malleolus;  E,  Mid-point  between 
outer  border  of  tendo  Achillis  and  tip  of 
external  malleolus  ;  F,  Incision  for  popliteal 

artery  in  upper  part  of  popliteal  space,  from  behind;   G,  Same,  in  lower  part  of  popliteal  space; 

H,  Of  posterior  tibial  in  its  upper  third  ;  I,  Same,  in  its  middle  third;  J,  Same,  in  its  lower  third  ; 

K,  Same,  behind  internal  malleolus  ;  L,  Incision  for  peroneal  in  middle  of  leg. 


IOO  OPERATIONS    UPON    THE    ARTERIES. 

Line  of  Artery. — From  outer  border  of  semimembranosus  (at  junction 
of  middle  and  lower  thirds  of  thigh)  obliquely  down  to  middle  of  popliteal 
space,  directly  posterior  to  the  knee-joint  (for  upper  part  of  artery);  and 
from  mid-point  of  popliteal  space  vertically  down  to  level  of  lower  border 
of  tubercle  of  tibia  (for  lower  part  of  artery).     (Fig.  51,  A,  B,  C.) 

Sites  of  Ligation. — May  be  ligated  either  in  its  upper  part  or  lower 
part — the  artery  being  tied  with  difficulty  in  its  middle,  owing  to  its  depth 
and  relations  (Figs.  45,  J,  and  51,  F  and  G). 

Indications  for  Ligation. — Rare,  other  than  wounds  and  aneurism — 
the  superficial  femoral  usually  being  ligated  instead. 

LIGATION  OF  POPLITEAL  ARTERY  IN  UPPER  PART  OF  POPLITEAL 

SPACE 

FROM    BEHIND. 

Position. — Patient  as  nearly  prone  as  feasible,  resting  on  side  of  shoulder 
and  chest,  with  limb  extended.  Surgeon  to  outer  side  of  left  limb,  cutting 
downward;  and  to  outer  side  of  right  limb,  cutting  upward  (or  inside  of 
right  limb,  cutting  downward). 

Landmarks. — Line  of  artery  and  upper  boundaries  of  popliteal  space. 

Incision. — About  9  cm.  (3^  inches)  in  length,  in  line  of  artery,  beginning 
at  outer  border  of  semimembranosus,  at  junction  of  middle  and  lower  thirds 
of  thigh,  and  passing  obliquely  downward  to  the  middle  of  the  popliteal 
space  (Fig.  51,  F). 

Operation. — Incise  skin  and  superficial  fascia.  Avoid  the  small  sciatic 
nerve.  Open  up  the  deep  fascia.  Retract  the  hamstring  muscles  to  the 
outer  and  inner  sides.  The  popliteal  nerve  is  first  encountered  crossing  from 
the  outer  to  the  inner  side — the  popliteal  vein  crossing  similarly.  Displace 
these  structures  laterally — when  the  artery  is  found,  generally  lying  in  fatty 
areolar  tissue. 

Collateral  Circulation. — Where  the  ligation  is  between  the  superior 
and  inferior  articular  arteries; — anastomotic^  magna,  superior  external  and 
internal  articular,  descending  branch  of  external  circumflex,  above;  with  in- 
ferior external  and  internal  articular  and  anterior  tibial  recurrent  (also,  possibly, 
posterior  tibial  recurrent  and  superior  fibular  of  anterior  recurrent),  below. 

Comment. — The  upper  part  of  the  popliteal  artery  may  also  be  tied 
from  the  inner  side  of  the  leg  (v.  i.) — but  the  above  operation  is  simpler,  unless 
the  popliteal  region  be  encroached  upon  by  some  pathological  condition. 

LIGATION  OF  POPLITEAL  ARTERY  IN  UPPER  PART  OF  POPLITEAL 

SPACE 

FROM    INNER   SIDE   OF    THIGH—  JOBERT'S   OPERATION. 

Position. — Patient  supine;  thigh  slightly  flexed;  fully  abducted  and 
rotated  outward;  knee  at  a  right  angle  and  resting  on  external  aspect.  Surgeon 
on  outside,  cutting  downward  on  right,  upward  on  left  (or  may  stand  on 
inner  side  of  left  and  cut  downward) . 

Landmarks. — Tendon  of  adductor  magnus. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  beginning  opposite  the 
junction  of  middle  and  lower  thirds  of  thigh,  and  running  parallel  with  and 
immediately  posterior  to  the  tendon  of  the  adductor  magnus  (which  is  inserted 
into  the  adductor  tubercle  on  the  internal  condyle  of  the  femur).     (Fig.  45,  J.) 

Operation. — Incise  skin  and  superficial  fascia.  Avoid  anterior  branch 
of  internal   cutaneous  nerve    (Fig.   52).     Divide  deep   fascia.     Expose   the 


LIGATION    OF    POPLITEAL    ARTERY. 


IOI 


anterior  edge  of  the  sartorius  and  retract  it  backward,  together  with  the 
internal  saphenous  vein,  if  in  view  (the  internal  saphenous  nerve  being  beneath 
the  sartorius,  out  of  view).  Having  thoroughly  divided  the  deep  fascia,  the 
adductor  magnus  tendon  is  identified  and  drawn  forward — then  the  semi- 


Fig.  52.— Ligation  of  Upper  Part  of  Right  Popliteal  from  Inner  Side  of  Thigh  : — A, 
Anterior  branch  of  internal  cutaneous  nerve;  B,  Internal  saphenous  vein  ;  C,  Sartorius  (its  anterior 
border  retracted  posteriorly  I  ;  D,  Internal  saphenous  nerve  (mainly  under  sartorius,  out  of  sight)  ;  E, 
Adductor  magnus  (drawn  anteriorly);  F,  Semimembranosus  (drawn  posteriorly);  G,  Popliteal 
artery  ;  H,  Popliteal  vein  (below  and  external  to  artery).  • 

membranosus  is  identified  and  drawn  backward — and  the  artery  is  then 
sought  between  these  two  structures,  near  the  bone  and  in  considerable 
fatty  areolar  tissue.  Both  popliteal  vein  and  nerve  lie  on  a  plane  posterior 
to  the  artery,  and  are  generally  not  brought  to  view. 


LIGATION  OF  POPLITEAL  ARTERY  IN  LOWER  PART  OF  POPLITEAL 

SPACE 

P.V  POSTERIOR  MEDIAN  INCISION. 

Position. — As  for  ligation  in  the  upper  part  of  the  space. 

Landmarks. — Boundaries  of  the  popliteal  space  (the  biceps  above,  and 
the  plantaris  and  outer  head  of  gastrocnemius  below,  forming  the  outer 
boundary; — and  the  semimembranosus  and  semitendinosus  above,  and  the 
inner  head  of  the  gastrocnemius  below,  forming  the  inner  boundary). 


102  OPERATIONS    UPON    THE    ARTERIES. 

Incision. — About  9  cm.  (3?  inches)  in  length,  beginning  at  the  middle 
of  the  popliteal  space  (on  a  level  with  the  knee-joint)  and  passing  downward 
between  the  two  heads  of  the  gastrocnemius  (Fig.  51,  G). 

Operation. — Incise  skin  and  superficial  fascia.  Avoid  the  external 
saphenous  vein  and  external  saphenous  nerve  in  the  outer  aspect  of  the 
wound,  or  the  communicans  poplitei  nerve  which  helps  form  the  external 
saphenous  nerve  (Fig.  53).  Divide  the  deep  fascia.  Expose  the  inner  and 
outer  heads  of  the  gastrocnemius,  with  the  sural  arteries  going  to  them — 
and  retract  these  and  the  plantaris  muscle  to  their  respective  sides.  Muscular 
branches  of  the  internal  popliteal  nerve  may  be  met  with  here,  and  maybe 


Fig-  53- — Ligation  of  Right  Popliteal  at  Lower  Part  of  Popliteal  Space: — A,  Inner 
head  of  gastrocnemius  (retracted  inward  l;  B,  Outer  head  of  gastrocnemius  (drawn  outward);  C, 
Plantaris;  D,  External  saphenous  vein  ;  E,  Communicans  poplitei  nerve;  F,  Internal  popliteal  nerve 
(drawn  inward)  ;  G,  Popliteal  vein  (drawn  inward]  ;  H,  Popliteal  artery  and  muscular  branches;  I, 
Popliteus  muscle. 


the  posterior  tibial  nerve.  The  external  saphenous  vein  is  the  guide  to  the 
popliteal  vessels.  The  internal  popliteal  nerve  is  found  most  superficial  of 
the  three  important  structures — the  popliteal  vein  next  (both  crossing  to  the 
inner  side,  toward  which  side  they  are  further  retracted) — and  the  artery 
deepest  of  all,  near  the  bone  and  in  much  fatty  areolar  tissue.  The  needle 
is  passed  from  the  side  of  the  vein,  flexure  of  the  knee  aiding  during  this 
stage. 

Comment. — A  continuation  upward  of  the  above  incision  would  amount 
to  ligation  of  the  popliteal  artery  in  the  middle  of  the  popliteal  space. 


SURGICAL    ANATOMY    OF    ANTERIOR    TIBIAL    ARTERY 


103 


Collateral  Circulation. — If  the  artery  be  ligated  between  the  superior 
and    inferior    articular   branches,    the 
collateral   anastomosis    would    be    the 
same  as  after  the  above  operation. 


SURGICAL  ANATOMY  OF  ANTERIOR 
TIBIAL  ARTERY. 

Description. — The  smaller  bifur- 
cation of  popliteal  artery,  at  lower 
border  of  popliteus  muscle,  passing 
thence  forward  between  the  two  heads 
of  tibialis  posticus,  through  aperture 
in  upper  part  of  interosseous  mem- 
brane, between  tibia  and  fibula,  to 
deep  part  of  front  of  leg — descending, 
at  first,  on  anterior  surface  of  interos- 
seous membrane,  then  on  the  tibia, 
and  finally  onto  front  of  ankle-joint, 
beneath  anterior  annular  ligament, 
where  it  becomes  dorsalis  pedis.  It 
is  accompanied  by  two  vena?  comites. 
The  anterior  tibial  nerve  accompanies 
its  lower  three-fourths,  lying  upon  its 
fibular  side,  though  partly  overlapping 
it  in  middle  of  leg. 

Relations.  —  Anteriorly  :  skin, 
superficial  fascia;  deep  fascia;  anterior 
tibial  nerve  (at  middle) ;  tibialis  an- 
ticus  (above) ;  extensor  longus  digi- 
torum  (above) ;  extensor  proprius  poi- 
nds (below) ;  anterior  annular  ligament 
(below).  Posteriorly:  interosseous 
membrane  (upper  two-thirds) ;  tibia 
and  ankle-joint  (lower  one-third).  Ex- 
ternally :  anterior  tibial  nerve  (above 
and  below) ;  extensor  longus  digitorum 
(upper  third) ;  extensor  proprius  poi- 
nds (middle  third).  Internally  :  tibi- 
alis anticus  (upper  two-thirds) ;  ex- 
tensor proprius  pollicis  (crosses  lower 
part  of  arterv). 

Branches. — Posterior  tibial  recur- 
rent, superior  fibular  (sometimes),  an- 
terior tibial  recurrent,  muscular,  in- 
ternal malleolar,  external  malleolar. 

Line  of  Artery. — From  inner  side 
of  head  of  fibula,  to  center  of  line  be- 
tween the  malleoli — (according  to 
Kocher,  from  midway  between  ex- 
ternal surface  of  head  of  fibula  and 
center  of  tubercle  of  tibia,  to   the 


Fig.  54. — Incisions  for  Ligation  of 
Anterior  Tibial  and  Dorsalis  Pedis  Ar- 
teries : — A,  Incision  for  upper  third  of  anterii  >r 
tibial ;  B,  For  middle  third  of  anterior  tibial ; 
C,  For  lower  third  of  anterior  tibial  ;  D,  For 
dorsalis  pedis  just  below  ankle-joint;  E,  For 
dorsalis  pedis  in  first  interosseous  space;  F, 
Inner  side  of  head  of  fibula  ;  G,  Mid-point  be- 
tween two  malleoli. 


same   point  below).     The  artery  passes 


io4 


OPERATIONS    UPON    THE    ARTERIES. 


through  the  interosseous  membrane  about  3  cm.  (1}  inches)  below  the  level 
of  the  head  of  the  fibula. 

Indications  for  Ligation.— Wounds  (of  anterior  tibial  or  in  foot); 
aneurism. 

Sites  of  Ligation.— Upper  and  middle  thirds— rarely,  except  in  wounds. 
Lower  third — most  frequent  site.     (Fig.  54). 

LIGATION  OF  ANTERIOR  TIBIAL 

IN    ITS   UPPER   THIRD. 

Position. — Patient  supine;  leg  extended  and  rotated  inward.  Surgeon 
on  outer  side  (cutting  from  above  downward,  on  the  right — and  vice  versa). 

Landmarks. — Line  of  artery. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  in  line  of  artery — beginning 
about  2.5  cm.  (1  inch)  below  head  of  fibula  (Fig.  54,  A). 


Fig.  55. — Ligation  of  the  Upper  Third  of  the  Right  Anterior  Tibial  Artery: — 
A,  Anterior  tibial  artery;  B,  Vena;  comites;  C,  Anterior  tibial  nerve;  D,  Extensor  communis 
digitorum;  E,  Branch  of  internal  saphenous  vein;  F,  Tibialis  anticus  muscle. 

Operation. — Incise  skin,  superficial  fascia,  and  deep  fascia.  Define  the 
gap  between  tibialis  anticus,  internally,  and  extensor  longus  digitorum, 
externally,  and  retract  these  structures  to  their  respective  sides  (Fig.  55). 
Open  up  this  interval — flexing  the  foot  to  relax  the  parts.  Aim  to  reach  the 
external  aspect  of  the  tibia,  covered  by  the  tibialis  anticus,  and,  when  reached, 


LIGATION    OF    ANTERIOR    TIBIAL. 


I°5 


follow  down  to  the  interosseous  membrane,  upon  which  the  artery  will  be 
found.  Two  venae  comites  lie  in  very  close  contact,  in  front  of  and  behind  the 
artery.  The  anterior  tibial  nerve  may  not  yet  have  reached  the  outer  side 
of  the  artery.  If  the  vena;  comites  be  not  separable,  include  them  in  the 
ligature. 

Comment. — The  interval  between  the  tibialis  anticus  and  extensor 
longus  digitorum  is  the  key  to  the  situation,  and  is  rather  hard  to  find.  The 
outer  edge  of  the  tibialis  anticus. often  overlaps  the  extensor  longus  digitorum. 
And  also  one  may  get  into  the  septum  between  the  extensor  longus  digitorum 
and  peroneus  longus  and  work  down  toward  the  fibula.  Guides  to  the 
proper  intermuscular  gap,  accessory  to  the  sensation  of  touch,  are  the  "  white 
line"  (sometimes  visible)  and  a  small  artery  leading  to  the  anterior  tibial. 


Fig.  56. — Cross-section  through  the  Upper  Third  of  the  Right  Leg: — A,  Tibialis 
anticus;  B,  Extensor  longus  digitorum;  C,  Anterior  tibial  vessels  and  nerve;  D,  Musculocutaneous 
nerve;  E,  Peroneus  longus;  F,  F,  F,  F,  Gastrocnemius;  H,  Posterior  tibial  vessels  and  nerve; 
I,  Soleus;  J,  Internal  saphenous  vein  and  nerve;  K,  Popliteus.  (The  cross-section  modified 
from  Braune.) 


LIGATION  OF  ANTERIOR  TIBIAL 

IN  ITS  MIDDLE  THIRD. 

Position — Landmarks. — As  for  ligation  of  the  upper  third. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  in  line  of  artery,  with  its 
center  over  the  center  of  the  leg  (Fig.  54,  B). 

Operation. — Incise  skin,  superficial  and  deep  fascia.  Recognize  the 
interval  between  the  tibialis  anticus  (its  outer  edge  still  muscular)  internally — 
and  the  extensor  longus  digitorum  (its  inner  edge  tendinous)  externally.     A 


io6 


OPERATIONS    UPON   THE    ARTERIES. 


yellow  fatty  line  may  sometimes  indicate  the  interval.  Open  up  this  interval, 
flexing  the  foot.  Retract  these  muscles  to  their  own  sides — and,  deeper  in 
the  wound,  also  retract  the  extensor  proprius  pollicis  to  the  outer  side.  Follow 
down  the  gap  toward  the  tibia  (and  not  the  gap  between  the  extensor  longus 
digitorum  and  extensor  proprius  pollicis).  The  anterior  tibial  nerve  will  be 
found  slightly  overlapping  the  artery — draw  it  outward.  The  artery  will  be 
found  on  the  interosseous  membrane,  under  cover  of  the  muscular  fibers 
of  the  tibialis  anticus,  with  the  extensor  proprius  pollicis  on  its  outer  side. 
The  venae  comites  are  separated  with  difficulty,  and,  if  so,  may  be  included 
in  the  ligature. 


Fig.  57. — 'Ligation  of  Lower  Third  of  Right  Anterior  Tibial  :— A,  Tendon  of  tibialis 
anticus,  retracted  inward  ;  B.  Extensor  proprius  hallucis,  retracted  outward  ;  C,  Extensor  longus 
digitorum  ;  U,  Annular  ligament  ;  E,  Anterior  tibial  artery  and  branches  ;  F,  F,  Anterior  tibial  venae 
comites;  G,  Anterior  tibial  nerve;  H,  Inner  branch  of  musculocutaneous  nerve;  I,  Branch  of 
internal  saphenous  vein. 


LIGATION  OF  ANTERIOR  TIBIAL 

IX  ITS  LOWER  THIRD. 

Position. — As  for  ligation  of  the  upper  third — without  the  inward  rota- 
tion of  the  foot. 

Landmarks. — Line  of  artery. 

Incision. — From  5  to  7.5  cm.  (2  to  3  inches)  in  length,  with  center  over 
center  of  lower  third  of  leg  (Fig.  54,  C). 

Operation. — Incise  skin  and  fascia.  Clearly  identify  tendon  of  tibialis 
anticus.  Divide  the  upper  part  of  the  superior  band  of  the  anterior  annular 
ligament  in  the  line  of  the  wound  (Fig.  57).     Demonstrate  the  interval  be- 


LIGATION    OF    DORSALIS    PEDIS.  107 

tween  the  tendon  of  the  tibialis  anticus  and  tendon  of  the  extensor  proprius 
pollicis — flexing  the  foot  and  retracting  these  tendons  to  their  own  sides. 
The  anterior  tibial  artery  will  be  found  between  them,  lying  upon  the  anterior 
aspect  of  the  tibia  and  held  down  by  fatty  areolar  tissue — accompanied  by 
two  venae  comites,  and  with  the  anterior  tibial  nerve  on  the  outer  side.  Pass 
the  needle  from  the  nerve.  In  closing  the  wound,  suture  the  anterior  annular 
ligament. 

Comment. — If  the  artery  were  ligated  after  passing  beneath  the  obliquely 
crossing  extensor  proprius  pollicis,  it  would  then  have  the  tendon  of  the 
extensor  proprius  pollicis  to  its  inner  side  and  the  innermost  tendon  of  the 
extensor  longus  digitorum  to  its  outer  side. 

Collateral  Circulation. — (When  ligated  below  the  malleolar  branches.) 
External  malleolar  of  anterior  tibial,  with  anterior  peroneal  of  peroneal  and 
with  calcaneal  of  posterior  peroneal.  Internal  malleolar  of  anterior  tibial, 
with  internal  malleolar  of  posterior  tibial.  Dorsalis  pedis  and  branches, 
with  internal  plantar  of  posterior  tibial,  with  external  plantar  of  posterior 
tibial,  with  anterior  peroneal  of  peroneal,  and  with  calcaneal  of  posterior 
peroneal.  Muscular  branches  of  anterior  tibial  anastomosing  through  the 
interosseous  membrane  with  muscular  branches  of  posterior  tibial. 


SURGICAL   ANATOMY  OF  DORSALIS   PEDIS    (OF  ANTERIOR   TIBIAL). 

Description. — Continuation  of  anterior  tibial — extending  from  bend  of 
ankle  along  tibial  side  of  foot  to  apex  of  first  intermetatarsal  space — passing 
into  sole  (as  communicating  artery)  between  two  heads  of  first  dorsal  inter- 
osseous. The  anterior  tibial  nerve  lies  upon  its  outer  side.  The  artery  is 
accompanied  by  two  venae  comites. 

Relations. — Anteriorly:  Skin,  superficial  fascia;  deep  fascia;  anterior 
annular  ligament;  extensor  longus  pollicis;  innermost  tendon  of  extensor 
brevis  digitorum.  Posteriorly:  (from  above  downward)  Astragalus;  scaph- 
oid; internal  cuneiform;  ligament  of  first  and  second  metacarpals.  Ex- 
ternally :  Innermost  tendon  of  extensor  longus  digitorum  (above) ;  innermost 
tendon  of  extensor  brevis  digitorum  (below) ;  anterior  tibial  nerve.  In- 
ternally :  Extensor  longus  pollicis. 

Branches. — Tarsal;  metatarsal;  dorsalis  hallucis;  communicating  (plantar 
digital). 

Line  of  Artery. — From  center  of  line  connecting  two  malleoli,  to  proximal 
end  of  first  metatarsal  space. 

Indications  for  Ligation. — Rare — wounds,  aneurism. 

Sites  of  Ligation. — At  ankle-joint  (involves  cutting  anterior  annular 
ligament);  below  ankle-joint  (general  site);  at  first  interosseous  space  (Fig. 
54,  D  and  E). 


LIGATION  OF  DORSALIS  PEDIS 

JUST  BELOW  ANKLE-JOINT. 

Position. — Patient  supine;  foot  resting  on  heel  and  extended.  Surgeon 
below  foot,  on  either  side,  cutting  downward  (or  on  outer  side  of  both  limbs, 
cutting  downward  on  right,  and  upward  on  left).     Assistant  steadies  foot. 

Landmarks. — Line  of  artery. 


io8 


OPERATIONS    UPON    THE    ARTERIES. 


Incision. — From  2.5  to  5  cm.  (1  to  2  in.),  in  line  of  artery,  passing  from 
lower  border  of  anterior  annular  ligament — between  tendon  of  extensor 
pollicis  and  inner  tendon  of  extensor  longus  digitorum  (Fig.  54,  D). 


Fig.  58. — Ligation  of  Right  Dorsalis  Pedis  Just  below  Ankle-joint: — A,  A,  Branches  of 
internal  saphenous  vein  ;  B,  Internal  branch  of  musculocutaneous  nerve  and  its  divisions  ;  C,  Tendon 
of  extensor  proprius  hallucis ;  D,  Inner  tendon  of  riexor  longus  digitorum  ;  E.  Inner  tendon  of  exten- 
sor brevis  digitorum  ;  F,  Dorsalis  pedis  artery  ;  G,  Venae  comites  of  dorsalis  pedis  artery  ;  H,  Ante- 
rior tibial  nerve;  I,  Annular  ligament. 

Operation. — Incise  skin  and  superficial  fascia.  Tributaries  of  internal 
saphenous  vein  and  the  internal  branch  of  the  musculocutaneous  nerve  lie 
in  the  line  of  incision  (Fig.  58).  Open  up  the  deep  fascia  between  the  tendon 
of  the  extensor  proprius  pollicis  and  innermost  tendon  of  flexor  longus  digitorum 
— when  the  artery  will  be  found  upon  the  tarsal  ligaments.  The  anterior 
tibial  nerve  lies  upon  its  fibular  side — two  vena?  comites  accompanying  the 
artery.     Avoid  opening  the  tendon  sheaths. 

Comment. — When  the  artery  is  tied  at  the  base  of  the  first  interosseous 
space,  an  incision  is  made  from  the  apex  of  the  first  interosseous  space,  passing 
down  between  the  first  and  second  metatarsals.  The  artery  is  found  emerging 
from  under  the  innermost  tendon  of  the  extensor  brevis  digitorum,  which 
is  retracted  inward. 


SURGICAL  ANATOMY  OF  POSTERIOR  TIBIAL  ARTERY. 

Description. — Larger  and  more  direct  division  of  popliteal  artery — ■ 
extending  from  lower  border  of  popliteus  muscle  (on  level  with  lower  border 
of  tubercle  of  tibia),  down  tibial  side  of  back  of  leg,  between  superficial  and 
deep  muscles,  to  middle  of  fossa  between  tip  of  internal  malleolus  and  os 
calcis — and  dividing,  under    abductor    hallucis,    into    internal    and    external 


LIGATION    OF    POSTERIOR    TIBIAL.  109 

plantar  branches.  It  arises  midway  between  tibia  and  fibula,  covered  by 
the  superficial  muscles — lower  down  it  lies  behind  the  tibia — and  at  its  lower 
third  it  is  covered  by  only  skin  and  fascia,  and  then  passes  beneath  the  internal 
annular  ligament.  It  is  accompanied  by  two  vena?  comites.  The  posterior 
tibial  nerve  crosses  the  artery,  from  the  inner  to  outer  side,  about  2.5  to  4 
cm.  (1  to  1 J  inches)  below  inferior  border  of  popliteus,  and  runs  thence  along 
its  fibular  aspect. 

Relations. — Anteriorly:  (From  above  downward)  tibialis  posticus; 
flexor  longus  digitorum;  tibia;  internal  lateral  ligament  of  ankle-joint.  Pos- 
teriorly: Skin;  superficial  fascia;  gastrocnemius;  soleus;  deep  intermuscular 
(transverse)  fascia  binding  artery  to  underlying  muscles;  posterior  tibial 
nerve  (crossing  from  inner  to  outer  side  above,  and  then  running  along  fibular 
side).  In  lower  third,  covered  only  by  skin  and  fascia.  Externally  :  Poste- 
rior tibial  nerve  (lower  three-fourths) ;  vena  comes.  Internally :  Posterior 
tibial  nerve  (upper  one-fourth);  vena  comes.  At  Ankle-joint:  Posterior 
tibial  artery  lies  under  internal  annular  ligament  and  abductor  hallucis — 
resting  upon  internal  lateral  ligament  of  ankle — having  tibialis  posticus  and 
flexor  longus  digitorum  in  front — and  posterior  tibial  nerve  and  flexor  longus 
hallucis  behind  and  externally. 

Branches. — Peroneal,  muscular,  medullary,  cutaneous,  communicating, 
internal  malleolar,  internal  calcaneal,  external  plantar,  internal  plantar. 

Line  of  Artery. — Lower  half — line  from  a  point  5  cm.  (2  inches)  below 
center  of  popliteal  space,  to  midway  between  tip  of  internal  malleolus  and 
center  of  convexity  of  heel.  Upper  half — forms  a  slight  curve  inward  from 
this  line. 

Indications  for  Ligation. — Wounds;  aneurisms. 

Sites  of  Ligation. — Upper  third — not  frequent — difficult  because  of 
depth.  Middle  third — same.  Lower  third — most  usual  site.  Behind  ankle 
— also  common.     (Fig.  51,  H,  I,  J,  K.) 


LIGATION  OF  POSTERIOR  TIBIAL 

IN  ITS  UPPER  THIRD— ABOVE  ORIGIN'  OF  PERONEAL  BRANCH. 

Position. — As  for  ligation  of  lower  part  of  popliteal  artery  (page  101). 

Landmarks. — Popliteal  boundaries  (page  101);  head  of  fibula. 

Incision. — Begins  in  popliteal  space,  on  level  with  head  of  fibula,  and 
passes  directly  down  the  middle  line  for  about  7.5  cm.  (3  inches)  (Fig.  51,  H). 

Operation. — Incise  skin,  superficial  fascia,  avoiding  external  saphenous 
vein  and  nerve.  Divide  deep  fascia,  exposing  two  heads  of  gastrocnemius. 
Incise  their  connecting  raphe  freely  and  separate  them  fully,  avoiding  their 
nerves  and  vessels  as  much  as  possible.  Expose  the  upper  border  of  the 
soleus  beneath  the  external  head  of  the  gastrocnemius.  Retract  the  plantaris 
(found  between  the  outer  head  of  the  gastrocnemius  and  soleus).  The 
lower  border  of  the  popliteus,  opposite  which  the  posterior  tibial  nerve  begins, 
about  corresponds  with  the  upper  border  of  the  soleus — so  that  after  re- 
tracting the  internal  popliteal  nerve  and  vein  to  the  inner  side,  draw  the 
upper  border  of  the  soleus  downward  (or  nick  its  upper  border)  and  thus 
expose  the  bifurcation  of  the  popliteal  artery  into  anterior  tibial  (passing 
through  the  interosseous  membrane)  and  posterior  tibial  (descending  on 
the  deep  muscles).  Pass  the  needle  between  the  anterior  tibial  and  peroneal 
branches. 

Collateral   Circulation. — (When   ligated   between   the  bifurcation  and 


no 


OPERATIONS    UPON    THE    ARTERIES. 


origin  of  the  peroneal.)  Peroneal  of  posterior  tibial,  with  communicating 
and  muscular  branches  of  the  posterior  tibial;  external  calcaneal  of  peroneal, 
with  internal  calcaneal  of  external  plantar;  external  malleolar  of  anterior 
tibial,  with  external  plantar;  internal  malleolar  of  anterior  tibial,  with  internal 
malleolar  of  posterior  tibial;  dorsalis  pedis  and  branches,  with  internal  and 
external  plantar. 


F'g-  59- — Ligation  of  Middle  Third  of  Right  Posterior  Tibial: — A,  Internal  saphenous 
vein;  B,  Internal  saphenous  nerve;  C,  Soleus,  incised  vertically,  and  margins  of  incision  well 
retracted;  D,  Inner  border  of  gastrocnemius  strongly  retracted  outward  ;  E,  Transverse  intermuscu- 
lar fascia  ;  F,  Flexor  longus  digitorum  ;  G,  Tibialis  posticus  ;  H,  Posterior  tibial  artery  ;  I,  I,  Poste- 
rior tibial  venae  comites  ;  J,  Posterior  tibial  nerve. 


LIGATION  OF  POSTERIOR  TIBIAL 


IN  ITS  MIDDLE  THIRD. 


Position. — Patient  supine;  knee  flexed;  leg  on  outer  side.  Surgeon  to 
outer  side,  cutting  downward  on  right,  and  upward  on  left. 

Landmarks. — Inner  margin  of  tibia. 

Incision. — From  7.5  cm.  to  10  cm.  (3  to  4  inches)  in  length,  placed 
parallel  with  and  2  cm.  (f  inch)  behind  the  inner  margin  of  the  tibia,  along 
its  middle  third  (Fig.  51,  I). 

Operation. — Incise  skin  and  superficial  fascia.  Avoid  internal  saphenous 
vein  and  internal  saphenous  nerve  (Fig.  59).  Divide  the  deep  fascia.  The 
inner  edge  of  the  gastrocnemius  should  be  identified  here — and  retracted 
outward.  Having  gone  through  the  deep  fascia,  the  soleus  is  exposed,  and 
is  to  be  divided  along  its  attachment  to  the  tibia,  and  its  outer  part  retracted. 


LIGATION    OF    POSTERIOR    TIBIAL. 


The  transverse  intermuscular  fascia  (between  superficial  and  deep  muscles 
of  back  of  leg)  is  now  in  view,  and  is  incised  in  the  axis  of  the  limb,  whereby 
the  flexor  longus  digitorum  is  reached — and,  by  following  along  the  surface 
of  this  muscle  until  nearly  opposite  the  outer  border  of  the  tibia,  the  vena 
comes  interna,  posterior  tibial  artery,  vena  comes  externa,  and  posterior 
tibial  nerve  are  met  in  order,  lying  upon  the  tibialis  posticus,  or  between  it 
and  the  flexor  longus  digitorum.  Pass  the  needle  from  the  nerve,  including 
the  vena?  comites  if  unavoidable — flexing  the  knee  and  foot  to  relax  the 
structures.     (Fig.  60.) 


Fig.  60. — Cross-section  of  the  Middle  of  the  Right  Leg: — A,  Tibialis  amicus;  B, 
Extensor  longus  digitorum;  C,  Extensor  pollicis;  D,  Anterior  tibial  artery,  vein,  and  nerve; 
E,  Peronei;  F,  Tibialis  posticus;  G,  Long  saphenous  vein  and  nerve;  H,  Flexor  longus  digitorum; 
I,  Posterior  tibial  artery,  veins,  and  nerve;  J,  Soleus;  K,  Gastrocnemius;  L,  Peroneal  artery 
and  veins.     (The  cross-section  modified  from  Braune.) 

Comment. — The  knife  should  be  held  at  a  right  angle  to  the  surface 
of  the  muscle,  in  cutting  through  the  soleus,  pointing  toward  the  tibia  until 
the  transverse  fascia  is  reached — and  thereby  wandering  too  deeply,  or  in 
the  wrong  direction,  is  less  likely.  If  one  incise  too  near  the  tibia,  the  flexor 
longus  digitorum  may  be  divided  and  the  interosseous  membrane  reached. 
While  incising  the  soleus,  do  not  mistake  its  central  membranous  tendon 
for  the  transverse  intermuscular  fascia.  The  artery  lies  about  3  cm.  (i| 
inches)  external  to  the  inner  border  of  the  tibia. 


112  OPERATIONS    UPON    THE    ARTERIES. 

LIGATION  OF  POSTERIOR  TIBIAL 

IN  ITS  LOWER  THIRD. 

Position. — As  for  the  middle  third. 
Landmarks. — Line  of  artery. 

Incision. — About  5  cm.  (2  inches)  in  length,  in  line  of  artery,  with  its 
center  over  the  lower  third  of  the  leg — which  should  fall  midway  between 
the  inner  border  of  the  tendo  Achillis  and  the  inner  border  of  the  tibia 
(Fig-  51,  re- 
operation.— Incite  skin  and  superficial  fascia.  Divide  the  deep  fascia 
binding  down  the  flexor  tendons — when  the  artery  will  be  found  lying  be- 
tween the  flexor  longus  digitorum  and  flexor  longus  pollicis — the  posterior 
tibial  nerve  lying  to  its  fibular  side,  with  the  venae  comites  surrounding  the 
artery. 

Comment. — If  the  incision  be  at  the  upper  part  of  the  lower  third  of 
the  artery,  the  vessel  will  be  found  upon  the  flexor  longus  digitorum.  If 
the  incision  be  at  the  lower  part  of  the  lower  third,  the  upper  part  of  the 
internal  annular  ligament  must  be  cut. 


G 

—     1 

"1 


Fig.  61. — Ligation  of  Right  Posterior  Tibial  behind  Internal  Malleolus: — A,  Branch 
of  internal  saphenous  vein;  B,  Branch  of  internal  saphenous  nerve;  C,  Internal  annular  ligament 
(incised);  D,  Tendon  of  flexor  longus  hallucis;  E,  Tendon  of  flexor  longus  digitorum;  F,  Tendon 
of  tibialis  posticus  ;  G,  Posterior  tibial  artery  ;  H,  H,  Posterior  tibial  vense  comites  ;  I,  Posterior  tibial 
nerve. 


LIGATION  OF  POSTERIOR  TIBIAL 

BEHIND  INTERNAL  MALLEOLUS. 

Position. — As  for  ligation  of  the  lower  third. 
Landmarks. — Internal  malleolus. 

Incision. — About  5  cm.   (2  inches)  in  length,  placed  about  1.3  cm.  (\ 
inch)  posterior  to  and  parallel  with  the  inner  malleolus  (Fig.  51,  K). 


LIGATION    OF    POSTERIOR    TIBIAL. 


Operation. — Incise  skin  and  superficial  fascia — during  which  branches 
of  the  internal  saphenous  vein  are  encountered  (Fig.  61).  Expose  the  in- 
ternal annular  ligament  and  divide  it  over  the  vessels — the  artery  being  found 
in  the  interval  between  the  flexor  longus  digitorum  and  flexor  longus  hallucis, 
surrounded  by  its  vena;  comites  and  with  the  nerve  upon  its  fibular  side  (Fig. 
62). 


Fig.  62. — Cross-section  of  the  Right  Leg  just  Above  the  Ankle: — A,  Extensor 
proprius  pollicis;  B,  Anterior  tibial  vessels  and  nerve;  C,  Peroneus  brevis;  D,  Peroneus  longus; 
E,  Flexor  longus  pollicis;  F,  Tibialis  anticus;  G,  Extensor  proprius  pollicis;  H,  Tibialis  posticus; 
I,  Flexor  longus  digitorum;  J,  Posterior  tibial  artery,  veins,  and  nerve;  K,  Tendo  Achillis.  (The 
cross-section  modified  from  Braune.) 

Comment. — Keep  the  knife  pointed  toward  the  tibia,  in  making  the 
incision.  Avoid  opening  the  sheaths  of  the  tendons.  Behind  the  internal 
malleolus  and  posterior  surface  of  the  tibia  are  four  compartments,  which, 
passing  from  tip  of  malleolus  toward  heel,  are — first,  a  canal  in  the  annular 
ligament  for  the  posterior  tibial  muscle  tendon — a  second  canal  for  the  flexor 
longus  digitorum  tendon — a  third  space  occupied  bv  the  posterior  tibial 
artery,  its  venae  comites,  and  the  posterior  tibial  nerve — and  a  fourth  canal 
for  the  flexor  longus  hallucis. 


114  OPERATIONS    UPON    THE    ARTERIES. 

SURGICAL  ANATOMY  OF  PERONEAL  BRANCH  OF  POSTERIOR 
TIBIAL  ARTERY. 

Description. — Arises  from  posterior  tibial  about  2.5  cm.  (1  inch)  below 
inferior  border  of  popliteus — and  curves  (with  convexity  outward  and  upward) 
obliquely  outward  and  downward  to  fibula — descending  thence  close  to  inner 
border  of  fibula,  to  lower  third  of  leg,  where  the  anterior  peroneal  is  given  off 
(which  pierces  the  interosseous  membrane  to  front  of  leg) — thence  passes, 
as  posterior  peroneal,  to  inferior  tibiofibular  joint  and  external  malleolus. 
It  is  accompanied  by  two  venae  comites. 

Relations. — (From  origin  to  bifurcation.)  Anteriorly :  (from  above 
downward)  Tibialis  posticus;  fibrous  bed  between  origins  of  tibialis  posticus 
and  flexor  longus  hallucis.  Posteriorly:  (from  above  downward)  Soleus; 
flexor  longus  hallucis  (completing  fibrous  canal  of  artery). 

Branches. — Muscular,  nutrient,  anterior  peroneal,  communicating, 
posterior  peroneal,  external  calcanean. 

Line  of  Artery. — From  middle  of  popliteal  space,  on  level  of  lower 
border  of  tubercle  of  tibia,  arching  slightly  outward  and  then  downward 
along  inner  border  of  posterior  surface  of  fibula.  For  purposes  of  ligation, 
the  artery  is  represented  by  a  line  from  posterior  border  of  head  of  fibula 
to  point  midway  between  external  malleolus  and  outer  margin  of  tendo 
Achillis. 

Indications  for  Ligation. — Rare — except  for  wounds,  when  the  vessel 
is  cut  down  upon  at  the  point  wounded. 

Sites  of  Ligation. — Upper  part — rare,  owing  to  depth.  Middle — usual 
site  (Fig.  51,  L). 


LIGATION    OF    PERONEAL    BRANCH    OF    POSTERIOR    TIBIAL 

IN  MIDDLE  OF  LEG. 

Position. — Patient  rests  on  shoulder  and  chest  of  opposite  side;  knee 
flexed;  leg  on  antero-internal  surface.  Surgeon  on  outer  side,  cutting  from 
below  on  right,  and  from  above  on  left. 

Landmarks. — External  border  of  fibula. 

Incision. — About  7.5  cm.  (3  inches)  in  length — parallel  with  and  just 
behind  external  border  of  fibula,  with  its  center  over  the  middle  of  the  leg— 
which  falls  behind  the  peronei  muscles  (Fig.  51,  L). 

Operation. — Incise  skin  and  superficial  fascia.  Branches  of  the  external 
saphenous  nerve  and  external  saphenous  vein  are  apt  to  be  encountered  here 
(Fig.  63).  Expose  the  soleus  (which,  at  this  site,  no  longer  arises  from  the 
fibula)  and  retract  it  upward  and  inward  (incising  its  lower  fibers  if  any  be 
found  attached  to  the  fibula  at  this  height).  Divide  the  deep  fascia  behind 
the  peronei.  Expose  the  flexor  longus  hallucis  and  incise  through  its  thick- 
ness, close  to  the  fibula — until  the  fibrous  canal  of  which  it  forms  the  roof 
is  reached.  Divide  the  aponeurotic  canal  and  expose  the  artery  lying  near 
the  fibula,  with  its  venae  comites 


SURGICAL    ANATOMY    OF    THE    EXTERNAL    PLANTAR   ARTERY.      1 15 


Fig.  63. — Ligation  of  Right  Peroneal  in  Middle  of  Leg: — A,  Branch  of  external  saph- 
enous nerve;  B,  Branch  of  external  saphenous  vein;  C,  Gastrocnemius,  retracted  inward;  D, 
Soleus,  retracted'  upward  and  inward  ;  E,  Peroneus  longus  ;  F,  Peroneus  brevis  ;  G,  Tibialis  posticus; 
H,  Flexor  longus  hallucis,  incised,  showing  roof  of  aponeurotic  canal  enclosing  vessels  ;  I,  Peroneal 
artery  ;  J,  Peroneal  venae  comites. 


SURGICAL    ANATOMY    OF    EXTERNAL    PLANTAR    BRANCH    OF    POS- 
TERIOR TIBIAL. 

Description. — Larger  of  two  terminal  branches  given  off  by  posterior 
tibial  at  inner  ankle.  Passes  from  beneath  internal  annular  ligament,  obliquely 
forward  and  outward  across  sole  of  foot  to  base  of  fifth  metatarsal — thence 
curves  forward  and  inward  to  base  of  first  interosseous  space — where  it 
anastomoses  with  communicating  branch  of  dorsalis  pedis,  to  form  plantar 
arch.     Two  venae  comites  accompany  the  artery. 

Relations. — First  part  (from  inner  ankle-joint  to  base  of  fifth  meta- 
tarsal): Rests  on  os  calcis;  flexor  accessorius;  flexor  minimi  digiti.  Covered 
by — skin;  superficial  fascia;  plantar  fascia;  abductor  hallucis;  flexor  brevis 
digitorum  and  abductor  minimi  digiti.  Lies  between — flexor  brevis  digi- 
torum  and  abductor  minimi  digiti.  Accompanied  by — external  plantar 
nerve  and  two  venae  comites.  Second  part:  (Plantar  arch;  from  base  of 
fifth  metatarsal  to  proximal  end  of  first  interosseous  space.)  Rests  on — - 
proximal  ends,  and  corresponding  interosseous  muscles,  of  second,  third, 
and  fourth  metatarsals.  Covered  by — skin;  superficial  fascia;  plantar  fascia; 
flexor  brevis  digitorum;  tendon  of  flexor  longus  digitorum;  lumbricales; 
branches  of  internal  plantar  nerve;  adductor  hallucis. 


n6 


OPERATIONS    UPON    THE    ARTERIES. 


Branches. — Muscular,  calcaneal,  cutaneous,  anastomotic,  articular,  pos- 
terior perforating,  digital. 

Line  of  Artery. — First  Part:  from  point  midway  between  tip  of  internal 
malleolus  and  great  tubercle  of  os  calcis,  to  base  of  fifth  metatarsal.  Second 
Part: — from  base  of  fifth  metatarsal,  to  posterior  part  of  ball  of  great  toe. 


Fig.  64. — Incisions  for  Liga- 
tion of  Plantar  Arteries: — A, 
Incision  for  external  plantar  in  sole  of 
foot;  B,  For  internal  plantar  in  sole  of 
foot;  C,  For  external  plantar  arch  at 
base  of  first  interosseous  space;  D,  Ball 
of  heel;  E,  Base  of  fourth  toe;  F,  Base 
of  first  toe. 


Fig.  65. — Ligation  of  Right  External  Plan- 
tar in  Sole  of  Foot: — A,  Superficial  fascia;  B, 
Abductor  minimi  digiti;  C,  Flexor  brevis  digitorum; 
D,  Deep  plantar  fascia;  E,  External  plantar  artery; 
F,  F,  External  plantar  venae  comites;  G,  External 
plantar  nerve. 


Indications  for  Ligation. — Wounds  and  aneurisms. 
Sites  of  Ligation. — At  origin — more  frequent  site.    In  the  sole.    Plantar 
arch — rare.     (Fig.  64,  A,  C.) 


LIGATION  OF  EXTERNAL    PLANTAR 

IN  SOLE  OF  FOOT. 

Position. — Patient  supine;  foot  resting  upon  heel,  steadied  upon  a  sup- 
port.    Surgeon  at  foot  of  table. 

Landmarks. — Ball  of  heel;  fourth  toe. 

Incision. — Along  arch  of  foot,  in  a  line  from  ball  of  heel  to  fourth  toe 
— about  6  cm.  (2  J  inches)  in  length  (Fig.  64,  A). 

Operation. — Divide  skin,  superficial  fascia,  fatty  areolar  tissue,  and 
plantar  fascia.  Expose  the  gap  between  the  flexor  brevis  digitorum  and 
abductor  minimi  digiti — in  which  the  artery  is  found,  with  accompanying 
nerve  and  veins  (Fig.  65). 


LIGATION    OF    INTERNAL    PLANTAR. 


117 


SURGICAL   ANATOMY  OF  INTERNAL  PLANTAR  BRANCH  OF  POSTE- 
RIOR TIBIAL. 

Description. — Smaller  of  two  terminal  branches  given  off  by  posterior 
tibial  at  inner  ankle — passing  forward  along  inner  side  of  sole,  generally 
to  first  interosseous  space,  to  anastomose  with  fifth  plantar  digital  of  com- 
municating branch  of  dorsalis  pedis. 

Relations. — First  covered  by  abductor  hallucis — then  lies  between 
abductor  hallucis  and  flexor  brevis  digitorum — and,  toward  distal  end,  is 
covered  by  skin  and  fascia. 

Branches. — Muscular,  cutaneous,  articular,  anastomotica,  superficial 
digital. 

Sites  of  Ligation. — At  origin — more  frequent.     In  sole.     (Fig.  64,  B.) 

LIGATION  OF  INTERNAL  PLANTAR 

AT  ORIGIN". 

Position — Landmarks — Incision — Operation. — As  for  ligation  of  ex- 
ternal plantar  at  origin. 


A 


Fig.  66. — Ligation  or  Right  Internal  Plantar  Artery  in  Sole  of  Foot: — A,  Super- 
ficial fascia;  B,  Abductor  hallucis;  C,  Flexor  brevis  digitorum;  D,  Internal  plantar  artery;  E,  E, 
Internal  plantar  venae  comites;  F,  Internal  plantar  nerve. 

LIGATION  OF  INTERNAL  PLANTAR 

IN  SOLE  OF  FOOT. 

Position. — As  for  external  plantar. 

Landmarks. — Heel;  great  toe. 

Incision. — Along  arch  of  foot,  in  line  from  point  of  heel  to  great  toe — 
about  6  cm.  (2^  inches)  in  length  (Fig.  64,  B). 

Operation. —Divide  skin,  superficial  fascia,  and  fattv  areolar  tissue. 
Expose  the  gap  between  the  abductor  hallucis  and  flexor  brevis  digitorum — 
in  which  interval  the  artery  is  found  (Fig.  66). 


Il8  OPERATIONS    UPON    THE    ARTERIES. 

TEMPORARY   OR   PROVISIONAL    LIGATION  OF  ARTERIES. 

Definition. — The  temporary  arrest  of  circulation  in  an  artery  by  means 
of  a  ligature  carried  beneath  the  vessel — whereby  the  artery  is  drawn  upon 
until  the  flow  ceases,  but  is  not  tied. 

Indications. — Where  it  is  desired  to  control  for  a  time  the  arterial  circu- 
lation during  the  steps  of  an  operation — or  where  a  ligature  is  placed  about 
an  artery  in  advance  of,  or  preparatory  for,  any  emergency  which  may  arise 
— (e.  g.,  temporary  ligature  of  common  carotid  in  the  removal  of  a  tumor 
of  the  neck,  or  of  the  femoral  in  popliteal  aneurism). 

Operation. — All  the  steps,  up  to  the  exposure  of  the  sheath  of  the  artery, 
are  similar  to  those  for  an  ordinary  ligation.  At  this  point,  instead  of  opening 
the  sheath,  the  sheath  itself  is  isolated  (unless  a  common  sheath  contain 
other  important  structures).  A  stout  ligature  (preferably  broad)  that  will 
not  cut  is  passed  beneath  the  sheath.  The  two  ends  of  the  ligature  are  not 
tied  upon  the  artery,  but  are  simply  grasped  by  clamp-forceps  in  the  hands 
of  an  assistant  (or  knotted  into  a  loop).  When  it  is  desired  to  control  all 
flow  through  the  vessel,  the  assistant  simply  lifts  the  artery  slightly  from 
its  position — the  under  wall  of  the  artery  is  thereby  pressed  into  contact 
with  the  upper  wall  by  the  loop  of  the  ligature,  over  which  the  artery  makes 
an  angle,  and  the  flow  ceases.  On  relaxing  tension,  the  artery  falls  back 
into  its  normal  position  and  the  flow  continues.  Where  no  further  need 
exists  for  this  control,  one  end  of  the  loop  is  drawn  upon  and  the  ligature 
slips  out  from  under  the  artery.  Where  the  temporary  is  converted  into  a 
permanent  ligature,  the  ligature  is  tightened  in  the  ordinary  manner — although, 
were  this  likelihood  foreseen,  it  would  be  better  to  open  the  sheath  of  the 
artery  at  first  and  place  the  temporary  ligature  directly  around  the  artery 
proper.     Floss  silk  is  especially  useful  for  provisional  ligatures. 

Comment. — As  this  subsidiary  operation  is  generally  resorted  to  in 
advance  or  in  the  course  of  some  more  major  operation,  the  steps  of  the 
temporary  ligation  are  modified  by  those  of  the  main  operation. 

INTERMEDIATE  LIGATION,  OR  LIGATURE  EN  MASSE. 

Definition. — Ligature  en  masse  for  parenchymatous  hemorrhage  is  a 
method  of  controlling  hemorrhage  which  comes  from  no  definite  vessels,  or 
from  inaccessible  sources,  or  as  a  capillary  oozing. 

Description. — A  fully  curved  needle,  armed  with  catgut,  is  made  to 
enter  the  tissue  to  one  side  of  the  site  from  which  the  flow  comes — passes 
deeply  into  the  parts,  and,  in  emerging,  more  or  less  completely  surrounds 
the  area  of  hemorrhage — which  is  controlled  by  the  tightening  of  the  ligature. 
Or,  in  hemorrhage  from  a  larger  area,  a  curved  needle,  held  in  a  holder, 
may  be  made  to  surround  the  area  from  which  parenchymatous  bleeding 
comes  by  circumventing  that  area  with  a  purse-string  ligature  introduced 
by  several  consecutive  insertions  of  the  needle — at,  for  instance,  four  points 
of  a  circle.  The  ends  of  beginning  and  ending  of  this  catgut  ligature  are 
then  drawn  and  knotted — only  tightly  enough  to  control  hemorrhage,  and 
not  tightly  enough  to  strangulate  the  parts. 

ARTERIORRHAPHY. 

Definition. — Suture  of  an  artery. 

Indications. — Arteriorrhaphy  may  be  required  in  longitudinal  wounds 
of  an  artery;  in  limited  transverse  or  oblique  wounds;  in  transverse  wounds 


ARTERIORRHAPHY. 


II9 


of  more  than  half  the  circumference;  in  complete  division,  or  in  division 
with  partial  resection  (the  resected  portion  not  exceeding  more  than  about 
2  cm. — I  inch). 

Exposure  of  the  Vessel  and  Repair  of  a  Longitudinal  or  Partial 
Transverse  Wound  of  an  Artery  by  Suture  of  the  Outer  Coats. — (i) 
With  aseptic  precautions,  the  sheath  of  the  artery  is  exposed  and  opened  with 
minimum  injury  to  vessel  and  surroundings.  If  the  circulation  have  not 
been  temporarily  controlled  by  a  constrictor,  or  some  form  of  pressure,  the 
artery  is  clamped  above  and  below  the  injury  with  special  forceps  (e.  g., 
Billroth's,  with  broad  blades  protected  by  pieces  of  rubber  drainage-tubes 
drawn  over  them;  or  probably  better,  by  means  of  floss  silk  lightly  tied  or 
looped).  (2)  Seize,  in  turn,  the  lips  of  the  wounded  artery  with  a  pair  of 
oculist's  rat-tooth  fixation-forceps.  Using  a  fully  curved  and  round  con- 
junctival needle  (or  straight  floss-needle,  or  cambric  needle)  threaded  with 


Fig.  67. — ARTERIORRHAPHY  IN  COMPLETE  CIRCULAR  DIVISION  OF  AN  ARTERY  (MURPHY'S 

Method)  : — A,  Intussusceptum,  with  sutures  passing  through  outer  and  middle  coats;  B,  Intus- 
suscipiens  (split  to  aid  invagination)  with  sutures  passing  through  all  coats. 
Fig   68. — C,  Same  showing  all  sutures  tied. 

twisted  silk  of  exact  size  as  eye  of  needle  (that  hemorrhage  may  not  occur 
through  the  needle-hole  which  the  silk  has  not  fully  filled),  penetrate  the 
tunica  adventitia  and  muscularis,  down  to  (but  not  through)  the  intima. 
The  lips  of  the  wound  are  pierced  immediately  opposite  each  other.  The 
knots  are  interrupted — are  from  1  to  2  mm.  (about  -^  to  TTr  inch)  apart — 
enter  artery  about  1.5  mm.  (y1^  inch)  from  edge  of  wound — and  are  lightly 
tied  with  a  reef-knot,  avoiding  inversion  of  the  lips  of  the  artery.  The  sheath 
of  the  artery  is  separately  sutured  over  the  vessel,  if  possible.  The  skin 
wound  is  closed  as  usual.  A  wound  in  the  long  axis  of  the  artery  tends  to 
gape  least,  and  a  transverse  wound  most.  If  the  artery  be  divided  through 
one-half  of  its  circumference,  it  should  be  entirely  divided  and  re-united  by 
some  method  of  suture,  preferably  by  invagination. 

Repair  of  Complete  Transverse  Division  of  an  Artery  by  Invagina- 
tion.— Murphy's  Method:  The  artery  is  united  end-to-end  by  invagination. 


120  OPERATIONS    UPON    THE    ARTERIES. 

A  piece  of  finely  twisted  silk  is  threaded  upon  two  needles — one  of  which 
is  passed  through  the  outer  and  middle  coats  of  the  proximal  end  (intussus- 
ceptum),  in  the  transverse  axis — then  both  needles,  held  side  by  side,  are 
simultaneously  passed  through  all  coats  of  the  distal  end  (intussuscipiens) 
about  7  to  12  mm.  (J  to  J  inch)  from  its  free  end,  passing  from  within  outward. 
Two  or  three  of  these  sutures  are  applied  equidistantly.  The  distal  end  is 
then  slit  a  short  distance  (the  slit  not  extending  as  low  as  the  sutures)  to  aid 
in  invagination — which  is  then  accomplished  by  traction  upon  the  sutures — 
which  are,  after  invagination  is  complete,  tied  lightly  with  reef-knot.  Rein- 
forcing sutures  are  placed  at  the  line  of  junction,  and  uniting  the  lips  of  the 
slit — but  do  not  pass  through  the  intima  of  the  intussusceptum.  (See  Figs. 
67  and  68.) 

Repair  of  Longitudinal  or  Oblique  Wounds  of  the  Larger  Vessels, 
or  of  Complete  Transverse  Division,  by  Combination  Cobbler's  Stitch 
through  all  the  Coats,  and  Interrupted  Sutures  through  the  Outer  Coats. 
— Based  upon  the  fact  that  union  between  approximated  endothelial  coats 
of  the  blood-vessels -rapidly  occurs — and  realizing  the  advantages  of  a  suture 
which,  while  applied  through  very  limited  available  extent  of  tissue,  must 
bring  together  relatively  broad  surfaces  of  vessel-wall  closely  and  strongly, 
in  order  to  withstand  the  constant  hammering  and  distention  of  the  arterial 
and  distention  of  the  venous  flow,  the  author  suggests  a  method  (original 
as  far  as  he  knows)  of  tightly  and  firmly  approximating  relatively  broad  sur- 
faces of  the  tunica  intima  of  the  larger  vessels,  especially  arteries,  by  means 
of  the  cobbler's  stitch  through  all  the  coats,  followed  by  reinforcing  the  margins 
of  the  wound  by  interrupted  sutures  through  the  tunica  adventitia  and  tunica 
muscularis. 

Irrespectively  of  the  theoretical  consideration  it  has  been  found,  practically, 
that  through-and-through  suturing  of  all  the  coats  of  a  vessel  is  not  followed 
by  harmful  consequences.  Therefore,  although  the  necessity  for  guarding 
against  this  complete  penetration  of  all  coats  now  no  longer  exists,  yet  in  the 
present  method,  notwithstanding  all  coats  are  actually  pierced,  the  effect  of 
the  suture  is  most  probably  not  that  of  a  through-and-through  suture — since 
the  method  of  its  application  makes  it  likely  that  little,  if  any,  portion  of  the 
stitch  itself  comes  into  contact  with  the  blood-current,  owing  to  the  recession 
upon  the  inner  aspect  of  the  vessel  and  protection  of  the  stitches  by  consequent 
contact  with  and  union  of  adjacent  intimre,  corresponding  to  and  caused  by 
the  external  ridging  produced  by  this  particular  form  of  suturing. 

The  materials  used  for  the  continuous  through-and-through  suture  are  the 
finest  chromic  gut,  having  sufficient  tensile  strength — and,  for  the  interrupted 
sutures  of  the  outer  coats,  fine  silk.  Fine  silk  or  fine  Pagenstecher  thread 
may  be  used  in  the  primary  as  well  as  in  the  secondary  suturing.  The  finest 
possible  special  round  needles  which  will  carry  the  suture  should  be  used — 
with  eyes  nearly  as  large  as  the  diameter  of  the  head  of  the  needle  as  mechani- 
cally possible,  that  the  thread  following  the  needle-puncture  may  completely 
fill  the  puncture  in  the  vessel-wall.  Where  feasible,  a  straight  needle  long 
enough  to  be  held  in  the  fingers  should  be  used — or,  where  necessary,  shorter, 
straight  needles  or  curved  ones  may  be  employed  in  a  convenient  form  of 
needle-holder.  During  the  placing  of  the  sutures  the  opposite  edges  of  the 
artery  are  held  in  contact  and  ready  to  receive  the  suture  by  two  delicate  dis- 
secting (ribbed,  but  not  toothed)  forceps  in  the  fingers  of  an  assistant,  who 
so  approximates  the  lips  of  the  vessel- wound  as  to  aid  the  operator  materially 
in  the  process  of  suturing  (Fig.  69,  F,  F).  Prior  to  closing  the  main  (skin) 
wound,  in  all  methods  of  vessel-suturing,  the  newlv  sutured  vessel-wall  should 


ARTERIORRHAPHY. 


121 


be  supported,  where  possible,  by  suturing  muscle,  or  other  resistant  neighboring 
tissue,  in  such  a  way  as  to  protect  the  vessel  at  this  site. 

While  necessarily  the  caliber  of  a  vessel  thus  sutured  is  encroached  upon, 
in  the  case  of  the  larger  vessels  this  encroachment  is  not  sufficient  to  be  of 
practical  importance — and,  in  the  case  of  smaller  vessels,  the  remaining  lessened 
channel  is  better  than  no  channel  at 
all,   which  was  the  case  in  formerly 
ligating  all  wounded  vessels. 

(A)  Suture  of  a  Longitudinal 
Vessel-wound. — The  opposite  lips  of 
the  wound  are  each  grasped  with  for- 
ceps and  held  in  contact  (Fig.  69, 
F,  F).  The  needles  (one  held  be- 
tween the  operator's  thumb  and  first 
finger  of  each  hand)  are  made  to 
enter  the  lips  of  the  wound  on  oppo- 
site sides  and  pass  in  opposite  direc- 
tions (Fig.  69,  B,  B),  beginning  just 
above  one  of  the  limits  of  the  wound, 
at  a  distance  of  about  1.5  mm.  (T*g- 
inch)  from  a  line  that  would  represent 
a  continuation  of  the  vessel-wound 
(Fig.  69,  A).  The  needles  now 
change  hands,  and  are  made  to  pass 
through  all  the  coats  in  an  opposite 
direction,  about  3  mm.  (|  inch)  fur- 
ther along  the  wound.  This  char- 
acteristic cobbler's  stitch  is  continued 
as  indicated  in  the  figure — the  thread 
being  drawn  tightly  at  the  end  of  each 
stitch.  Finally,  the  two  ends  of  the 
thread  are  tied  in  a  reef  knot  at  the 
far  end  of  the  wound.  This  method 
of  suturing  will  ridge  up  the  vessel 
at  the  site  of  its  application — approxi- 
mating two  surfaces  of  intima  slightly 
more  than  1.5  mm.  (y1^-  inch)  in 
width,  and  a  little  longer  than  the 
length  of  the  wound — and  causing  the 
two  free  margins  of  the  lips  of  the 
wound  to  lie  parallel,  presenting  them- 
selves prominently  forward  in  lateral, 
but  not  edge-to-edge,  contact,  as 
shown  in  Fig.  69.  This  lateral  con- 
tact is  now  converted  at  the  margins 

into  a  partial,  if  not  complete,  edge-to-edge  contact  by  the  reinforcing 
interrupted  silk  sutures — which  enter  the  tunica  adventitia  about  1  mm. 
(less  than  y1^  inch)  from  the  free  margin  (Fig.  69,  D,  D) — pass  through 
the  tunica  adventitia,  and  all  or  a  greater  part  of  the  tunica  muscularis — 
to  emerge  just  between  the  tunica  muscularis  and  tunica  intima — thence, 
crossing  the  inner  aspects  of  the  vessel-wall  wound,  enter  between  the 
tunica  intima  and  tunica  muscularis  of  the  opposite  lip — to  emerge 
through    the   tunica   adventitia  at  a  distance  corresponding  with  the    point 


Fig.  69. — Repair  of  Longitudinal 
Wound  of  Artery  by  Combination  Cob- 
bler's Stitch  through  all  Coats,  and 
Interrupted  Sutures  through  Outer 
Coats,  as  suggested  by  the  Author: — A, 
Beginning  of  cobbler's  stitch  through  all  coats; 
B,  B,  Needles  in  act  of  passing  through  same 
opening  in  opposite  directions,  in  characteristic 
cobbler  fashion;  C,  C,  Three  interrupted 
sutures  through  outer  coats,  ready  to  be  tied; 
D,  D,  Two  interrupted  sutures  tied,  passing 
through  outer  coats. 


122 


OPERATIONS    UPON    THE    ARTERIES. 


of  entrance — after  which  the  opposite  ends  of  the  interrupted  sutures  are 
tied  (Fig.  69,  C,  C) — thus  practically  bringing  the  margins  of  the  opposite 
lips  into  close  contact — and  thereby  affording  opportunity  of  union  not  only 
between  the  relatively  broad  surfaces  of  endothelial  coats,  but  also  between 
the  free  edges  of  the  corresponding  coats  at  their  margins.  While  this 
method  is  of  application  to  vessel-wounds  in  general,  it  is  particularly  applicable 
to  brittle,  atheromatous  vessels,  in  which  it  is  difficult  to  make  the  ordinary 
form  of  suture  hold. 

(B)  Suture  of  an  Oblique  Vessel-wound. — There  is  no  special  principle 
involved  in  suturing  wounds  which  cross  the  long  axis  of  a  vessel  obliquely 


' 


« 


"•:-. 


Fig.  70. — Repair  of  Oblique  Wound 
of  Artery  by  Combination  Cobbler's 
Stitch  through  all  Coats,  and  Inter- 
rupted Stitches  through  Outer  Coats, 
as  suggested  by  the  Author: — A,  A, 
Cobbler's  stitch  being  completed  by  needles 
passing  through  all  coats  in  opposite  direc- 
tions; B,  B,  Interrupted  sutures  passing 
through  outer  coats. 


Fig.  7 1 . — Repair  of  Complete  Trans- 
verse Division  of  Artery  by  Combina- 
tion Cobbler's  Stitch  through  all 
Coats,  followed  by  Interrupted  Su- 
tures through  Outer  Coats,  as  sug- 
gested by  the  Author: — A,  A,  Needles 
passing  in  opposite  directions  through  all 
coats,  in  act  of  placing  cobbler's  stitch; 
B,  Superficial  tier  of  interrupted  stitches 
through  outer  coats,  showing  three  untied 
and  two  tied. 


not  already  brought  out  in  the  longitudinal  suturing.  In  proportion  as  such 
wounds  correspond  with  the  long  axis  of  the  vessel  does  the  technic  corre- 
spond with  that  of  the  longitudinal  wounds — and  in  proportion  as  the  wound 
approaches  complete  encircling  of  the  vessel,  though  in  an  oblique  direction, 
is  the  technic  equivalent  to  that  employed  in  complete  transverse  division  of 
the  vessel  (Fig.  70). 

(C)  Suture  of  Complete  Transverse  Division  of  a  Vessel. — The  above 
principles  are  here  applied  to  a  circumferential  wound  of  a  vessel — the  edges 
of  the  wounded  vessel-wall  representing  a  transverse  section  rather  than  a 
longitudinal  or  an  oblique  one.  In  carrying  the  cobbler's  stitch  around  the 
vessel  it  is  well  to  calculate  that  corresponding  extents  of  the  circumference 


ARTERIORRHAPHY. 


123 


are  being  taken  up,  so  that  no  redundancy  of  any  one  aspect  will  be  left  in 
terminating  the  line  of  suture  (Fig.  71,  A,  A).  The  tier  of  reinforcing 
interrupted  sutures  is  applied  in  the  manner  described  for  longitudinal  wounds 
(Fig.  71,  B). 


Fig.  72. — Circular  Arteriorrhaphy  in  Complete  Division  of  an  Artery: — A,  Method  of 

Salomoni  and  Tomaselli — interrupted  sutures  through  all  coats. 

■fig-   73- — B,  Same,  method  of  Gliick — interrupted    sutures    through  outer  coats,  protected  by 

cylinder  of  decalcihed  bone,  ivory,  or  rubber. 

Other    Methods    of    Suturing    Arteries. — Besides    the   methods  above 
described,  end-to-end  union  may  be  accomplished  by  suturing  through  all 


Figs.  74,  75,  76. — Circular  Arteriorrhaphy,  after  Complete  Division  of  an  Artery:— 

The  methods  of  Bougie. 


the  coats  of  both  ends,  after  the  manner  of  Salomoni  and  Tomaselli  (Fig.  72., 
or  by  the  method  of  Gliick  (Fig.  73),  or  by  one  of  the  methods  of  Bougie 
(Figs.  74,  75,  76). 


124 


OPERATIONS    UPON    THE    ARTERIES. 


CLOSURE  OF  WOUNDS  OF  LARGER  ARTERIES  BY  SPECIAL  RUBBER 

PLASTER. 

BREWER'S    METHOD. 

Description. — The  portion  of  the  vessel  involved  in  the  wound  is  encircled 
by  several  turns  of  elastic  plaster.  This  plaster  is  made  by  coating  long, 
narrow,  ribbon-like  sheets  of  thin,  pure  rubber  with  the  material  of  which 
zinc  oxid  plaster  is  coated,  and  is  sterilized  by  formaldehyd  vapor.  Following 
the  application  of  the  plaster,  the  wounded  vessel  is  further  reinforced,  where 
possible,  by  bringing  neighboring  muscle  or  connective  tissue  into  contact 
with  it  in  the  process  of  suturing  the  wound. 

Position; — Landmarks; — Incision. — Determined  by  the  special  oper- 
ation. 

Operation. — Having  exposed  the  wounded  vessel,  the  artery  is  isolated 


Fig.  77. — Brewer's  Method  of  Closing  Arterial  Wounds  by  Special  Rubber 
Plaster: — The  femoral  artery  is  exposed  at  the  apex  of  Scarpa's  triangle.  The  circulation  is 
temporarily  controlled  by  special  artery  clamps  applied  above  and  below  the  wound  (here 
represented  by  a  longitudinal  slit  in  the  vessel-wall).  The  adhesive  rubber  ribbon  has  been 
drawn  under  the  vessel  and  is  held  taut  by  forceps. 

sufficiently  for  manipulation,  is  brought  out  of  its  sheath,  and  is  gently  com- 
pressed above  and  below  the  wounded  site  by  the  fingers,  or  by  some  special 
clamps  which  compress  just  enough  to  control  the  circulation  without  injuring 
the  vessel.  By  means  of  pledgets  of  gauze  wet  with  ether  the  wall  of  the 
artery  is  cleaned  of  blood  and  made  dry,  so  that  the  rubber  plaster  will  adhere. 
A  strip  of  the  rubber  ribbon  is  now  carried  under  the  artery,  with  its  adhesive 
surface  next  the  vessel,  the  two  corners  of  its  end  grasped  by  forceps,  preferably 
of  the  artery -clamp  kind  (Fig.  77).  The  shorter  end  of  the  adhesive  strip 
which  has  been  carried  beneath  the  artery  is  now  brought  up  over  and  into 
contact  with  the  vessel,  and  the  longer  end  of  the  plaster  carried  over  the  shorter 
end  by  reversing  the  position  of  the  ends  of  the  plaster,  so  that  they  will  now 


ANEURISMORRHAPHY. 


be  in  the  position  shown  in  Fig.  78.  During  this  manoeuver  the  plaster  is 
kept  gently  on  the  stretch,  so  as  to  subject  the  vessel  to  slight  pressure  and 
compression  in  the  act  of  rolling  the  plaster  around  it.  Two  or  more  encirclings 
are  made,  as  deemed  necessary — after  which  the  plaster  is  cut  transversely 
and  the  artery  allowed  to  drop  back  into  its  original  position  (Fig.  79).     The 


Fig.  70. — Same : — The  vessel  has  been  sur- 
rounded by  several  turns  of  the  rubber  plaster, 
which  is  then  cut  transversely. 


Fig.  78. — Brewer's  Method  of  Clos- 
ing Arterial  Wounds  by  Special  Rubber 
Plaster: — The  end  of  the  rubber  plaster  be 
neath  the  vessel  is  brought  into  contact  with 
the  vessel  by  carrying  the  forceps  grasping 
this  encl  to  the  left — after  which  the  longer 
end  is  carried  over  to  the  right. 

neighboring  parts,  where  possible,  are  so  sutured  as  further  to  support  the 
wounded  vessel.     The  main  wound  is  sutured  without  drainage. 


ANEURISMORRHAPHY 

OPERATION  FOR  RADICAL  CURE  OF  ANEURISM  BASED  UPON 

ARTERIORRHAPHY. 

MATAS'S    OPERATION. 

Description. — The  objects  sought  in  this  plastic  procedure  are  the  restor- 
ation of  the  blood-current  and  the  obliteration  of  the  aneurismal  sac.  The 
accomplishment  of  these  objects  is  dependent  for  its  success  upon  the  readily 
occurring  union  of  the  general  endothelial  lining,  which,  continuous  with  that 
of  the  vessel,  not  only  covers  the  common  arterio-aneurismal  orifice  between 
vessel  and  aneurismal  sac,  but  the  interior  of  the  sac  as  well.  In  operat- 
ing upon  the  saccular  form  of  aneurism  (Fig.  81)  the  aneurismal  sac  is  laid 


126 


OPERATIONS    UPON    THE    ARTERIES. 


open; — the  aneurismal  orifice  is  exposed  and  closed  by  suture  in  such  a  way 
as  not  to  interfere  with  the  circulation  through  the  main  vessel — and  the  cavity 
of  the  sac  is  completely  obliterated  by  suturing  its  walls  and  overlying  integu- 
mentary parts  to  its  floor.  In  operating  upon  the  fusiform  variety  (Fig.  89) 
in  those  cases  where  the  walls  are  pliable  and  available,  the  circulation  through 
the  part  is  restored  by  forming  a  new  blood-channel  by  suturing  the  adjacent 
floor  of  the  sac  over  a  temporarily  placed  rubber  tube — which  is  withdrawn 
just  before  tightening  the  final  sutures — after  which  the  aneurismal  sac  is 
obliterated.  In  the  fusiform  variety,  where  the  aneurismal  walls  are  so  bound 
down  or  are  of  such  consistency  as  to  make  it  impossible  to  bring  them  together 
to  form  a  new  channel;  the  two  orifices  are  closed  by  suture  and  the  restoration 

of  the  blood-current  is  permanently  aband- 
oned (Fig.  91) — the  sac,  however,  being  ob- 
literated in  the  usual  manner. 

Indications. — The  method  of  restoration 
of  current  is  applicable  in  all  cases  where — 
(a)  a  distinct  sac  exists  (whether  fusiform 
or  saccular);  (b)  where  the  proximal  circula- 
tion can  be  temporarily  controlled;  and  (c) 
where  the  sac-wall  is  sufficiently  free  and 
pliable  to  be  manipulated  in  the  necessary 
manner.  Where  the  aneurismal  sac  is  not 
sufficiently  free  and  pliable,  the  obliteration 
of  the  current,  as  well  as  the  sac,  is  necessary. 
In  the  fusiform  type  of  aneurism  two  open- 
ings of  the  main  vessel  exist — one  at  either 
end,  generally  with  a  groove  connecting  them. 
Here  a  new  blood-channel  is  built  over  a 
rubber  tube  temporarily  inserted  into  the 
openings  of  the  aneurism  and  lying  in  the 
groove,  or  along  the  bed  between  the  open- 
ings— thus  restoring  the  circulation.  In  the 
saccular  type  of  aneurism  a  single  opening  of 
the  main  vessel  exists.  Here  the  margins  of 
the  opening  are  brought  together  by  suture, 
leaving  the  artery  intact  and  capable  of  carry- 
ing on  circulation.  The  operation  differs 
slightly  in  the  different  types.  The  opera- 
tion, in  general,  will  be  described  in  the 
case  of  saccular  aneurisms — after  which  the 
special  features  of  the  other  types  will  be 
pointed  out. 
The  advantages  of  this  method  of  operating  are  the  following: — Restoration 
of  blood-current  through  the  main  vessel  in  favorable  cases; — simpler  tech- 
nic; — less  traumatism; — elimination  of  any  ligaturing; — no  disturbance  of 
structures  in  vicinity  of  aneurismal  sac; — preservation  of  collateral  circula- 
tion;— usual  prompt  healing  by  the  approximation  of  the  integumentary 
coverings  to  the  floor  of  the  sac. 

Position; — Landmarks; — Incision. — Will  be  determined  by  the  special 
aneurism. 

Operation. — (A)  For  the  closure  of  the  arterio-aneurismal  opening 
and  the  restoration  of  the  blood-current  in  the  artery,  in  saccular  aneu- 
risms : — (1)  Where  the  position  of  the  aneurism  permits,  the  entire  circulation 


Fig.  80. — Aneurismorrhaphy: 
■ — First  stage  of  operation.  Ex- 
posure of  popliteal  aneurism — a 
fusiform  aneurism  laid  open,  show- 
ing two  openings  and  an  intervening 
groove.      (Modified  from  Matas.) 


ANEURISMORRHAPHY. 


127 


through  the  limb  is  controlled  by  a  rubber  constrictor.  Otherwise  the  aneu- 
rism is  exposed  and  the  artery  is  controlled  proximally  by  Matas's  special 
curved  aneurism  clamp-forceps,  Crile's  clamps,  by  a  traction-loop  around  the 
vessel,  or  by  some  other  device.  In  cases  where  the  entire  circulation  of  the 
limb  cannot  be  preliminarily  controlled,  profuse  bleeding  may  occur,  on  laying 
open  the  aneurism,  from  the  collaterals  opening  into  the  sac.  (2)  A  free 
median  incision  of  the  overlying  parts  is  made — after  which  the  adjacent 
structures  are  retracted  away  from  the  presenting  aspect  of  the  aneurismal  sac 
(Fig.  80).  (3)  The  sac  is  now  incised  from  end  to  end — guarding  against 
sudden  hemorrhage  from  one  or  more  unknown  collaterals,  which  may  be 
temporarily  controlled  by  thrusting  a  gauze  pack  tightly  into  the  aneurismal 
sac.  (4)  All  laminated  fibrin  is  rubbed  off  the  walls  of  the  aneurism  with  gauze 
— and  the  walls  themselves  are  also  briskly  rubbed  with  gauze  to  promote 
endothelial  proliferation.  (5)  The  main  arterio-aneurismal  opening  is  now 
closed  by  two  tiers  of  interrupted  chromic  gut  sutures.  The  sutures  of  the 
first  tier  pass  through  the  margins  of  the  orifice  without  entering  the  lumen  of 
the  artery  and  without  piercing  the  entire  thickness  of  the  aneurismal  wall- 
extending  somewhat  beyond  both  poles  of  the  opening.  They  are  planned 
so  as  to  afford  broad  serous  surfaces  for  union  (Fig.  81).     A  rubber  tube, 


Fig.  81. — Aneurismorehaphy: — Operation  to  restore  current  in  saccular  aneurism — 
first  stage.  Placing  of  interrupted  sutures  through  borders  of  arterial  opening  into  aneurism — 
leaving  channel  of  vessel  intact.      (Modified  from  Matas.) 

temporarily  inserted  within  the  lumen  of  the  vessel,  may  be  used  to  aid  suturing, 
if  necessary — as  in  fusiform  aneurisms.  The  lumen  of  the  artery  is  thus  not 
interfered  with,  and  the  circulation  is 'preserved.  The  sutures  of  the  first  tier 
are  now  tied  (Fig.  82),  the  knots  being  to  one  side  of  the  median  line — thus 
approximating  the  two  sides  of  an  ellipse  (Fig.  81)  into  a  median  straight 
line  (Fig.  82).  A  second  or  reinforcing  tier  of  interrupted  sutures  is  now 
placed — not  only  strengthening  the  primary  line  of  sutures  against  leakage, 
but  also  ridging  up  the  floor  of  the  aneurismal  sac  and  helping,  thereby,  to 
obliterate  it  (Fig.  82).     The  details  of  the  two  tiers  of  suturing  are  better 


128 


OPERATIONS    UPON    THE    ARTERIES. 


seen  in  Fig.  87.     Both  of  these  tiers  of  suture  may  be  continuous  (Fig.  86). 
(6)  The  mouth  of  any  collateral  vessel  opening  into  the  sac  is  closed  by  two 


Fig.  82. — Aneurismorrhaphy: — Operation  to  restore  current  in  saccular  aneurism — 
second  stage.  The  interrupted  sutures  through  the  borders  of  the  arterial  opening  have  been 
tied.  A  second  tier  of  interrupted  sutures,  overlying  and  outlying  the  first,  is  being  placed 
through  the  inner  coats  of  the  aneurismal  sac — which,  upon  being  tied,  will  bury  the  first  tier 
and  ridge  up  the  floor  of  the  aneurism  in  the  median  line.     (Modified  from  Matas.) 

or  more  interrupted  sutures  placed  as  shown  in  Fig.  91,  and  tied  as  shown 
in  Fig.  92.  (7)  The  tourniquet  around  the  limb,  or  the  special  clamps  upon 
the  vessel,  is  now  removed  and  the  efficiency  of  the  suturing  tested.     All  hemor- 


___>c> 

i 

/*t 

F- 


Fig.  83. — Aneurismorrhaphy: — Cross-sec^on  of  the  parts  involved  in  the  operation  where 
the  current  is  restored,  together  with  the  complete  obliteration  of  the  sac  of  the  aneurism: — A 
Integuments;  B,  Aneurismal  sac;  C,  Walls  of  blood-channel;  D,  First  tier  of  sutures,  approxi- 
mating walls  of  blood-channel;  E,  Second  tier  of  sutures,  approximating  floor  of  sac  over  first 
tier;  F,  F,  Sutures  through  walls  and  into  floor  of  aneurism,  approximating  former  to  latter; 
G,  Suture  through  margin  of  integuments  and  into  floor  of  sac,  over  second  tier;  H,  Restored 
blood-channel.      (Modified  from  Matas.) 

Fig.  84. — Aneurismorrhaphy  : — Cross-section  of  the  parts  involved  in  the  operation  where 
the  blood-channel,  together  with  the  aneurismal  sac,  are  completely  obliterated.  The  figures 
are  the  same  as  in  the  above,  except  that  H  here  represents  the  obliterated  blood-channel.  (Mod- 
ified from  Matas.) 


ANEURISMORRHAPHV. 


129 


rhage  in  the  general  wound  is  controlled  by  ligature.  (8)  The  empty  aneu- 
rismal  sac  is  next  obliterated.  This  is  accomplished  by  means  of  four  sutures 
placed  in  the  manner  shown  in  Fig.  88.  Four  interrupted  sutures  of  chromic 
gut,  kangaroo-tendon,  or  silkworm  gut  are  placed,  as  indicated  in  the 
illustration,  in  the  floor  of  the  aneurism  by  means  of  an  ordinary  curved  needle 
or  Reverdin  needle,  passing  deeply  into  but  not  through  the  walls  of  the  sac 
(Fig.  88,  A,  A).  Each  one  of  the  free  ends  of  these  four  loops  is  now  brought 
out  through  the  corresponding  aspect  of  the  outer  wall  (or  roof)  of  the  aneurism 
and  overlying  integumentary  parts,  by  means  of  a  Reverdin  needle  (Fig.  88, 
B,  B),  which  is  passed  through  the  skin  on  into  the  aneurism  through  all  the 


Fig.  85. — Aneurismorrhaphy: 
— Final  stage  of  operation.  The 
walls  of  the  aneurism-sac  and  the 
integuments  are  sutured  to  the  floor 
of  the  sac  over  gauze  rollers,  thus 
firmly  approximating  the  former  to 
the  latter.       (Modified  from  Matas.) 


Fig.  86. — Aneurismorrhaphy  : — Operation  to 
restore  current  in  saccular  aneurism.  In  the  present 
instance  both  tiers  of  sutures  are  continuous — the  first 
has  been  placed  and  is  being  tightened — and  the  second 
is  being  placed.  The  principles  of  the  operation,  other- 
wise, are  the  same  as  in  the  corresponding  operation 
by  interrupted  sutures  (Figs.  Si  and  82).  (Modified 
from  Matas.) 


intervening  structures.  These  sutures  are  tightly  tied  over  small  gauze  rolls — 
thereby  firmly  infolding  and  compressing  the  roof  of  the  aneurismal  sac  and 
all  overlying  structures,  to  the  floor  of  the  sac  and  the  central  elevation,  or 
ridging,  formed  by  the  two  tiers  of  suturing.  The  result  of  the  tying  of  these 
sutures  and  the  consequent  relation  of  the  parts  are  shown  in  the  diagrammatic 
cross-section  (Fig.  83).  The  two  flaps  thus  inturned  consist  of  aneurism-wall 
and  integumentary  coverings — the  approximation  obliterating  all  dead  space 
between  the  wall  of  the  sac  and  the  integuments,  on  the  one  side,  and  the  floor 
of  the  sac,  on  the  other.  (9)  The  main  wound  is  now  closed  by  a  median 
line  of  interrupted  sutures  (Fig.  85). 


l3° 


OPERATIONS    UPON    THE    ARTERIES. 


Fig.  87. — Aneurismorrhaphy: — Showing  in  greater  detail  the  steps  of  the  last  two  illus- 
trations (Figs.  81  and  82).  All  but  two  of  the  first  tier  of  interrupted  sutures  have  been  placed 
and  tied.  The  second  tier  is  being  placed  and  is  in  the  act  of  burying  under  the  first  tier  and 
ridging  up  the  floor  of  the  aneurism.     (Modified  from  Matas.) 

(B)  For  the  closure  of  the  arterio-aneurismal  opening  and  the  resto- 
ration of  the  blood-current  in  the  artery,  in  fusiform  aneurisms : — The 

preliminary  and  final  steps  are  the  same  as  just  described.     Owing  to  the 
distance  between  the  orifices  which  usually  exists  in  fusiform  aneurisms,  and 


Fig.  88. — Aneurismorrhaphy: — Operation  to  restore  current  in  saccular  aneurism — 
third  stage.  The  second  tier  of  interrupted  sutures  is  here  shown  tied.  A,  A,  Placing  interrupted 
sutures,  with  curved  needle,  in  floor  of  aneurism,  preparatory  to  approximating  the  aneurism- 
wall  to  the  floor  of  the  aneurism;  B,  B,  Reverdin  needle  in  act  of  drawing  the  sutures  (just  placed) 
through  the  aneurism  wall.  (The  final  tying  of  these  four  sutures  is  shown  in  Fig.  83,  F,  F, 
and  Fig.  85.)      (Modified  from  Matas.) 


ANEURISMORRHAPHY. 


131 


Fig.  S9. — Aneurismorrhaphy  : — Operation  to  restore  current  in  fusiform  aneurism. 
Suturing  borders  of  opening  and  of  connecting  groove  over  a  temporary  rubber  tube — the  ends 
of  which  are  seen  projecting  into  the  lumen  of  the  vessel,  at  either  end.  The  interrupted  form 
of  suture  is  here  shown.     (Modified  from  Matas.) 

the  inability  to  form  a  channel  along  this  intervening  distance  without  some 
form  of  support,  a  rubber  tube  (the  end  of  a  catheter,  for  instance)  is  inserted 
into  these  openings  and  made  to  occupy  the  groove  which  generally  exists 
between  the  two  openings  (Fig.  89).     Over  this  tube  the  sac  is  sutured,  as 


Fig.  90. — Aneurismorrhaphy: — Operation  to  restore  current  in  fusiform  aneurism. 
The  interrupted  sutures  placed  in  the  preceding  figure  have  been  tied  at  the  two  ends — 
while  those  in  the  center  are  being  held  apart  during  the  withdrawal  of  the  rubber  tube, 
after  which  these  also  are  tied.  Some  of  the  second  tier  of  sutures  are  shown  in  place,  ready 
to  be  tied.     (Modified  from  Matas.) 


132 


OPERATIONS    UPON    THE    ARTERIES. 


Fig.  91. — Aneurismorrhaphy: — Operation  to  obliterate  openings  and  channel  in  fusiform 
aneurism.  All  of  the  first  tier  of  sutures  is  placed,  and  the  lower  half  tied,  obliterating  the  lower 
opening  and  half  of  the  channel.  The  lower  half  of  the  second  tier  is  placed,  but  not  tied. 
Sutures  are  seen  in  the  mouth  of  a  collateral,  opening  upon  the  wall  of  the  sac.  (Modified 
from  Matas.) 

in  Witzel's  gastrostomy  (page  959).      All  the  sutures  are  placed  before  any 
are  tied.     The  end  sutures  are  then  tied  over  the  tube — when  the  tube  is  with- 


Fig.  92. — Aneurismorrhaphy: — Operation  to  obliterate  openings  and  channel  in  fusiform 
aneurism — second  stage.  The  second  tier  of  suturing  (which  is  here  a  continuous  suture)  is 
shown,  entirely  concealing  the  first  tier  and  all  evidence  of  openings  and  channel.  A,  A,  Placing 
interrupted  sutures,  with  curved  needle,  in  floor  of  aneurism,  preparatory  to  approximating  the 
aneurism  wall  to  the  floor  of  the  aneurism;  B,  B,  Reverdin  needle  in  act  of  drawing  the  sutures 
(just  placed)  through  the  aneurism  wall.  (The  final  tying  of  these  four  sutures  is  shown  in 
Fig.  83,  F,  F,  and  Fig.  85.)  The  closure  of  the  mouth  of  a  collateral  vessel  is  shown  in  the  wall 
of  the  aneurism-sac.     (Modified  from  Matas.) 


OPERATION    FOR    RADICAL    CURE    OF    ARTERIOVENOUS    ANEURISMS.    133 

drawn  through  the  separated  middle  sutures,  which  are  then  tied  (Fig.  87). 
The  operation  is  completed  in  the  general  manner — a  second  tier  of  sutures 
being  used  here  as  elsewhere. 

(C)  For  the  obliteration  of  both  blood-channel  and  aneurismal  sac, 
in  fusiform  aneurisms : — In  cases  of  fusiform  aneurism  where  it  is  found  that, 
owing  to  such  circumstances  as  the  adhesion  of  the  floor  of  the  aneurismal  sac 
to  some  unyielding  structure,  or  owing  to  some  pathologic  change  preventing 
the  necessary  manipulation  of  the  sac-wall,  a  new  blood-channel  cannot  be 
made,  nothing  remains  but  to  close  both  arterio-aneurismal  orifices  and  the 
intervening  groove  without  attempting  to  bring  about  the  restoration  of 
circulation.  In  these  cases  both  the  orifices  and  intervening  groove  are  closed 
by  a  double  tier  of  sutures,  placed  in  the  ordinary  manner  (Figs.  91  and  92), 
after  which  the  sac  is  treated  in  the  usual  way.  The  cross-section  of  an 
obliterating  operation  of  this  nature  is  shown  in  Fig.  84. 

Comment. — (I)  Union  takes  place  between  the  serous  surfaces  lining 
the  sac  (the  arteries  being  mesoblastic  in  origin).  (2)  The  sutures  should 
take  strong  hold  in  the  walls  of  the  sac.  (3)  Superfluous  sac-wall  is  to  be 
excised.  (4)  The  perisaccular  structures  should  not  be  disturbed  more  than 
absolutely  necessary,  as  most  of  the  nourishment  of  the  sac  comes  to  it  through 
these  structures.  (5)  Firm  pressure  should  be  applied  in  the  outer  dressing 
over  the  aneurism  site,  to  aid  in  keeping  in  contact  the  parts  held  by  the 
transfixion  sutures.  (6)  In  the  case  of  the  limbs,  the  part  is  to  be  elevated 
and  kept  swathed  in  cotton-batting  to  maintain  the  temperature  of  the  part, 
applying  artificial  heat  if  necessary. 


OPERATION  FOR  THE  RADICAL  CURE  OF  ARTERIOVENOUS  ANEU- 
RISMS, WITH  PRESERVATION  OF  CIRCULATION  IN  ARTERY  AND 
VEIN. 

MATAS-BICKHAM    OPERATION. 

Description. — This  technic  consists,  as  suggested  by  the  author,  in  the 
application  to  the  arteriovenous  type  of  aneurisms  of  the  method  of  radical 
cure  which  Matas  applies  to  ordinary  arterial  aneurisms- — with  the  modifications 
necessitated  by  the  special  forms  of  arteriovenous  aneurisms,  thus  preserving 
the  integritv  of  both  artery  and  vein  and  sparing  the  patient  the  great  risk 
attendant  upon  the  loss  of  circulation  through  one  or  both  of  these  vessels. 
Where  this  form  of  operation  can  be  carried  out,  the  composite  aneurismal  sac 
is  exposed — its  double  blood-supply  controlled — the  sac  incised — the  openings 
of  artery  and  vein  sutured- — and  the  common  sac  either  obliterated  by  approxi- 
mation of  its  walls,  as  carried  out  in  the  operation  of  aneurismorrhaphy — or 
the  sac  is  excised  in  whole  or  in  part  and  the  orifices  closed  by  suturing. 

Indications. — In  all  cases — (a)  where  a  distinct  sac  exists;- — (b)  where 
the  arteriovenous  circulation  through  the  aneurism  can  be  controlled  prior 
to  incising  the  sac; — and  (c)  where  the  structure  and  surroundings  of  the  sac 
will  admit  of  the  necessary  manipulations.  It  is  a  known  fact  that  the  nature 
of  arteriovenous  aneurisms  cannot  always  be  determined  clinically,  and  are 
often  only  discovered  when  the  site  has  been  exposed  by  operation.  But  it 
would  be  warrantable  to  expose  the  aneurism  in  every  appropriate  case  and, 
where  feasible,  make  an  attempt  to  preserve  the  circulation  through  both 
vessels. 

Position; — Landmarks; — Incision. — Determined  by  the  special  opera- 
tion. 


134 


OPERATIONS    UPON    THE    ARTERIES. 


Operation. — (A)  Upon  the  Varicose-aneurism  Type  of  Arterio- 
venous Aneurisms,  with  Preservation  of  the  Sac— In  these  cases  an 
aneurismal  sac  intervenes  between  artery  and  vein,  communicating  with 
both  vessels  by  separate  mouths   (Fig.  93).     After  temporarily  controlling 


Fig.  93. — Varicose-aneurism  Type  of  Arteriovenous  Aneurism  of  Left  Common 
Femoral  Artery  and  Vein — showing  the  Application  to  this  Class  of  Aneurisms  of  the 
Matas  Method  of  Operating  upon  Ordinary  Aneurisms: — The  opening  of  the  femoral 
artery  into  the  common  aneurismal  sac  is  shown  on  the  right,  with  interrupted  Lembert  gut 
sutures  in  position,  ready  to  be  tied.  The  opening  of  the  femoral  vein  is  seen  on  the  left,  with 
similar  Lembert  sutures  in  position.  On  the  left  of  the  sac  two  gut  sutures  are  in  the  act  of 
being  placed,  which,  when  tied,  will  approximate  the  roof  of  the  sac  (including  skin  and  inter- 
vening tissues,  which  are  not  here  shown)  to  the  floor  of  the  sac.  Similar  sutures  will  approxi- 
mate the  roof  and  floor  of  the  sac  upon  the  right.  (From  Bickham,  "Annals  of  Surgery," 
May,  1904.) 


the  circulation  through  the  involved  vessels,  lay  open  the  intervening  aneuris- 
mal sac,  locate  both  the  arterial  and  venous  openings  into  it,  and  close  them 
off  by  fine  chromic  gut  Lembert  sutures  applied  interruptedly,  followed 
by  obliteration  of  the  sac  by  suturing  its  roof,  including  the  overlying  parts, 
to  its  floor.  It  is  to  be  remembered  that  an  endothelial  layer  usually  lines 
the  cavity  of  an  arteriovenous  aneurism,  and  is  especially  apt  to  be  present 
near  the  openings  into  the  sac;  although  the  absence  of  an  endothelial  lining 


OPERATION    FOR    RADICAL    CURE    OF    ARTERIOVENOUS    ANEURISMS.    135 

would  not  seem  to  be  a  contraindication  to  the  application  of  this  method, 
as  the  surfaces  of  even  a  pure  connective-tissue  sac  could  be  roughened  by 
curettement  or  friction  to  promote  adhesion  of  its  walls.  This  lechnic  is 
shown   in   Fig.  93. 

(B)    Operation   upon  the  Aneurismal-varix  Type  of  Arteriovenous 


Fig.  94. — Aneurismal-varix  Type  of  Arteriovenous  Aneurism  of  Left  Common 
Femoral  Artery  and  Vein: — The  opening  of  the  femoral  artery  into  the  varicosed  vein  is 
shown,  with  interrupted  Lembert  gut  sutures  in  position,  ready  to  be  tied.  The  longitudinal 
incision  in  the  vein,  for  approaching  the  arteriovenous  opening  (and  which  is  here  made  somewhat 
unnecessarily  long)  is  shown  in  the  act  of  being  closed  by  two  methods  of  suturing — above,  by 
the  continuous  Lembert  of  the  outer  coats — below,  by  interrupted  ordinary  sutures  of  the  outer 
coats.     (From  Bickham,  "Annals  of  Surgery,"  May,  1904.) 

Aneurisms,  with  Preservation  of  the  Sac. — In  these  cases  there  is  a  vari- 
cosed dilatation  of  a  vein,  caused  by  the  force  of  the  arterial  circulation  poured 
into  it  through  a  direct  communication  from  an  artery,  without  an  intervening 
aneurismal  sac  (Fig.  94).  After  temporarily  controlling  the  circulation 
through  the  involved  vessels,  make  a  longitudinal  incision  through  the  enlarged 
and  varicosed  vein  for  as  limited  an  extent  as  would  seem  to  afford  approach 


i36 


OPERATIONS    UPON    THE    ARTERIES. 


to  the  opening  into  the  vein,  and  so  placed  as  to  lie  directly  opposite  this 
communicating  opening  from  the  artery,  retract  the  lips  of  this  wound  in  the 
vein,  thus  exposing  the  interior  of  the  vein  and  the  arterial  communication, 
suture  up  the  opening  of  the  artery  into  the  vein  in  the  usual  Matas  manner, 
and  then  close  the  incised  vein  by  a  continuous  lateral  suture  of,  approxi- 
mately, the  Lembert  type.  Fig.  94  illustrates  tin's  technic.  Owing  to  the 
fact,  in  aneurismal-varix  cases,  that  foreign  material  will  be  left  in  contact 
with  the  venous  current  by  this  manner  of  suturing  (which  does  not  apply  in 
the  varicose-aneurism  cases),  with  the  consequent  theoretical  possibility  of 


U^" 


Fig.  95. — Same  as  Fig.  94,  showing  a  continuous  Lembert  gut  suture,  which,  having  been 
passed  through  the  outer  coats  of  the  thickened  vein  at  the  angle  of  junction  of  vein  and  artery, 
and  knotted,  is  passed  on  between  the  coats  of  the  vein  until  its  varicosed  cavity  is  entered  very 
near  one  end  of,  and  immediately  above,  the  first  tier  of  interrupted  sutures — and  is  then  made 
to  bury  i  1  this  first  tier  and  itself  in  continuous  Lembert  fashion — and,  emerging  at  the  opposite 
angle  of  junction  of  vein  and  artery,  is  tied  in  the  same  manner  as  at  its  entrance.  (This  suture 
is  not  yet  tightened  throughout.)      (From  Bickham,  "Annals  of  Surgery,"  May,  1904.) 

pieces  of  the  suture  forming  emboli,  it  would  be  well  to  use  very  fine  gut  for 
this  suture,  and  to  tie  very  small,  closely  cut  knots.  Or  it  would  be  better 
still  to  bury-in  the  row  of  interrupted  Lembert  sutures,  closing  off  the  arterial 
opening,  by  means  of  a  continuous  buried  suture  introduced  from  without 
entirely  through  the  vein,  at  one  of  the  angles  of  junction  of  artery  and  vein, 
passing  in  continuous  Lembert  fashion  above  the  interrupted  sutures,  through 
part  of  the  thickness  of  the  wall  of  the  vein,  and  out  through  the  entire  thickness 
of  the  vein  at  the  opposite  angle  of  junction  of  artery  and  vein,  in  very  much 
the  same  manner  as  a  subcuticular  suture  is  passed,  and  so  placed  that  the 
suture  throughout  its  entire  length  and  its  points  of  entrance  and  exit  to  and 


OPERATION    FOR    RADICAL    CURE    OF  ARTERIOVENOUS    ANEURISMS.    137 

from  the  vein  is  also  buried,  which,  in  the  case  of  a  thickened,  varicosed  vein 
would  be  easier  of  accomplishment  than  in  a  normal  vein.  This  second  tier 
of  suturing  is  shown  in  Fig.  95. 

(C)  Operation  upon  the  Varicose-aneurism  Type  of  Arteriovenous 
Aneurisms,  with  Excision  of  the  Sac. — More  recently,  successful  artery- 
suturing  and  vein-suturing  have  been  demonstrated,  and  these  principles  may 
be  applied  to  arteriovenous  aneurisms.  In  those  cases  of  the  varicose- 
aneurism  type  where  both  arterial  and  venous  circulation  can  be  controlled 
proximally  to  the  sac,  and  the  sac  exposed  by  dissection,  the  aneurismal  sac 


Fig.  96. — Varicose-aneurism  of  Left  Common  Femoral  Artery  and  Vein,  treated 
by  Excision  of  the  Sac,  followed  by  Suturing  of  the  Openings  in  the  Vessels: — Upon 
the  right,  a  small  elliptical  piece  of  the  sac  is  shown  connected  with  the  arterial  opening,  with 
the  first  tier  of  interrupted  Lembert  gut  sutures  in  position,  ready  to  be  tied.  Upon  the  left, 
a  similar  elliptical  piece  of  sac  has  been  left  connected  with  the  venous  opening.  The  first 
row  of  Lembert  sutures  has  been  tied,  and  a  second  tier  of  ordinary  sutures  through  all  the  coats 
is  being  applied,  burying  in  the  first  tier.  Fig.  96  is  the  same  as  Fig.  93,  with  the  sac  excised. 
(From  Eickham,  "Annals  of  Surgery,"   May,   1904.) 

may,  in  appropriate  cases,  be  excised  up  to  very  near  the  arterial  and  venous 
openings  into  it,  and  these  openings  then  closed  by  a  row  of  interrupted 
Lembert  gut  sutures,  followed  by  a  second  burying-in  row  through  the  free 
margins  of  the  small  portion  of  the  sac  left  around  the  jug-like  opening  into 
the  artery  and  vein,  as  shown  in  Fig.  q6. 

(D)  Operation  upon  the  Aneurismal-varix  Type  of  Arteriovenous 
Aneurisms,  with  Excision  of  the  Sac. — In  those  cases  of  the  aneurismal- 
varix  type,  where,  similarly,  both  the  arterial  and  venous  circulation  may  be 
arrested   proximally   to   the   arteriovenous   communication,   and   this   site   of 


138 


OPERATIONS    UPON    THE    ARTERIES. 


communication  be  exposed  by  dissection,  the  artery  and  enlarged  vein  may, 
in  appropriate  cases,  be  severed  from  each  other  by  an  incision  through  the 
connecting  opening,  made  parallel  with  artery  and  vein,  and  these  openings 
closed  by  lateral  suture  with  fine  gut  or  silk,  the  openings  left  by  the  incision 
of  the  connection  between  artery  and  vein  being,  in  the  aneurismal-varix,  less 
jug-like  and  with  less  free  margin  than  in  the  varicose  aneurism.     This  technic 


Fig.  97. — Aneurismal-varix  of  Left  Common  Femoral  Artery  and  Vein,  treated 
by  Severance  of  Vessels  from  each  other,  followed  by  Suturing  of  their  Openings: — 
On  the  right,  interrupted  gut  sutures  are  shown  passing  through  the  outer  coats  of  the  artery, 
ready  to  be  tied.  On  the  left,  a  continuous  Lembert  gut  suture  through  the  outer  coats  is  shown 
closing  the  venous  opening.  Fig.  97  is  the  same  as  Fig.  94,  with  the  vessels  cut  apart.  (From 
Bickham,   "Annals  of  Surgery,"   May,    1904.) 


is  shown   in   Fig.  97.     If   necessary,   these  openings  left   by  the  liberating 
incision  could  be  trimmed  into  elliptical  shapes. 

Comment. — While  recognizing  that  it  is  ideal  to  excise  the  aneurismal 
sac  of  a  varicose  aneurism  and  suture  up  the  openings  in  the  artery  and  vein, 
and  to  cut  apart  artery  and  vein  in  an  aneurismal-varix  and  somewhat  similarly 
suture  up  the  openings  in  the  vessels  which  the  severing  of  the  common  con- 
nection between  them  has  left,  leaving  the  circulation  intact  in  both  class  of 
cases — yet  there  must  occur  cases  in  which  there  is  difficulty  of  satisfactorily 
exposing  the  parts,  or  where  there  is  difficulty  in,  and  contraindication  to, 
the  removal  of  the  sac  of  a  varicose  aneurism,  or  the  cutting  apart  of  artery 
and  vein  in  an  aneurismal  varix- — and  in  such  cases  the  Matas  method  would 


OTHER    OPERATIONS    FOR    RADICAL    CURE    OF    ANEURISM.  139 

seem  to  be  a  desirable  technic.  And  while  one  feature  is  common  to  all  of 
these  more  modern  methods,  and  that  is,  the  retention  of  the  circulation  through 
artery  and  vein,  yet  it  may  be  questioned  where,  from  the  circumstances  of 
the  case,  it  is  optional,  whether  the  Matas  method  would  not  really  be  preferable 
in  dealing  with  the  varicose  aneurism  type  of  cases;  for  it  would  seem  the 
suturing  together  of  the  roof  and  floor  of  the  sac  would  strengthen  the  suturing 
of  the  arterial  and  venous  openings  into  the  sac  and  make  secondary  hemor- 
rhage less  likely,  and  also  accomplish  the  end  with  less  traumatism. 


LIGATION  FOR   RADICAL  CURE  OF  ANEURISM. 

Description. — Several  methods  of  applying  ligatures  for  the  radical  cure 
of  aneurism  have  been  adopted — either  as  a  means  alone  or  in  conjunction 
with  other  steps. 

Methods. — (I)  Antyllus's  Method  ("Old  Method"): — The  sac  is  incised 
— the  clots  are  turned  out — and  the  involved  artery  ligated  above  and  below 
the  sac.  (2)  Anel's  Method: — Ligature  of  the  involved  artery  just  above 
(proximal  to)  the  sac.  (3)  Hunter's  Method: — Ligature  of  the  main  vessel  in- 
volved at  some  distance  above  (proximal  to)  the  sac,  so  that  one  branch,  at 
least,  intervenes  between  sac  and  ligature,  thereby  only  partly  cutting  off  the 
circulation  through  the  sac.  (4)  Brasdor's  Method: — Ligature  of  the  main 
artery  involved  beyond  (distal  to)  the  sac,  entirely  cutting  off  the  circulation 
through  the  sac.  (5)  YVardrop's  Method: — Ligature  of  one  or  more  of  the 
distal  branches.  (6)  Extirpation: — Ligature  of  the  main  vessel  (and  collateral 
branches)  above  and  below  the  sac,  with  extirpation  of  the  aneurism — with 
or  without  opening  the  sac. 


OTHER  OPERATIONS  FOR  RADICAL  CURE  OF  ANEURISM. 

Acupuncture. — A  method  of  treating  aneurisms  by  the  introduction  of 
long  needles  into  their  sacs.  Several  long,  fine  needles  are  simultaneously 
introduced,  by  the  safest  route,  through  overlying  integuments,  into  and 
through  the  wall  of  the  aneurism — and  on  beyond,  until  in  contact  with  the 
opposite  wall.  Here  they  are  allowed  to  quietly  rest  for  several  hours,  and 
are  then  withdrawn.  Repetition  of  this  process  may  be  resorted  to  upon 
successive  occasions.     Coagulation  is  thus  favored. 

Needling  (Macewen's  Operation). — The  introduction  of  one  or  two 
long  needles  into  the  sac,  with  irritation  of  its  wall.  A  long,  fine  needle  is 
introduced,  by  the  safest  route,  through  skin  and  connective  tissue,  into  and 
through  the  wall  of  the  aneurism — and  is  pushed  on  until  in  contact  with 
the  inner  surface  of  the  opposite  wall.  The  wall  of  the  aneurism  is  then 
gently  irritated  by  a  process  of  scratching,  by  means  of  the  point  of  the  needle 
— which  is  then  withdrawn.  The  interior  of  the  sac  should  be  evenly  irritated 
throughout,  or  at  different  sites  consecutively.  This  direct  irritation  of  the 
wall  should  be  only  great  enough  to  produce  a  reparative  exudation  together 
with  a  deposit  of  fibrin — and  thus  white  thrombi  are  formed  upon  the  surface 
of  the  sac.  Two  or  more  needles  may  be  used  simultaneously  in  a  large  sac, 
and  several  hours  may  be  consumed  in  the  process — and  their  use  repeated 
upon  successive  occasions. 

Introduction  of  Wire. — A  fine  cannula  is  introduced,  by  the  safest  route, 
through  skin,  fascia,  and  wall  of  aneurism,  into  the  cavity  of  the  sac.  Through 
this  cannula  several  vards  of  fine  wire  (according  to  size  of  aneurism)  are 


140  OPERATIONS    UPON    THE    ARTERIES. 

introduced  and  left,  the  cannula  being  withdrawn.  Cure  is  effected  by  the 
clotting  of  blood  upon  this  wire  meshwork.  Catgut,  silk,  horsehair,  and  the 
like  have  been  used — but  silvered  copper  wire  has  proved  the  most  satis- 
factory. 

Comment. — The  method  of  aneurismorrhaphy  is  preferable  to  all  others 
in  those  cases  where  the  circulation  can  be  controlled  prior  to  opening  the 
sac.  Second  to  this,  or  where  this  method  cannot  be  applied,  one  of  the 
methods  of  ligation,  with  or  without  extirpation  of  the  sac,  should  be  used. 


ARTERIAL  FORCIPRESSURE. 

Definition. — Pressure  of  artery  by  artery-clamp  forceps. 

Description. — This  is  the  ordinary  method  of  controlling  hemorrhage 
by  seizing  arteries  in  a  wound,  upon  an  amputation  stump  or  in  the  course 
of  any  operation — by  means  of  clamp  or  hemostatic  forceps.  The  forceps 
are  allowed  to  remain  in  situ  for  a  period  of  time  after  their  application,  but 
are  not  twisted  upon  their  axis  (as  in  the  following  operation).  The  hemostat 
should  grasp  the  bleeding  end  of  the  artery,  and  as  little  else  as  possible. 
Where  circumstances  allow,  the  artery  to  be  subjected  to  forcipressure  should 
be  cleared  of  surrounding  connective  tissue  by  a  stroke  or  two  of  the  knife, 
especially  in  the  case  of  the  larger  vessels.  In  the  case  of  the  smaller  arteries, 
the  forceps  may  be  removed  and  nothing  further  done,  with  fair  certainty 
that  no  further  bleeding  will  occur  from  the  crushed  vessels.  In  the  case 
of  the  larger  arteries,  a  catgut  ligature  should  be  applied  over  the  point  of  the 
forceps,  just  prior  to  their  removal  (Fig.  293,  B). 

Comment. — In  some  operations,  as  in  vaginal  hysterectomy  by  the 
clamp  method,  the  forceps  are  left  in  the  wound  for  twenty-four  or  forty- 
eight  hours  or  longer. 


ARTERIOSTREPSIS. 

Definition. — Torsion  of  an  artery  by  means  of  artery-clamp  forceps. 

Description. — The  operation  consists  in  the  seizing  of  the  divided  end 
of  an  artery  with  forreps  and  twisting  it  through  two  or  three  revolutions,  in 
the  direction  of  its  long  axis — causing  a  rupture  and  retraction  of  its  inner 
and  middle  coats  wdthin  the  outer  coat.  A  clot  forms  and  organizes  upon 
and  in  the  roughened  inner  coats  and  is  protected  by  the  outer  coat.  The 
twisting  should  cease  short  of  causing  a  complete  severance  of  the  end  of  the 
artery.  This  is  the  common  method  of  arresting  hemorrhage  from  the 
smaller  vessels  bleeding  in  a  wound  or  upon  the  surface  of  an  amputation 
stump,  and  its  use  should  be  confined  to  such  vessels,  although  the  femoral 
artery  has  been  successfully  controlled  by  torsion  (occurring  in  accidents). 
The  technic  differs  slightly  in  the  application  of  arteriostrepsis  to  small  and 
medium  vessels:  (a)  Upon  Smaller  Arteries: — seize  the  extremity  of  the  bleed- 
ing vessel  with  catch-forceps,  including  as  little  tissue,  other  than  the  sheath 
of  the  artery,  as  possible — draw  it  out  from  its  connections  and  twist  it  around 
two  or  three  times  and  release  the  hold,  (b)  Upon  Medium  Arteries: — seize 
the  extremity  of  the  severed  artery,  in  its  long  axis,  with  catch-forceps,  and 
draw  the  vessel  out  of  its  sheath  for  about  1.3  to  2  cm.  (J  to  f  inch).  With 
a  second  pair  of  catch-forceps,  grasp  the  bared  artery  about  1.3  cm.  (^  inch) 
from  its  extremity,  at  a  right  angle  to  its  long  axis,  and  hold  steadily.     Then 


TREATMENT    OF    VASCULAR    NEOPLASMS.  141 

rotate  the  vessel  two  or  three  times  by  means  of  the  terminal  forceps,  and 
let  go.  Thus  the  proximal  forceps  prevent  the  artery  from  being  twisted  in 
its  sheath,  which  would  sever  its  vasa  vasorum  in  their  passage  from  the 
sheath  to  the  arterv.  Only  that  portion  of  the  artery,  therefore,  between  the 
clamps  is  twisted.     Ligation  is  generally  to  be  preferred  to  arteriostrepsis. 


THE  TREATMENT  OF  VASCULAR  NEOPLASMS   BY  INJECTION  OF 
WATER  AT  HIGH  TEMPERATURE. 

WYETH'S  OPERATION. 

Description. — This  method  of  treatment  consists  in  the  injection  into 
the  substance  of  vascular  neoplasms  (angeiomata)  of  water  at  a  temperature 
of  from  190°  to  2120  F.  and  over — the  object  being  immediately  to  coagulate 
the  blood  and  albuminoids  of  the  tissues.  The  vascular  tumors  thus  far 
treated  by  the  author  of  the  operation  have  been  arterial  angeiomata  (cirsoid 
aneurisms),  capillary  angeiomata  (''  mother's  marks"),  and  venous  angeiomata 
(cavernous  nawi). 

Instruments. — Syringe  with  metallic  cylinder  and  an  adjustable  piston, 
and  needles  of  various  sizes.  The  water  is  usually  gotten  from  some  im- 
mediately adjacent  vessel  in  which  it  has  come  to  a  boil,  and  under  all  aseptic 
precautions.  In  cirsoid  aneurisms  and  in  the  larger  cavernous  narvi,  where 
the  water  should  be  kept  at  the  boiling-point  during  the  use  of  the  needle 
and  syringe,  the  author  of  the  operation  has  devised  a  long  metallic  instru- 
ment under  the  cylinder  of  which  a  Bunsen  burner  is  held  during  operation. 

Operation. — (1)  The  region  of  the  injection  is  rendered  aseptic  in  the 
usual  manner.  The  operation  is  done  under  complete  narcosis.  The  quan- 
titv  and  temperature  of  the  water  will  vary  according  to  the  size  and  nature 
of  the  growth.  (2)  In  arterial  and  venous  angeiomata  the  needle  is  carried 
deeply  into  the  substance  of  the  growth  and  from  30  to  60  minims  of  water 
are  thrown  out  in  one  site — the  needle  is  then  withdrawn  from  1.3  to  2.5 
cm.  (J  to  1  inch)  and  about  the  same  amount  injected — and  the  same  steps 
repeated  in  different  sites  until  the  whole  tumor  is  solidified.  While  using 
water  of  a  temperature  sufficiently  high  to  coagulate  the  blood  and  albu- 
minoids of  the  neighboring  tissues,  it  should  not  be  delivered  into  the  part 
so  exceedingly  hot  nor  with  such  pressure  as  to  cause  subsequent  sloughing 
of  the  overlying  parts.  Evidence  of  sufficient  distention  of  the  part  to  dis- 
continue the  injection  in  that  particular  site  is  given  by  slight  bleaching 
of  the  skin.  (3)  In  capillary  angeiomata,  especially  upon  delicate  parts, 
water  a  little  loelow  boiling  (about  1900  F.)  should  be  used — and  only  about 
two  to  six  minims  thrown  in  at  a  single  puncture — beginning  at  the  periphery 
of  the  growth.  Sloughing  is  more  apt  to  occur  in  the  capillary  angeiomata. 
The  injection  may  be  repeated  in  from  seven  to  ten  days,  if  necessary.  (4) 
A  surgical  dressing  is  then  applied  and  the  part  kept  at  rest. 

Comment. — (i)  Especial  care  is  advised  in  the  cases  of  angeiomata  of  the 
neck  and  scalp,  because  of  oedema.  (2)  No  more  than  from  five  to  six 
ounces  should  be  injected  at  one  sitting  in  the  largest  growths  and  very  much 
less  in  most  cases.  (3)  Sloughing  of  the  tissues  from  the  action  of  the  boiling 
water  deposited  in  their  midst  is  possible,  and  is  an  important  consideration 
in  localities  when  this  occurrence  would  be  functionally  or  cosmetically  serious. 


CHAPTER  II. 

OPERATIONS  UPON  THE  VEINS. 

PHLEBOTOMY. 

Definition. — Incision  of  a  vein,  or  venesection.  A  method,  now  rarely 
practised,  of  depletion  by  bleeding,  for  its  effect  upon  the  system.  One  of 
the  veins  of  the  elbow  is  usually  selected. 

Indications. — Pulmonary  engorgement;  engorgement  of  the  right  heart; 
many  inflammatory  states  in  sthenic  persons. 

Preparation. — Bend  of  elbow  shaved. 

Position. — Patient,  holding  arm  extended  and  abducted,  sits  upright, 
that  warning  by  approaching  syncope  may  be  given.  Surgeon  stands  in 
front  and  to  right  of  either  arm. 

Instruments  and  Accessories. — Lancet  or  bistoury;  fillet  or  constrictor; 
round  object  to  grasp  (roller  bandage);  a  graduated  "bleeding-bowl"  or 
measure;  gauze  compress;  bandage. 

Operation. — Apply  the  constrictor  around  the  lower  third  of  the  arm, 
that  the  return  venous  flow  may  be  obstructed  and  veins  about  the  elbow 
made  prominent,  while  not  firmly  enough  to  obstruct  the  arterial  flow.  The 
grasping  and  manipulating  of  the  fingers  about  some  object  will  aid  the 
distention  of  the  veins.  The  most  prominent  vein  at  the  bend  of  the  elbow 
is  now  selected.  The  median  basilic  vein  (which  is  crossed  by  the  internal 
cutaneous  nerve  and  is  parallel  with  and  separated  from  the  brachial  artery 
by  the  bicipital  fascia)  is  generally  chosen — because  of  its  greater  prominence, 
and  because  of  being  steadied  by  the  underlying  bicipital  fascia.  The  median 
cephalic  vein  (which  is  covered  by  skin  and  fascia  alone  and  rests  upon  the 
external  cutaneous  nerve)  is  often  chosen — and  is  also  sometimes  the  more 
prominent.  The  vein  is  steadied  by  pressure  of  the  left  thumb  just  below 
the  intended  incision.  The  lancet  or  bistoury,  with  its  back  to  the  arm,  is 
thrust  through  the  skin  over  the  vessel,  and  into  the  distended  vein  beneath 
— and  is  made  to  cut  its  way  upward  and  outward  at  a  single  stroke — cal- 
culating to  sever,  in  an  oblique  direction,  about  two-thirds  of  the  vein.  Upon 
removing  the  thumb,  the  bleeding  is  allowed  to  continue  until  approaching 
faintness  indicates  a  sufficient  loss — when  the  constrictor  is  removed,  the 
gauze  pad  placed  over  the  wound,  and  a  figure-of-eight  bandage  applied 
to  the  elbow. 

Comment. — (i)  If  bleeding  continue,  the  vein  is  to  be  entirely  severed 
— and  the  wound  may  even  be  enlarged  and  the  vessel  doubly  ligated.  (2) 
The  internal  saphenous  vein  may  also  be  used. 


PHLEBORRHAPHY. 

Definition. — The  suture  of  a  wound  in  a  vein,  without  occluding  the 
caliber  of  the  vessel. 

142 


LATERAL    LIGATION    OF    VEINS. 


143 


Indications. — Where,  in  the  case  of  a  limited  wound  to  one  of  the  larger 
veins,  it  is  desired  to  control  hemorrhage  without  permanently  destroying 
the  function  of  the  vein  by  transverse  ligation — and  where  the  wound  is  too 
long  for  lateral  ligation. 

Operation. — Having  well  exposed  the  vein  and  controlled  the  hemorrhage 
from  the  vessel  by  distal  compression  (by  constrictor,  digital  compression, 
or  temporary  ligature),  one  of  the  lips  of  the  wounded  vein  is  steadied  with 
fine  forceps,'  while  a  fine  needle,  armed  with  finest  catgut,  pierces  this  lip, 
including,  if  possible,  only  the  external  and  part  of  the  middle  coat.  The 
opposite  lip  is  similarly  steadied  and  similarly  pierced,  in  the  opposite  direction 


Fig.  98.— Phlebokrhaphy:— Forceps   are  seen  everting    lip  of   wound    for  passaj 

interrupted  sutures. 


of   needle  and 


(penetrating  part  of  the  middle  and  the  entire  thickness  of  the  outer  coat). 
By  tying  the  ligatures  carefully,  the  two  lips  are  brought  into  even  apposition. 
Interrupted  sutures,  closely  applied,  will  more  safely  repair  the  wound  than 
continuous  suture  (Fig.  98). 

Comment. — This  method  is  especially  applicable  where  (a)  the  wound 
is  longitudinal  (and  therefore  the  lips  tend  to  lie  parallel),  and  (b)  where 
the  wound  extends  in  any  one  direction  a  distance  greater  than  equivalent 
to  the  diameter  of  the  lumen.  Sometimes  instead  of  approximating  lip  to 
lip,  the  edges  of  the  wound  are  sutured  upon  themselves. 


LATERAL  LIGATION  OF  VEINS. 

Description. — The  application  of  a  ligature  to  the  wall  of  a  vein  for 
the  purpose  of  closing  a  wound  in  the  vein  without  obliterating  its  lumen. 
Indications. — Wound  of  one  of  the  larger  veins,  where  it  is  desired  to 


144  OPERATIONS    UPON    THE    VEINS. 

control  hemorrhage  without  destroying  the  function  of  the  vein  by  transverse 
ligation. 

Operation. — Having  controlled  hemorrhage  and  brought  the  vein  well 
into  the  field  of  operation,  seize  the  two  lips  of  the  wounded  vein  in  a  single 
bite  of  a  pair  of  dissecting  forceps — draw  them  outward  from  the  wall  of 
the  vein  in  the  form  of  a  small  cone  (whose  apex  is  formed  by  the  forceps) — and, 
around  the  base  of  the  cone,  tie,  with  a  reef-knot,  a  ligature  of  fine  chromicized 
catgut,  relaxing  the  tension  upon  the  cone  at  the  moment  of  tightening  the 


F'&-  99- — Lateral  Ligation  of  a  Vein  : — Forceps  are  shown   drawing  outward  and  puckering 
together  the  wounded  lateral  wall  of  a  vein,  around  which  a  ligature  is  being  tied. 

knot — and  thus  throwing  into  folds  the  walls  of  the  rent  in  the  vessel  very 
much  as  one  puckers  together  the  mouth  of  a  sac  with  a  draw-string.  The 
ligature  is  cut  short  and  the  temporary  compression  relaxed — and  the  wound 
closed  as  in  an  ordinary  ligation  (Fig.  99). 

Comment. — This  method  is  applicable  where  the  wound  does  not  extend 
in  any  one  direction  a  distance  equivalent  to  the  diameter  of  the  lumen. 
Transverse  wounds  gape  more  than  longitudinal  ones  and  are  thus  especially 
suitable  for  this  form  of  ligature. 


TRANSVERSE  LIGATION  OF  VEINS. 

Description. — The  ordinary  ligation  of  a  vein  (in  contradistinction  to 
lateral  ligation). 

Indications. — Wounds;  arteriovenous  aneurism;  simple  and  suppurative 
phlebitis;  thrombosis;  angeiomata. 

Operation. — As  for  ligation  of  arteries,  in  general  principle. 


TEMPORARY  LIGATION  OF  VEINS. 

Description. — As  for  same  operation  upon  arteries  (page  118). 
Indications. — As  in  temporary  ligation  of  an  artery  (e.  g.,   temporary 


PHLEBECTOMY.  145 

ligation  of  internal  jugular  vein  in  removal  of  tumor  of  neck — or  while  ligating 
or  suturing  a  wound  of  the  vein). 

Operation.— Same,  practically,  as  for  the  corresponding  operation  upon 
the  arteries  (page  118). 


VENOUS  LIGATION  EN  MASSE. 

Description. — For  parenchymatous  hemorrhage. 

Operation. — Practically  identical  with  intermediate  ligation,  or  ligation 
en  masse,  described  under  Arteries  (page  118). 


VENOUS  FORCIPRESSURE. 

Description. — A  method  of  control  of  venous  hemorrhage,  corresponding 
with  arterial  forcipressure  (page  140) — though  of  more  limited  application. 


PHLEBOSTREPSIS. 
Description. — Corresponding  with  arteriostrepsis  (page  140). 

ACUPRESSURE  OF  VEINS. 

Description. — Pressure  of  vein  by  needle — the  pressure  being  applied 
directly  or  indirectly.  Rarely  resorted  to  at  present.  Formerly  much  used 
for  varicose  veins,  nasvi,  and  venous  hemorrhage. 

Operation. — Several  methods  of  acupressure  exist,  differing  in  but  minor 
details.  The  following  is  the  most  generally  applicable  method :  The  needle 
(or  pin)  enters  the  skin  near  the  involved  vein — passes  under  the  vein  as  closely 
as  possible — and  emerges  from  the  skin  on  the  opposite  side.  Over  this 
needle,  in  a  figure-of-eight  fashion,  a  silk  ligature  is  wound — thus  compressing 
the  vein  between  needle  and  ligature. 


PHLEBECTOMY. 

Description. — Excision  of  a  vein,  in  whole  or  in  part. 

Indications. — The  usual  causes  for  which  veins  are  removed  are  vari 
cosity  (e.  g.,  excision  of  varicosed  veins  of  leg,  or  of  a  varicocele)  and  throm- 
bosis, especially  suppurative  (e.  g.,  excision  of  internal  jugular  for  suppurative 
thrombosis  following  middle-ear  disease). 

Operation. — As  illustrative  of  the  technic  of  phlebectomy  in  general, 
partial  excision  of  the  internal  saphenous  will  be  described  for  varicosity 
of  that  vein  and  its  branches — the  operation  consisting  in  the  total  removal 
of  sections  of  the  vein  and  its  branches  at  intervals  along  its  course.  (1) 
The  site  and  course  of  the  varicose  veins  are  previously  marked  with  nitrate 
of  silver  stain  (on  the  preceding  day,  to  allow  of  darkening),  that  the  land- 
marks may  not  be  lost  during  operation.  The  limb  is  shaved.  An  Esmarch 
is  generally  used  to  control  hemorrhage.  (2)  Over  the  course  of  the  vein 
(or  slightly  to  one  side,  or  obliquely  crossing  it)  incisions  of  from  8  to  15  cm. 


146  OPERATIONS    UPON    THE    VEINS. 

(3  to  6  inches)  are  made  at  intervals — extending,  if  necessary,  from  the  inner 
side  of  the  foot  to  the  saphenous  opening  in  the  thigh.  These  incisions  are 
especially  placed  over  the  most  marked  groups  of  veins — and  those  nearer 
the  saphenous  opening  are  usually  the  first  attacked.  The  skin  and  bands 
of  fibrous  tissue  binding  down  the  vein  are  divided  and  the  involved  veins 
exposed.  The  vein  and  its  branches  are  entirely  isolated  to  the  extent  of 
the  incision,  by  blunt  and  sharp  dissection.  The  vein  is  then  gently  drawn 
upon,  so  as  to  bring  into  the  open  wound  as  much  of  itself  and  branches  as 
possible — when  it  is  gut-ligatured  at  both  ends,  each  branch  being  also  liga- 
tured— after  which  the  main  vein  and  its  branches  are  cut  away.  This  site 
of  operation  is  then  packed  with  gauze,  until  removal  at  all  indicated  sites  is 
accomplished — to  allow  of  cessation  of  all  bleeding  before  suturing.  (3) 
The  edges  of  the  skin  wound  are  then  sutured  with  silk,  or  silkworm-gut — 
after  which  the  limb  is  dressed,  immobilized,  and  slightly  elevated. 

Comment. — (1)  The  removal  of  the  vein  in  sections  appears  to  give  as 
good,  or  better,  results  as  the  attempt  to  remove  the  entire  vein.  (2)  Avoid 
wounding  the  veins  in  operation,  which  increases  the  difficulties.  (3)  Avoid 
including  a  nerve  filament  in  the  ligature,  which  has  caused  much  subsequent 
pain. 


INTRAVENOUS  INFUSION  OF  NORMAL  SALT  SOLUTION. 

Description. — Injection  of  normal  salt  solution  into  the  venous  circula- 
tion. 

Indications. — Hemorrhage;  shock;  sepsis;  suppression  of  urine;  and  other 
conditions. 

Preparation  of  Normal  Salt  Solution. — The  physiological  salt  solution 
for  man  is  a  mixture  of  0.6  of  1  per  cent,  of  sodium  chlorid  in  water  (approx- 
imately, one  dram  of  sodium  chlorid  to  one  pint  of  water).  This  mixture  is 
to  be  sterilized  and  used  at  a  temperature  of  1150  to  1200  F. — being  allowed 
to  pass  from  an  elevated  funnel  or  jar  through  a  rubber  tube  and  special 
cannula  into  the  vein.  The  salt  may  be  sterilized  first — or  the  solution  may 
be  sterilized  after  preparation.  The  operation  is  conducted  aseptically 
throughout. 

Preparation. — Patient's  elbow  is  shaved  and  protected  by  aseptic  dressing 
(if  occasion  allow). 

Position. — Patient  recumbent;  arm  extended,  abducted  and  supine. 
Surgeon  on  right  side  of  both  arms — or  on  right  side  of  right,  cutting  from 
above;  and  on  left  side  of  left,  cutting  from  below. 

Instruments  and  Accessories. — Scalpel;  dissecting  forceps;  artery- 
clamp  forceps;  funnel;  rubber  tube;  bulbous-pointed  cannula;  aneurism- 
needle;  ligature;  suture;  needle  and  holder;  constrictor  for  arm;  gauze  com- 
press, cotton  and  bandage. 

Operation. — The  most  prominent  vein  at  the  bend  of  the  elbow  is  chosen 
(see  Phlebotomy,  page  126).  If  the  vein  be  prominently  marked,  incise 
directly  over  and  parallel  with  it.  If  not  marked,  incise  obliquely  across 
the  known  course  of  the-  median  basilic  vein,  the  incision  running  parallel 
with  the  direction  of  the  bicipital  fascia.  Proceed  carefully  until  the  vein  is 
located.  Expose  from  2.5  to  4  cm.  (1  to  i|  inches)  of  the  vein.  Pass  two 
catgut  ligatures  beneath  the  vein,  about  2.5  cm.  (1  inch)  apart — and  tie  the 
distal  one  permanently  (Fig.  100).  With  a  pair  of  sharp-pointed  scissors, 
curved  on  the  flat,  an  oblique  incision  is  made  through  one-half  of  the  vein, 
between  the  two  ligatures,  the  apex  of  the  "V"  pointing  distally.     Into  this 


INTRAVENOUS    INFUSION    OF    NORMAL    SALT    SOLUTION. 


147 


oblique  opening  into  the  vein,  the  cannula  (after  seeing  that  no  air  is  in  the 
instrument)  is  introduced — and  the  proximal  ligature  is  tightened  about  it 
with  a  friction-knot.  Through  this  is  allowed  to  flow,  by  static  pressure,  as 
much  fluid  as  is  indicated  (generally  from  one  to  six  pints).  The  cannula 
is  then  withdrawn — the  proximal  ligature  is  tightened  and  tied  permanently 


C-  -n— U- 


Fig.  100. — Intravenous  Infusion  of  Normal  Salt  Solution  : — A,  Bandage  tourniquet ;  E, 
Median  basilic  vein;  C,  Distal  (to  heart)  ligature  tied  about  vein;  D,  Proximal  (to  heart)  ligature 
loosely  placed  and  ready  to  be  tied  about  vein  ;  E,  Forceps  grasping  tongue  of  wound  in  vein  just 
made  by  curved  scissors  ;  F,  tip  of  cannula  about  to  enter  vein  and  around  which  ligature  will  be  tied  ; 
G,  Stop-cock. 


— and  the  vein  completely  severed.     The  wound  is  sutured  and  the  dressing 
applied. 

Comment. — The  fluid  may  be  thrown  into  an  open  vein  in  a  stump — 
or  any  convenient  vein  in  a  wound  may  be  opened.  The  basilic  vein  itself 
may  be  used — or  the  internal  saphenous.  Szumann's  infusion  solution  con- 
sists of  six  parts  of  sodium  chlorid,  one  part  of  carbonate  of  soda,  and  one 
thousand  parts  of  sterilized  water,  heated  to  a  temperature  of  no°  to  1120  F. 
Szumann's  formula   may  be   expressed  as   follows: 

R.      Sterilized  water 32  oz. 

Sodium  chlorid 1  ^2  dr. 

Sodium  carbonate 15  gr. 

Mix  and  heat  to  1  io°  or  1 1 2°  F. 


CHAPTER  III. 

OPERATIONS  UPON  THE  LYMPHATIC  GLANDS 

AND  VESSELS. 

SURGICAL  ANATOMY  OF  THORACIC  DUCT. 

Course  and  Relations. — (i)  Abdominal  portion: — (from  origin  to  dia- 
phragm);— Begins  in  abdomen  at  receptaculum  chyli,  on  anterior  surface 
of  second  lumbar  vertebra,  lying  behind  and  to  right  side  of  aorta  and  between 
aorta  and  right  crus  of  diaphragm.  At  aortic  opening  in  diaphragm  (in 
front  of  twelfth  dorsal  vertebra)  it  still  lies  to  right  of  aorta  and  has  vena 
azygos  major  to  its  right.  (2)  Thoracic  portion  : — (from  diaphragm  to 
superior  thoracic  opening) ; — Runs  up  posterior  mediastinum  between  aorta 
and  vena  azygos  major,  in  front  of  sixth  to  twelfth  dorsal  vertebr&\  Opposite 
to  fifth  dorsal  vertebra  it  passes  to  left  behind  esophagus  and  aortic  arch 
to  enter  superior  mediastinum,  whence  it  emerges  through  superior  thoracic 
opening  into  root  of  neck,  (a)  In  Posterior  Mediastinum  (from  below 
upward) — Anteriorly ;  pericardium;  esophagus;  arch  of  aorta.  Posteriorly  ; 
sixth  to  twelfth  dorsal  vertebras;  anterior  common  ligament;  right  inferior 
intercostal  arteries;  vena  azygos  minor  (sometimes  one  of  left  middle  inter- 
costal veins  and  vena  azygos  tertia).  Left;  thoracic  aorta.  Right;  vena 
azygos  major;  right  pleura,  (b)  In  Superior  Mediastinum; — anteriorly; 
first  part  of  left  subclavian  artery.  Posteriorly ;  upper  dorsal  vertebra? 
(first  to  fifth.)  Left ;  left  pleura.  Right ;  esophagus.  (3)  Cervical  por- 
tion : — (from  superior  thoracic  opening  to  termination) ; — From  superior 
thoracic  opening  it  ascends  on  left  side  of  neck  to  level  of  seventh  cervical 
vertebra — curves  thence  downward,  forward,  and  outward,  arching  over 
apex  of  left  pleura — passing  in  front  of  subclavian  artery,  scalenus  anticus 
muscle,  vertebral  vein — and  behind  left  internal  jugular  vein,  and  behind 
and  then  externally  to  left  common  carotid  artery — and,  receiving  left  jugular 
lymphatic  trunk,  empties  into  left  innominate  vein  at  junction  of  left  internal 
jugular  and  left  subclavian  veins. 

Course  and  Relations  of  Right  Lymphatic  Duct. — About  1.3  to  2 
cm.  (^  to  f  inch)  in  length — formed  by  union  of  subclavian  and  jugular 
lymphatic  ducts — passes  downward  and  inward — and  empties  into  venous 
circulation  at  junction  of  right  internal  jugular  and  subclavian  veins. 


SUTURE  OF  THORACIC  DUCT. 

Description. — Suture  of  the  thoracic  duct  is  indicated  in  wounds  of 
the  duct  occurring  from  external  injury,  or  in  the  course  of  an  operation. 

Operation. — The  method  of  suturing  the  thoracic  duct  is  similar  to 
that  employed  in  suturing  a  vein  (see  Phleborrhaphy,  page  142).  Having 
completed  the  technic  of  suturing  the  duct  itself,  the  neighboring  tissues 
should  be  drawn  over  and  sutured  about  the  wound  in  the  duct,  to  aid  in 
closing  and  reinforcing  the  sutured  site — and  the  overlying  skin  should  be 


SURGICAL    ANATOMY    OF    AXTERO-LATERAL    ASPECT    OF    NECK.       149 

sutured  throughout  and  pressure  applied.  Minimum  nourishment  should 
be  administered  to  the  patient,  to  keep  the  duct  as  empty  as  possible  until 
union  of  the  wound  has  occurred. 

Comment. — If  possible,  the  right  duct  should  be  similarly  dealt  with. 


LIGATION  OF  THORACIC  DUCT. 

Description. — The  thoracic  duct,  where  completely  severed  by  accident, 
has  been  ligated,  and  recovery  lias  followed — although  there  has  been  a 
question  as  to  whether,  in  such  cases,  a  branch  of  the  main  duct  has  not 
existed  and  maintained  the  circulation.  Suturing,  however,  is  always  prefer- 
able to  ligation,  where  possible.  Where  ligation  is  performed,  the  technic 
is  the  same  as  that  for  ligating  a  vein  (pages  143  and  144). 

Comment. — The  right  lymphatic  duct  may  also  require  ligation  if  its 
divided  ends  be  discovered  in  a  wound. 


SURGICAL  ANATOMY  OF  ANTERO-LATERAL  ASPECT  OF  NECK. 

Boundaries  of  Antero-lateral  Aspect  of  Neck. — Superiorly :  lower 
border  of  body  of  inferior  maxilla,  and  imaginary  line  from  angle  of  inferior 
maxilla  to  mastoid  process.  Inferiorly  :  upper  border  of  clavicle.  Ante- 
riorly :  median  line  of  neck.     Posteriorly :  anterior  border  of  trapezius. 

Subdivisions  of  Quadrilateral  Surface  of  Neck. — (a)  Anterior  Triangle 
— divided,  by  digastric  muscle  above  and  anterior  belly  of  omohyoid  below, 
into  submaxillary,  superior  carotid,  and  inferior  carotid  triangles,  (b) 
Posterior  Triangle — divided,  by  posterior  belly  of  omohyoid,  into  occipital 
and  subclavian  triangles. 

Anterior  Triangle. — Boundaries,  anteriorly:  median  line  of  neck, 
from  chin  to  sternum.  Posteriorly :  anterior  margin  of  sternomastoid 
muscle.  Superiorly  :  lower  border  of  body  of  inferior  maxilla,  and  line 
from  angle  of  inferior  maxilla  to  mastoid  process  (base).  Inferiorly:  at 
sternum  (apex).  This  triangle  is  subdivided  into  submaxillary,  superior 
carotid,  and  inferior  carotid  triangles. 

Submaxillary  Triangle. — Boundaries  :  Superiorly — lower  border  of 
inferior  maxilla,  and  line  from  angle  of  inferior  maxilla  to  mastoid  process. 
Inferiorly — posterior  belly  of  digastric  and  stylohyoid.  Anteriorly — anterior 
belly  of  digastric  (or  middle  line  of  neck).  Coverings:  integument;  super- 
ficial fascia;  platysma;  deep  fascia;  branches  of  facial  nerve;  branches  of 
superficialis  colli  nerve.  Floor:  anterior  belly  of  digastric;  mylohyoid; 
hyoglossus.  Contents  :  Muscles — styloglossus,  stylopharyngeus.  Ligaments 
— stylomaxillary  (separating  anterior  from  posterior  part  of  triangle).  Ar- 
teries— external  carotid,  posterior  auricular,  temporal,  internal  maxillary, 
mylohyoid  branch  of  inferior  dental,  facial  with  submaxillary  and  submental 
branches,  internal  carotid.  Veins — internal  jugular,  facial,  submaxillary. 
Nerves — facial,  pneumogastric,  glossopharyngeal,  mylohyoid  branch  of  in- 
ferior dental.  Other  Structures— parotid  gland,  submaxillary  gland,  lymph- 
atic glands. 

Superior  Carotid  Triangle. — Boundaries  :  Superiorly — posterior  belly 
of  digastric.  Inferiorly — anterior  belly  of  omohyoid.  Posteriorly — anterior 
border  of  sternomastoid.  Coverings:  integument;  superficial  fascia;  pla- 
tysma; deep  fascia;  branches  of  facial  nerve;  branches  of  superficialis  colli 


150       OPERATIONS    UPON    THE    LYMPHATIC    GLANDS    AND    VESSELS. 

nerve.  Floor:  parts  of  thyrohyoid;  hyoglossus;  inferior  constrictor  of 
pharynx;  middle  constrictor  of  pharynx.  Contents:  Arteries — common 
carotid;  internal  carotid;  external  carotid;  superior  thyroid;  lingual;  facial; 
occipital;  ascending  pharyngeal.  Veins — internal  jugular;  superior  thyroid; 
lingual;  facial;  occipital  (sometimes);  ascending  pharyngeal.  Nerves — 
descendens  hypoglossi;  hypoglossal;  pneumogastric;  sympathetic;  spinal 
accessory;  superior  laryngeal;  external  laryngeal.  Other  Structures — larynx; 
pharynx;  lymphatic  glands. 

Inferior  Carotid  Triangle. — Boundaries:  Superiorly — anterior  belly 
of  omohyoid.  Anteriorly — middle  line  of  neck.  Posteriorly — anterior  margin 
of  sternomastoid.  Coverings:  integument;  superficial  fascia;  platysma; 
deep  fascia;  descending  branch  of  superficialis  colli  nerve.  Floor:  scalenus 
anticus  (superiorly  and  externally);  longus  colli  (inferiorly  and  internally); 
rectus  capitis  anticus  major  (between  and  superiorly);  vertebral  artery  and 
vein  (between  and  inferiorly).  Contents:  Muscles — sternohyoid;  sterno- 
thyroid. Arteries — common  carotid  (not  strictly);  inferior  thyroid;  vertebral. 
Veins — internal  jugular.  Nerves — pneumogastric;  descending  filaments  from 
loop  between  descendens  and  communicans  hypoglossi;  recurrent  laryngeal; 
sympathetic.  Other  Structures — larynx;  trachea;  thyroid  gland;  lymphatic 
glands. 

Posterior  Triangle. — Boundaries  :  Anteriorly — posterior  border  of 
sternomastoid.  Posteriorly — anterior  border  of  trapezius.  Superiorly — ■ 
occiput  (apex).  Inferiorly — superior  border  of  clavicle  (base).  This  triangle 
is  subdivided  into  the  occipital  and  subclavian  triangles. 

Occipital  Triangle. — Boundaries:  Anteriorly — posterior  border  of 
sternomastoid.  Posteriorly — anterior  border  of  trapezius.  Inferiorly — 
posterior  belly  of  omohyoid.  Coverings:  integument;  superficial  fascia; 
platysma;  deep  fascia.  Floor:  splenius  capitis;  levator  anguli  scapulas; 
middle  scalenus;  posterior  scalenus.  Contents  :  Arteries — transversalis  colli. 
Veins — transversalis  colli.  Nerves — spinal  accessory;  descending  branches 
of  cervical  plexus.     Other  Structures — lymphatic  glands. 

Subclavian  Triangle. — Boundaries: — Posteriorly — posterior  belly  of 
omohyoid.  Inferiorly — upper  border  of  clavicle.  Anteriorly — posterior 
border  of  sternomastoid  (base).  Coverings  : — integument;  superficial  fascia; 
platysma;  deep  fascia;  descending  branches  of  cervical  plexus.  Floor  :— 
first  rib,  first  serration  of  serratus  magnus.  Contents  : — Arteries — subclavian 
(third  part);  suprascapular;  transversalis  colli.  Veins — subclavian  (some- 
times); suprascapular;  transversalis  colli;  external  jugular;  small  vein  from 
cephalic  to  external  jugular.  Nerves — brachial  plexus,  small  nerve  to  sub- 
clavius.     Other  Structures — lymphatic  glands. 

Lymphatic  Glands  of  Head  and  Neck. — Consist  of  superficial  and 
deep  glands.  (A)  Superficial  glands  of  head  and  neck : — Consist  of 
transverse  and  vertical  sets.  (1)  Transverse  set  of  superficial  glands: — 
Extend  transversely  from  occiput  along  mastoid  process,  zygoma,  and  lower 
border  of  jaw,  to  symphysis  menti,  and  comprise  following  groups; — (a)  Oc- 
cipital or  Suboccipital — below  superior  curved  line  of  occipital  bone,  between 
skin  and  insertion  of  complexus  muscle,  (b)  Posterior  Auricular,  or  Sterno- 
mastoid— behind  ear,  between  skin  and  insertion  of  sternomastoid.  (c) 
Parotid — in  front  of  ear,  between  skin  and  parotid  gland,  some  being  embedded 
within  parotid  gland,  (d)  Buccal — on  surface  of  buccinator,  between  it 
and  skin,  (e)  Submaxillary — in  digastric  triangle,  between  skin  and  mylo- 
hyoid and  hyoglossus.  (f)  Suprahyoid — in  middle  line,  between  anterior 
bellies  of  digastric,  between  skin  and  mylohyoid.     (2)  Vertical  set  of  super- 


REMOVAL    OF    LYMPHATIC    GLANDS    OF    NECK.  151 

ficial  glands  (superficial  cervical  chain) : — (a)  Anterior — in  front  of  neck, 
between  hyoid  bone  and  sternum,  and  between  skin  and  superficial  muscles. 
(b)  Middle  (superficial  cervical  chain) — chiefly  along  external  jugular  vein, 
mainly  in  posterior  triangle  of  neck,  between  platysma  and  deep  cervical 
fascia,  (c)  Posterior — over  trapezius,  between  it  and  skin.  (B)  Deep  glands 
of  head  and  neck : — Comprising  those  of  head  and  neck.  (1)  Those  of 
head  : — Consisting  of  following  groups: — (a)  Lingual — on  external  surface  of 
hvoglossus  and  geniohyoglossus.  (b)  Internal  Maxillary — on  lateral  aspect 
of  pharynx,  behind  buccinator  muscle,  (c)  Posterior  Pharyngeal — between 
posterior  surface  of  pharynx  and  rectus  capitis  anticus  major,  near  base  of 
skull.  (2)  Those  of  neck  : — Consisting  of  following  sets; — (a)  Superior  set — 
along  internal  jugular  vein,  from  base  of  skull  to  level  of  thyroid  cartilage, 
(b)  Inferior  set — along  internal  jugular  vein,  from  thyroid  cartilage  to  near 
clavicle. 


REMOVAL  OF  LYMPHATIC  GLANDS  OF  NECK. 

General  Considerations. — In  the  case  of  diseased  cervical  glands,  an 
operation  may  be  undertaken — (1)  for  the  removal  of  one  or  a  few  defined 
glands,  in  one  or  more  of  the  regions  of  the  neck,  in  which  case  a  single  or 
several  incisions,  more  or  less  limited,  are  so  placed  as  most  readily  and 
safely  to  expose  the  involved  glands; — or  (2)  for  the  removal  of  glands  widely, 
deeply,  and  indistinctly  disseminated  throughout  the  antero-lateral  aspect 
of  the  neck,  in  which  case  one  or  more  extensive  incisions  are  necessary, 
both  for  the  removal  of  the  glands  and  in  order  to  give  room  in  which  to 
safeguard  important  structures  during  their  removal.  Removal  of  dis- 
seminated cervical  glands  will  be  first  described — and  removal  of  isolated 
glands  will  be  referred  to  under  Comment. 

Indications  for  Removal  of  Cervical  Lymphatic  Glands. — Chronic 
tubercular  adenitis  (most  frequently) ;  acute  non-tubercular  suppurative 
adenitis;  enlargement  secondarily  from   neighboring  malignant  growths. 

Preparation. — Shaving  of  all  hairy  parts  at  site  of  and  bordering  upon 
field  of  operation. 

Position. — Patient  supine;  shoulders  raised;  neck  resting  over  a  support, 
to  render  it  prominent;  head  so  turned  as  to  increase  prominence,  length, 
and  width  of  neck,  and  in  order  to  drag  glands  out  from  under  protecting 
tissues.     Surgeon  on  side  of  operation;  assistant  opposite. 

Landmarks. — The  triangles  of  the  neck. 

Instruments. — Scalpels;  scissors,  straight,  curved,  blunt  and  sharp; 
dissecting  forceps;  toothed  forceps;  artery-clamp  forceps;  blunt  dissector; 
retractors;  tenacula;  grooved  director;  aneurism-needle;  needles;  needle- 
holder;  sutures;  ligatures;  sterilized  water  on  hand  to  flood  neck  in  case  of 
opening  large  vein  in  an  inaccessible  localitv. 

Incision. — Various  forms  of  incision  have  been  used,  singly  or  combined. 
Where  the  entire  antero-lateral  aspect  of  the  neck  is  to  be  exposed,  a  X-shaped 
incision  (Fig.  101)  may  be  used — BC  extending  from  over  the  mastoid  process 
to  the  interval  between  the  sternal  and  clavicular  attachment  of  the  sterno- 
mastoid,  passing  down  the  middle  of  the  sternomastoid  or  along  its  anterior 
border — BA  extending  transversely  forward  from  the  upper  end  of  the  oblique 
incision  to  the  angle  of  the  jaw,  and  thence  along  the  lower  border  of  the 
jaw  to  the  symphysis — CD  extending  transversely  outward  along  the  upper 
border  of  the  clavicle,  as  far  toward  the  acromioclavicular  articulation  as 
necessarv.      If  only  the  anterior  triangle  of  the   neck  be  involved,  the  por- 


152 


OPERATIOXS    UPON    THE    LYMPHATIC    GLANDS    AND    VESSELS. 


tion  ABC  of  the  incision  is  alone  used — if  the  posterior  triangle,  the  portion 
BCD. 

Operation. — (i)  Incise  directly  through  skin,  superficial  fascia,  platysma, 
and  deep  fascia — the  diagonal  portion  of  the  X-shaped  incision  being  first 
made;  that  is,  the  portion  over  the  anterior  border  of  the  sternomastoid. 
Sever  the  external  jugular  vein  between  two  ligatures.  Branches  of  the 
superficialis  colli  nerve  will  be  cut,  but  the  auricularis  magnus  and  occipitalis 
minor  should  be  retracted  backward,  if  exposed.  This  incision  is  carried 
down  to  and  exposes  the  whole  length  of  the  sternomastoid  muscle.  (2) 
Carry  the  upper  incision  transverselv  downward   to  the  angle  of  the  jaw, 


N, 


Fig.  1 01. —Incisions  for  Exposing  Lymphatic  Glands  of  Cervical  Rf.c.ion  :—BC,  Line  over 
anterior  border  of  sternomastoid,  from  mastoid  process  to  interval  between  sternal  and  clavicular 
origins  of  sternomastoid  ;  BA,  Line  from  mastoid  process  to  angle  of  jaw,  and  thence  forward  along 
its  lower  border;  CD,  Line  from  sternoclavicular  articulation  outward  along  upper  border  of  clavicle. 
Anterior  triangle  of  neck  is  exposed  by  raising  flap  ABC;  Posterior  triangle,  by  raising  flap  BCD  ; 
Entire  antero-lateral  aspect  of  neck,  by  raising  both  flaps.  Following  incisions  may  be  used  for 
removing  isolated  groups  of  glands  ;  EF,  Incision  parallel  with  anterior  border  of  sternomastoid  ; 
GH,  parallel  with  posterior  border ;  IJ,  Transverse  oblique  in  upper  part  of  neck  ;  KL,  Transverse 
oblique  in  lower  part  of  neck. 


and  then  forward  along  the  lower  border  of  the  inferior  maxilla  toward  the 
symphysis,  passing  through  the  skin,  superficial  fascia,  platysma,  and  deep 
fascia — and  exposing,  without  injury,  the  parotid  gland,  facial  nerve,  tribu- 
taries of  temporomaxillary  vein,  facial  artery  and  vein,  submaxillary  and 
submental  glands.  The  facial  artery  and  vein  may  be  divided  between  two 
ligatures,  if  necessary.  (3)  The  lower  incision  is  now  carried  transversely 
along  the  upper  border  of  the  clavicle,  as  far  toward  its  outer  end  as  necessary 
— passing  through  skin,  superficial  fascia,  platysma,  and  deep  fascia — 
dividing  some  of  the  descending  superficial  branches  of  the  cervical  plexus 
and  a  few  minor  vessels.     (4)  Having  now  completed  these  three  incisions, 


REMOVAL    OF    LYMPHATIC    GLANDS    OF    NECK.  153 

two  triangular  flaps  are  carefully  dissected  up  and  turned  aside — an  anterior 
flap  (ABC),  having  the  same  boundaries  as  the  anterior  triangle  of  the  neck, 
is  turned  forward,  hinging  on  the  anterior  median  line  of  the  neck — and  a 
posterior  flap  (BCD),  having  the  same  boundaries  as  the  posterior  triangle 
of  the  neck,  is  turned  backward,  hinging  on  the  anterior  margin  of  the  tra- 
pezius (or  on  a  line  posterior  to  that,  if  the  lower  transverse  incision  have 
been  extended  posteriorly  to  the  acromioclavicular  articulation).  Thus, 
the  superficial  parts  having  been  turned  aside,  the  entire  antero-lateral  quadri- 
lateral surface  of  the  neck  is  exposed  on  a  plane  with  the  important  structures 
and  in  easy  access  to  those  structures.  (5)  All  glands  are  now  dissected  out, 
together  with  their  surrounding  connective  tissue — being  sought  in  the  locali- 
ties indicated  in  the  above  summary  (see  Lymphatic  Glands  of  Head  and 
Neck,  page  150) — guarding,  at  the  same  time,  the  important  anatomical 
structures  enumerated  under  Surgical  Anatomy  of  the  Triangles  of  the  Xeck. 
(6)  If  avoidable,  the  sternomastoid  should  not  be  cut — it  generallv  being 
possible,  in  such  a  free  exposure,  to  retract  it  alternately  well  forward  and 
backward  in  order  to  remove  the  glands  partly  or  entirely  covered  In-  it, 
slightly  flexing  the  chin  on  the  sternum  to  lessen  tension.  Where,  however, 
it  proves  a  barrier  to  thorough  and  safe  work,  it  should  be  unhesitatingly 
severed — the  emergence  of  the  spinal  accessory  nerve  from  its  posterior 
border  being  exposed,  and  the  muscle  divided  transversely  below  the  nerve 
The  upper  end  of  the  muscle  is  then  turned  upward  and  backward  with 
the  uninjured  nerve,  and  the  lower  end  downward  and  forward — and  the 
important  structures  beneath  it  thus  easily  brought  to  view.  (7)  In  com- 
pleting the  operation,  the  cut  ends  of  the  sternomastoid  should  be  carefully 
sutured  with  interrupted  buried  catgut  sutures.  The  flaps  are  now  turned 
back  into  place  and  sutured  throughout — the  flaps  being  sutured  to  each 
other  first,  then  along  the  superior  transverse  line,  and,  last,  along  the  inferior 
transverse  line — the  wound  being  closed  throughout  with  silkworm-gut  or 
silk — and  firm  pressure,  to  occlude  dead  spaces,  made  in  the  dressing.  The 
neck  and  head  are  steadied  in  some  form  of  retentive  apparatus  until  union 
has  occurred. 

Removal  of  Isolated  Lymphatic  Glands  of  the  Neck. — These  isolated 
glands  will  belong  to  one  of  the  groups  of  superficial  or  deep  glands  given, 
with  their  relations,  upon  a  preceding  page.  The  position,  direction,  and 
extent  of  the  incision  for  their  exposure  will  be  determined  by  the  special 
group  of  glands  involved  and  the  extent  of  the  involvement — the  general 
rule  being  that  the  incision  is  so  placed  as  to  reach  the  site  most  readily  and 
with  greatest  safety  to  neighboring  structures — and  mav  be  a  single  vertical, 
transverse,  or  oblique  straight  incision,  making  an  opening  whose  lips  have 
to  be  retracted  to  expose  the  parts; — or  a  combination  of  these; — or  a  curved 
incision,  thereby  forming  a  flap,  which  is  temporarily  turned  back.  The 
two  most  generally  used  forms  of  incision,  however,  are  those  which  are 
more  or  less  parallel  with  one  of  the  borders  of  the  sternomastoid  (Fig.  101, 
EF  or  GH) — or  more  or  less  parallel  with  the  natural  obliquely  transverse 
crease  crossing  the  neck  about  on  a  level  with  the  hyoid  bone,  in  the  cleavage 
line  of  the  skin  (Fig.  101,  IJ  or  KL).  The  incision  may  be  placed  over  the 
submaxillary,  superior  carotid,  or  inferior  carotid  triangle,  of  the  anterior 
triangle  of  the  neck,  or  over  the  occipital  or  subclavian  triangle,  of  the  posterior 
triangle — or  over  the  posterior  aspect  of  the  neck,  between  the  anterior  border 
of  the  trapezius  and  the  posterior  median  line,  and  between  the  superior 
border  of  the  scapula — or  may  involve  several  triangles. 

Comment. — (i)  Great  care  is  necessary  in  removing  glands  from  thin- 


154       OPERATIONS    UPON    THE    LYMPHATIC    GLANDS    AND    VESSELS. 

walled  veins.  Should  a  vein  be  wounded,  the  opening  should  be  caught  up 
instantly  and  laterally  ligated,  if  the  wound  be  appropriate,  or  sutured,  or 
even  transversely  ligated.  If  so  situated  that  closure  cannot  be  immediately 
made,  the  part  should  be  flooded  with  water,  so  that  water  stands  over  the 
open  vein,  to  prevent  the  drawing-in  of  air  until  the  vein  can  be  secured. 
(2)  The  important  nerves  are  to  be  particularly  guarded.  (3)  The  arteries 
and  arterial  hemorrhage  give  far  less  concern  than  the  veins  and  venous 
hemorrhage.  (4)  It  is  better  to  dissect  the  glands  out  in  masses  or  chains, 
together  with  their  adherent  connective  tissue — invisible,  impalpable  glands 
being  thus  more  thoroughly  removed.  (5)  Glands  should  be  removed  with 
their  capsules  intact.  (6)  The  sternohyoid  and  omohyoid  may  also  be  divided 
and  subsequently  sutured.  (7)  All  bleeding  should  be  immediately  con- 
trolled as  encountered,  and  ligated  as  soon  as  convenient. 


SURGICAL  ANATOMY  OF  AXILLARY  REGION. 

Description. — The  axilla  is  a  pyramidal  space  between  the  upper  lateral 
wall  of  thorax  and  inner  wall  of  arm — its  apex  corresponding  with  interval 
between  first  rib  on  inner  side,  clavicle  in  front,  and  upper  edge  of  scapula 
behind; — its  base,  broad  at  chest  and  narrow  at  arm,  is  composed  of  skin 
and  dense  fascia,  extending  between  inferior  border  of  pectoralis  major  in 
front,  and  inferior  border  of  latissimus  dorsi  behind. 

Boundaries. — Anteriorly — pectoralis  major  (throughout) ;  pectoralis 
minor  (its  center).  Posteriorly — subscapulars  (above);  teres  major  and 
latissimus  dorsi  (below).  Internally — first  to  fourth  ribs;  first  to  third 
intercostal  muscles;  serratus  magnus.  Externally — humerus;  coracobrachi- 
al;  biceps. 

Contents. — Arteries  : — axillary  (along  external  wall,  nearer  anterior  than 
posterior  boundary);  superior  thoracic;  acromial  thoracic;  long  thoracic; 
alar  thoracic;  subscapular;  anterior  circumflex;  posterior  circumflex.  Veins  : 
— axillary  (to  inner  side  of  axillary  artery) ;  receiving  venae  comites  of  brachial 
artery  and  tributaries  of  branches  of  axillary  artery.  Nerves: — brachial 
plexus  lies  to  outer  side  of  first  part  of  axillary  artery; — the  second  part  of 
axillary  artery  has  the  outer,  inner,  and  posterior  cords  of  plexus  in  the  rela- 
tions expressed  by  their  names; — the  third  part  of  the  artery  has,  anteriorly, 
inner  head  of  median  nerve;  posteriorly,  musculospiral  and  circumflex; 
externally,  median,  musculo-cutaneous;  internally,  ulnar,  internal  cutaneous, 
lesser  internal  cutaneous.  Posterior  thoracic  (on  serratus  magnus).  In- 
tercosto-humeral.  External  and  internal  anterior  thoracic,  crossing  in  front 
and  behind  axillary  artery  respectively.     Glands  : — see  below. 

Axillary  Lymphatic  Glands.— Are  arranged  in  four  groups:  (a)  Axillary 
glands  proper — median  set;  three  or  four  in  number;  along  axillary  artery 
and  vein,  (b)  Pectoral  glands;  inner  or  anterior  set;  four  or  five  in  number; 
along  long  thoracic  artery,  below  great  pectoral  muscles  and  on  serratus 
magnus.  (c)  Subscapular  glands — external  or  posterior  set;  two  in  number; 
along  subscapular  artery,  under  latissimus  dorsi.  (d)  Subclavian  or  infra- 
clavicular— superior  set;  two  in  number;  near  cephalic  vein;  just  below  clavicle 
in  fossa  under  pectoralis  major  and  deltoid,  upon  costocoracoid  membrane. 

Axillary  Lymphatic  Trunk. — Efferent  trunk  from  above  sets  of  glands 
— runs  upward  along  subclavian  vein — emptying  into  thoracic  duct  on  left, 
and  into  right  lymphatic  duct  on  right. 


REMOVAL    OF    AXILLARY    LYMPHATIC    GLANDS. 


155 


REMOVAL  OF  AXILLARY  LYMPHATIC  GLANDS. 

Description. — The  removal  of  the  axillary  glands  is  done,  in  the  majority 
of  cases,  in  connection  with  the  removal  of  neighboring  malignant  growths, 
especially  those  involving  the  breast — and,  in  such  cases,  the  incision  for 
exposing  the  axillary  region  is  merely  a  prolongation  into  the  axilla  of  the 
incision  for  the  original  operation.  The  steps,  therefore,  of  the  operation 
for  the  removal  of  these  glands  will  be  found  sufficiently  described  under 
the  operations  for  the  radical  removal  of  the  breast  (pages  738  to  744).  Where 
it  is  planned  to  remove  enlarged  ax- 
illary glands  alone  and  as  a  distinct 
operation,  the  incision  is  placed 
over  the  involved  glands  (Fig.  102). 


SURGICAL  ANATOMY  OF 
SCARPA'S  TRIANGLE. 

Description. — A  triangular 
area  just  below  fold  of  groin. 

Boundaries.  —  Base  (above) ; 
Poupart's  ligament.  Externally; 
sartorius.  Internally;  adductor 
longus.  Apex  (below) ;  junction  of 
sartorius  and  adductor  longus. 

Roof. — Skin;  superficial  fascia; 
fascia  lata. 

Floor. —  (From  without  in- 
ward.) Iliacus;  psoas;  pectineus; 
adductor  brevis;  adductor  longus. 

Contents. —  Arteries;  common 
femoral  (from  middle  of  base  to 
apex);  superior  epigastric;  superfi- 
cial circumflex  iliac;  superficial  ex- 
ternal pudic;  deep  external  pudic; 
profunda  femoris.  Veins;  femoral 
(to  inner  side  of  artery) ;  profunda 
femoris;  tributaries  of  branches  of 

femoral;         internal        saphenous.  Fig.  io2.-Incision  for  Exposing  Axillary 

Nerves;    anterior    crural    (to    outer  Lymphatic    Glands:— Passing    between    biceps 

Side   of    arterv)  ;    crural    branch    of  and  pectoral  muscles,  in  front,  and  the  scapular 

,    '  '                .  muscles,  posteriorly;  to  which  may  be  added  one 

gemtocrural;     external     cutaneous.  or  more  modifying  incisions,  as  necessitated  by 

Lymphatics;  superficial  and   deep     the  special  case, 
glands. 

Inguinal  Lymphatic  Glands. — Consist  of  two  following  sets;  (1)  Super- 
ficial Glands ;  Oblique  or  Inguinal  Set — along  Poupart's  ligament,  upon 
fascia  lata.  Vertical  or  Saphenous  Set — around  saphenous  opening  and  upon 
fascia  lata.  (2)  Deep  Glands ;  along  upper  part  of  femoral  vessels,  one  or 
more  being  within  femoral  canal. 


156      OPERATIONS    UPON   THE   LYMPHATIC    GLANDS   AND    VESSELS. 


REMOVAL  OF  INGUINAL  LYMPHATIC  GLANDS. 

Description. — The  operation  will  differ  according  to  site  and  amount 
of  glandular  involvement — and  the  lines  of  incision  are  given  accordingly. 
Indications. — Glands  enlarged  or  broken  down  as  a  result  of  venereal 
disease;  tubercular  glands;  simple,  chronic,  and  suppurative  adenitis;  malig- 
nant involvement. 

Preparation. — Groin  shaved. 

Position. — As  for  ligation  of  femoral  artery  at  base  of  Scarpa's  triangle 

(page  95). 

Landmarks. — Given  under  Sur- 
gical Anatomy  of  Scarpa's  Triangle. 
Instruments. — As  for  removal 
of  cervical  glands  (page  151). 

Incisions.— (1)  Where  the  ob- 
lique (superficial)  set  of  glands  are 
involved — an  incision  may  be  made 
parallel  with  and  just  below  Pou- 
part's  ligament,  with  its  center  over 
the  enlarged  glands  (Fig.  103,  B); 
or  just  above  Poupart's  ligament 
(Fig.  103,  A).  (2)  Where  the 
vertical  (superficial  and  deep)  sets 
are  involved — the  incision  is  made 
along  the  course  of  the  femoral 
artery,  with  its  center  over  the 
enlarged  glands  (Fig.  103,  B).  (See 
ligation  of  common  femoral  at  base 
of  Scarpa's  triangle,  page  93.)  (3) 
Where  all  three  sets  are  involved — 
the  incision  may  be  a  combination  of 
the  above  two,  being  somewhat 
T->haped. 

Operation. — Divide  skin  and 
superficial  fascia  in  the  direction  or 
directions  indicated  above.  The 
superficial  vessels  encountered  are 
ligated.  The  superficial  glands 
(oblique  and  vertical  sets)  will  be 
found  upon  the  fascia  lata,  in  the  positions  indicated.  To  reach  the  deep 
glands  (lying  along  the  great  vessels)  the  fascia  lata  is  incised  in  the  line  of  the 
femoral  artery  (as  for  ligation  of  that  artery).  Important  structures  are  to  be 
avoided  and  the  glands  sought  along  the  course  of  the  artery  and  vein.  The 
general  principles  mentioned  under  the  removal  of  cervical  lymphatic  glands 
are  applicable  here — and  elsewhere,  wherever  glandular  tissue  is  removed. 


Fig.  103. — Incisions  for  Exposing 
Inguinal  Lymphatic  Glands: — A,  Oblique 
incisions  just  below  and  parallel  with  Pou- 
part's ligament,  for  oblique  superficial  set 
of  glands;  B,  Vertical  incision  over  femoral 
artery,  for  vertical  superficial  and  deep  sets. 
A  T-shaped  incision  may  be  made  by  uniting 
these,  where  all  three  sets  are  involved. 


CHAPTER  IV. 

OPERATIONS  UPON  THE  NERVES,  PLEXUSES, 
AND  GANGLIA. 

Note. — The  operations  which  may  be  performed  upon  Nerves,  Plexuses, 
and  Ganglia  will  be  first  described — and  then  the  operations  for  the  exposure 
of  the  more  important  nerves,  plexuses,  and  ganglia  will  be  given.  Having 
exposed  a  nerve,  any  of  the  operations  about  to  be  described  may  be  applied 
to  it,  as  indicated. 

NEUROTOMY. 

Description. — Section  of  a  nerve.  Neurotomy  may  be  transverse  (e.  g., 
as  when  performed  for  neuralgia  of  a  sensory  nerve,  or  spasm  of  a  motor 
nerve) ;— or  longitudinal  (e.g.,  as  done  in  some  cases  of  neurorrhaphy  and 
neuroplasty). 

Indications. — Neuralgia  of  sensory  nerves;  spasm  of  motor  nerves; 
preliminary  to  neurorrhaphy  or  neuroplasty. 

Preparation — Position — Landmarks —  Surgical  Anatomy  — Incision. 
— Determined  by  the  special  nerve  involved. 


Fig.  104. — Neurotomy  of  Supraorbital  Nerve. 


Operation. — Having  exposed  and  isolated  the  individual  nerve,  it  is 
lifted  from  its  bed  by  forceps  and  divided  with  a  scalpel  or  scissors.  The 
cut  ends  are  allowed  to  fall  back  into  place — or,  better,  should  be  so  dropped 
back  into  the  wound  as  to  make  re-union  unlikely.  The  wound  is  closed  as 
usual.     No  special  after-treatment  is  carried  out  (Fig.  104). 

Comment. — Chiefly  applicable  to  smaller  sensory  nerves — and,  rarely, 
smaller  motor  nerves.     Not  generally  successful  in  neuralgias. 

i57 


158       OPERATIONS    UPON   THE    NERVES,    PLEXUSES,    AND    GANGLIA. 


NEURECTOMY. 

Description. — Excision  of  a  nerve.  Neurectomy  may  be  partial  or  com- 
plete. As  ordinarily  performed,  only  a  small  part  of  the  length  of  the  nerve 
is  removed. 

Preparation— Position — Landmarks — Surgical  Anatomy— Incision. 
— Determined  by  the  special  nerve. 

Indications. — Neuralgia  of  sensory  nerves;  spasm  of  motor  nerves. 


Fig.  105. — Neurectomy  of  Supraorbital  Nerve. 

Operation. — The  nerve  having  been  exposed  and  brought  well  into 
the  field,  is  lifted  out  of  its  bed  with  forceps — and  from  2  to  3  cm.  (1  to  1^ 
inches)  of  its  trunk  is  excised  with  scalpel  (preferable  to  scissors,  which  partly 
crush).  The  ends  are  then  allowed  to  drop  back  into  position — and  the 
wound  is  closed  (Fig.  105). 

Comment. — Total  excision  is  most  frequently  done  by  avulsion  (page  159). 


NEURECTASY. 

Description. — Nerve-stretching. 

Indications. — Neuralgia  of  sensory  and  spasm  of  motor  nerves. 

Preparation — Position — Landmarks — Surgical   Anatomy — Incision. 

- — Determined  by  the  nerve  operated  upon. 

Operation. — The  nerve  is  freely  exposed  and  separated  by  blunt  dis- 
section sufficiently  for  manipulation.  Small  nerves  are  stretched  by  means 
of  a  nerve-hook  inserted  beneath  them.  Large  nerves  are  stretched  by  being 
grasped  between  thumb  and  finger — the  nerve  is  steadily  and  evenly  pulled 
from  its  center  for  about  five  minutes — then  from  its  periphery  for  about 
five  minutes.  The  extremes  of  force  employed  may  be  represented  by  a 
pull  of  a  half-pound  for  the  supraorbital — and  from  thirty  to  sixty  pounds 
(according  to  the  judgment  of  the  operator)  for  the  sciatic.  The  manipu- 
lation is  done  with  as  limited  disturbance  to  the  surrounding  structures  as 
possible.  After  the  stretching,  the  nerve  is  dropped  back  into  place  and  the 
incision  closed.  In  the  after-treatment,  the  part  should  be  immobilized  until 
union  of  the  wound  occurs.     Temporary  paralyses  of  motion  and  sensation 


NERVE-AVULSION. 


J59 


are  to  be  expected  (Fig.  106).     The  breaking  strain  of  the  principal  nerves 
of  the  body  has  been  given  by  Nombetta  as  the  following: — 

Great  sciatic 183  pounds 

Internal  popliteal 114 

Anterior  crural 83 

Median  crural 83 

Ulnar  and  radial 59 

Brachial  plexus  in  the  neck 48-63 

Brachial  plexus  in  the  axilla 35~8i 


Fig.  106. — Neurectasy  of  Infraorbital  Nerve. 

Comment. — Sensory  nerves  seem  more  dulled  by  traction  in  a  direction 
away  from  the  cord — motor  nerves  more  dulled  by  traction  toward  the  cord. 


• 


Fig.  107.— Nerve-avulsion  of   Infraorbital. 

NERVE-AVULSION. 

Description. — The  tearing  away  of  a  nerve  from  its  central  and  peripheral 
connections. 

Indications. — Neuralgia.     Chiefly  used  upon  branches  of  the  fifth  nerve. 

Preparation— Position— Landmarks— Surgical  Anatomy— Incision. 
— Determined  by  the  special  nerve. 


160       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

Operation. — Having  exposed  the  nerve  involved,  it  is  grasped  by  catch- 
forceps  (firmly,  but  not  strong  enough  to  crush  and  break  it) — and  then 
slowly  wound  around  the  forceps  (by  twisting  the  latter  between  the  fingers) 
— until  the  nerve  is  torn  away  from  its  connections,  both  proximally  and 
distallv.  Branches  of  the  nerve  are  also  sometimes  avulsed,  to  a  greater  or 
less  extent  along  with  the  main  trunk — as  well  as  a  part  or  the  whole  of  a 
ganglion.  The  nerve  may,  also,  be  partly  cut — either  distallv  (generally) 
or  peripherally.  The  wound  is  closed  throughout,  in  the  usual  manner 
(Fig.   107). 

NEURORRHAPHY. 

Description. — Suturing  of  nerve  which  has  been  partially  or  entirely 
divided.  Neurorrhaphy  may  be  primary,  or  immediate,  where  the  nerve 
is  sutured  at  once, — or  secondary,  where  the  suturing  is  done  subsequent 
to  repair  of  injury. 

Indications. — Repair  of  injury  to  nerve.     Neuroplasty. 

Preparation — Position — Landmarks — Surgical  Anatomy — Incision. 
— Determined  by  the  nerve  involved. 

Operation  of  Primary,  or  Immediate,  Neurorrhaphy. — The  severed 
nerve-ends  are  exposed  in  the  wound  and  brought  well  within  reach.  See 
if  they  be  cleanly  cut.  If  not,  gently  grasp  them  with  forceps  and  cut  them 
cleanlv,  and  preferably  transversely,  with  a  sharp  knife,  with  a  minimum 
sacrifice  of  nerve-tissue.  The  ends  are  brought  and  held  in  apposition,  in 
their  normal  relations,  anterior  aspect  to  anterior  aspect,  and  the  like.     If 


Figs.  108-112. —  Methods  of  Nerve-suturing: — I. — A   B,  C,  Sutures  passing  through  entire 
thickness  of  nerve  and  sheath;  D,  E,  Sutures  passing  through  nerve-sheath  only. 

the  ends  cannot  be  approximated,  flex  or  extend  the  limb  to  increase  the 
length,  or  stretch  both  ends  gently  (preferably  grasping  them  with  the  fingers). 
It  is  desirable  that  there  should  be  no  tension  upon  the  sutures.  The  junction 
is  made  with  a  fine  cambric  needle  threaded  with  fine  chromic  catgut  and 
held  in  a  needle-holder.  One  of  several  methods  of  suturing  may  be  adopted; 
— (a)  The  sutures  may  be  passed  entirely  through  the  sheath  and  nerve,  in 
two  or  more  directions,  and  about  3  mm.  (i  inch)  from  the  ends.  The 
needle  passes  from  before  backward  through  the  entire  thickness  of  the 
proximal  end — then  similarly  through  the  distal  end,  from  behind  forward— 


NEURORRHAPHY. 


161 


and  the  suture  is  tied  lightly,  so  as  not  to  have  tension.  A  second  suture  may 
be  applied  antero-posteriorly,  or  laterally — and  as  many  as  seem  needed 
accurately  to  coapt  the  ends.  This  is  the  most  general  method  of  nerve- 
suturing  (Figs.  108-112,  A,  B,  C).     (b)  Sutures  may  be  passed  through  the 


Figs.  113-117. — Methods  or  Nerve-suturing: — II. — A,  B,  Sutures  passing  through 
sheath  and  part  of  nerve;  C,  Sutures  through  sheath,  reinforced  by  relaxation-suture  through 
entire  nerve;  D,  Nerve  cut  obliquely  and  united  by  suture  through  sheath  and  part  of  nerve; 
E,  Same  with  relaxation-suture. 

nerve-sheath  alone,  encircling  the  nerve  proper.  This  is  the  preferable 
operation — but  is  possible  only  in. large  nerves  (Figs,  in,  112,  D,  E).  (c) 
Part  of  the  sutures  may  pass  through  the  nerve  and  sheath  (as  in  a) — and 
part  through  the  sheath  only  (as  in  b)  (Figs.  113,  114,  115,  A,  B,  C).     (d) 


Figs.  118-121. — Methods  of  Nerve-suturixg  : — III. — A,  Reinforcing  through-and- 
through  suture  by  lateral  suture  through  loops  of  first  suture;  B,  C,  D,  Various  methods  of 
union  by  approximation  of  lateral  aspects  of  nerve,  after  freshening. 

After  paring  the  larger  end,  it  may  be  split  down  its  center  for  about  1.3  cm. 
{\  inch) — the  smaller  end  may  be  beveled  on  two  sides  and  sutured  between 
the  lips  of  the  split  end  (Fig."  122,  A),  (e)  One  end  may  be  beveled  on  its 
upper  surface,  the  other  on  its  lower  surface — the  two  freshened  surfaces 
are  then  placed  in  contact  and  sutured  through  and  through  (Figs.  116  and 


162       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 


117,  D,  E).  This  requires  a  greater  length  of  nerve  than  some  of  the  other 
methods.  Other  methods  are  shown  in  Figs.  118  to  121  and  123,  B,  and  124, 
C.  Having  completed  the  union  of  the  nerve-ends,  the  wound  is  sutured  and 
the  limb  immobilized  so  as  to  minimize  tension  for  about  ten  days — the  part 
is  then  gently  massaged  daily  and  the  splint  reapplied  between  times  and  not 
removed  for  about  six  weeks.  Primary  union  is  particularly  to  be  sought.  The 
restraining  splint  should  be  such  as  will  hold  the  part  so  that  the  nerve  will  be 
relaxed. 

Operation  of  Secondary  Neurorrhaphy. — Having  applied  Esmarch's 
bandage,  one  may  cut  directly  down  upon  the  supposed  site  of  the  nerve  ends. 
It  is  better,  however,  deliberately  to  incise  for  and  expose  both  proximal 
and  distal  nerve-trunks,  above  and  below  the  involvement,  on  anatomical 
grounds.  Much  difficulty  may  be  experienced  in  finding  the  nerve-ends, 
unless  traced  down  and  upward,  as  the  case  may  be,  from  the  nerve-trunks. 
The  proximal  end  is  easier  to  find,  and  apt  to  be  bulbous  and  sensitive.  The 
distal  end  is  apt  to  be  atrophied.  Sufficient  freeing  of  the  nerve-ends  to 
enable  them  to  meet  is  necessary.     While  in  primary  suturing  the  severed 

ends  may  or  may  not 
require  trimming  before 
suturing,  in  secondary 
suturing  they  are,  in  ad- 
dition to  being  freed 
from  connective  tissue, 
always  to  be  excised. 
Having  identified  the 
nerve-ends,  dissect  away 
all  intervening  fibrous 
tissue.  With  a  sharp 
knife  cut  away  trans- 
versely the  proximal 
end  until  healthy  nerve 
tissue  is  reached.  In 
the  case  of  the  distal 
end,  simply  cut  away 
enough  of  the  upper 
end  to  afford  good  ap- 
proximation (for  degen- 
erative processes  will 
have  extended  far  down 
this  end  under  any  cir- 
cumstances). If  the  ends  can  now  be  made  to  meet  without  too  much  ten- 
sion, they  are  sutured  together  by  one  of  the  methods  described  under  primary 
neurorrhaphy.  If  greater  length  be  necessary,  as  is  almost  invariably  the 
case,  it  may  generally  be  gotten  by  first  carefully  stretching  the  ends — after 
which  they  are  united  by  suture.  If  sufficient  length  cannot  be  thus  secured, 
neuroplasty  must  be  done  (page  163).  Following  secondary  neurorrhaphy 
the  wound  is  closed,  the  limb  splinted,  and  the  same  after-treatment  carried 
on  as  after  the  primary  operation — although  results  are  not  to  be  expected 
so  soon.     Restoration  of  function  may  require  from  one  to  two  years. 

Comment. — Where  stretching  is  resorted  to  to  gain  length  in  secondary 
suturing,  it  should  be  applied  before  excising  the  nerve-ends — traction  being 
made  upon  the  nerve-ends  themselves,  which  are  afterward  removed.  And 
if  tension  be  too  great  upon  the  sutured  ends,  relaxation-sutures  may  be 
applied  above  and  below  the  line  of  finer  approximation  sutures. 


«f 


Figs.  122-124. — Less  Usual  Methods  of  Nerve- 
suturing: — IV. — A,  Suturing  of  beveled  end  between  lips  of 
split  end;  B,  C,  Method  of  uniting  sound  upper  and  lower 
portions  of  nerve  by  splitting  and  suturing  contracted  portion. 


NEUROPLASTY. 


163 


NEUROPLASTY. 

Description. — The  union  of  severed  nerve-ends  by  processes  of  plastic 
elongation  of  the  nerve  itself, — or  by  the  interposition  of  nerve  or  other 


Figs.  125-128. — Neuroplasty : — I. — A,  B,  Union  by  splitting  both  ends  of  nerve  and  uniting 
split  ends  end-to-end;  C,  D,  Same,  with  split  ends  united  laterally. 

material — in  cases  where  the  loss  of  nerve-substance  is  so  great  that  the 
severed  ends  cannot  be  brought  and  held  together  by  the  ordinary  methods 


Figs.  129-132. — Neuroplasty: — II. — A,  Splitting  one  end,  with  union  of  lateral  aspect 
of  split  end  to  lateral  aspect  of  opposite  entire  end  freshened  laterally;  B,  Same,  with  union 
end-to-end;  C,  D,  Same  as  in  B,  in  case  of  bulbous  ends. 


164       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 


— Neitroplasty: — III. — A,  B, 
Doubly  splitting  both  ends,  with  union  of  split  ends 
end-to-end;  C,  Interpolation  of  section  of  nerve. 


of  suturing.     The  object  sought  in  the  latter  cases  is  the  supplying  of  a  sub- 
stance between  the  cut  ends  along  which  the  nerve-fibers  may  grow  from 

the  proximal  to  the  distal  end 
(as  the  tendrils  of  a  vine  grow 
along  a  trellis).  The  operations 
of  nerve-anastomosis,  nerve- 
grafting,  and  nerve-implanta- 
tion are  also  instances  of  neuro- 
plasty. 

Indications.— Where,  in 
primary  operations,  consider- 
able nerve-substance  has  been 
destroyed  by  the  cause  of  the 
injury — or,  in  secondary  oper- 
ations, the  retraction  of  the 
severed  ends  has  been  very 
great — so  that  by  no  other 
means  can  the  ends  of  the 
nerves  be  brought  and  kept 
together. 

Preparation  —  Position  — 
Landmarks  —  Surgical  Anat- 
omy —  Incision. — Determined 
by  the  special  operation. 

Operation. — Having  exposed 
and   isolated   the   severed   ends, 

and,  in  the  case  of  secondary  operations,  freed  them  from  connective  tissue 

and  freshened  them  by  partial  excision,  one  of  the  following  means  of  bringing 

and    holding    the    ends    in    contact    is 

resorted  to: — (a)  At  points  as  far  from 

the  ends  of  the  nerves  as  indicated  by 

the  length  of  the  intervening  space  to  be 

filled,  divide  each  nerve  half-way,  trans- 
versely— split  each  end  back  to  within 

about    6    mm.  (|    inch)    of    its    end — 

bend  the  two  cut  portions  toward  each 

other — and  suture  them  end  to  end,  or 

laterally  (Figs.   125-128,  A,  B,   C,  D). 

In  filling  smaller  gaps,  one  trunk  only 

may   be   split — bent   back   to  the  other 

end — and   both   freshened   and   sutured 

(Figs.   129   and    130,    A,   B).     (b)  Sec- 
tions of  nerves  from  a  freshly  amputated 

human  limb,  or  from  the  lower  animals, 

may    be    interposed    in    the    gap    and 

sutured    at    both    ends    by    one    of    the 

methods     given     under     neurorrhaphy. 

This    interposed    part    does    not    grow, 

but    only    serves    the    role    of   a    trellis 

(Fig.   135,    C).         (c)  A   solid   cylinder 

of  decalcified  bone  may  be  interposed 

and  sutured  to  the  ends  of  the  nerves,     (d)  Strands  of  fine  catgut  may  be 

made  to  bridge  the  interval,  as  a  guide  to  the  new  nerve-fibers  (Fig.   136,  A). 


C2E^ 


) 


Figs.  136-138. — Neuroplasty  : — IV. 
— A,  Union  by  strands  of  gut  alone;  B,  C, 
Same,  reinforced  with  decalcified  bone 
cylinder. 


NERVE-ANASTOMOSIS;    NERVE-GRAFTING;    NERVE-IMPLANTATION.    165 

(e)  The  proximal  and  distal  ends  of  the  nerve  may  be  enclosed  in  a  hollow 
cylinder  of  decalcified  bone  (Figs.  137  and  138,  B,  C).  (f)  Proceed  as  in 
Fig.  133,  A — then  shift  the  cut  ends  laterally,  and  approximate  as  shown  in 
Fig.  134,  B.  (g)  Combine  methods  (d)  and  (e) — the  combined  method  of 
bridging  with  catgut  and  enclosure  in  decalcified  bone  tube.  One  end  of  the 
catgut  bridge  is  slipped  through  the  tube,  sutured  to  the  other  end,  and  drawn 
back  within  the  tube  (Figs.  136  and  138,  B,  C).  (h)  Shortening  of  the  limb, 
by  resection  of  its  bone  or  bones,  to  allow  of  approximation  of  the  ends  of 
the  nerve.  (The  musculospiral  has  been  thus  successfully  treated.)  Of 
the  above  methods,  method  (a)  is  the  one  most  generally  used.  Having 
completed  the  neuroplastic  operation,  the  wound  is  closed  and  the  part  immo- 
bilized in  a  position  to  relax  the  nerve. 


NERVE- ANASTOMOSIS;    NERVE-GRAFTING;    NERVE-IMPLANTATION. 

Description. — The  grafting  of  any  portion  of  an  injured  nerve  into  the 
trunk  of  a  neighboring  nerve.  In  the  case  of  a  divided  and  retracted  nerve,  the 
severed  upper  end  is  grafted  into  the  intact  nerve  at  a  point  opposite  its  level, 


<3S23| 


D 

Figs.  139-142. — Nerve-grafting: — I. — A,  B,  Engrafting  of  freshened  lower  end  of 
divided  median  nerve  (for  instance)  upon  intact  ulnar  nerve;  C,  D,  Engrafting  of  freshened 
upper  and  lower  ends  of  divided  median  nerve  upon  intact  ulnar  nerve. 

above — and  the  severed  lower  end  grafted  into  the  intact  trunk  opposite  its 
level,  below — that  is,  at  points  where  they  can  be  conveniently  brought  into 
contact  with  the  sound  nerve.  The  object  sought  is  to  switch  the  interrupted 
nerve-stream,  or  nerve-impulse,  from  the  proximal  end  of  the  cut  nerve  into 
the  neighboring  sound  nerve — thence  to  have  it  conveyed  along  this  used 
nerve  down  to  the  point  where  the  distal  end  of  the  cut  nerve  is  sutured  to  the 
utilized  nerve — and  thence  returned  to  the  original  nerve  and  transmitted 
along  the  distal  portion  of  the  cut  nerve  to  its  final  distribution,  as  though  no 
interruption  to  its  normal  course  and  transmission  had  occurred.  An  illus- 
tration would  be  a  divided  median  nerve  and  an  intact  ulnar  nerve — where 
the  upper  end  of  the  median  nerve  is  sutured  to  the  upper  part  of  the  ulnar — 


166       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

and  the  lower  end  of  the  median  to  the  lower  part  of  the  ulnar  (Figs.  141 
and  142,  C,  D).  The  object  finally  sought  is  to  have  nerve-fibrils  grow 
down  this  nerve  from  the  proximal  cut  end  to  the  distal  cut  end.  The  method 
is  of  limited  application,  because  of  the  necessity  of  finding  large  nerves  in 
close  proximity — the  upper  extremity  being  about  the  only  locality  in  which 
the  method  can  be  utilized  (Figs.  143  and  144),  or  the  lower  end  only  may  be 
grafted  upon  the  sound  nerve — the  impulse  from  the  latter  passing  into  the 
impaired  nerve  and  going  on  to  its  distribution  (Fig.  143,  A  and  B). 

Preparation— Position — Landmarks — Surgical  Anatomy — Incision. 
— Determined  by  the  individual  operation. 

Operation. — Expose,  isolate,  and  excise  the  proximal  and  distal  ends 
of  the  severed  nerve,  supposing  it  to  be  a  secondary  case.     Also    through 


Figs.  143  and  144. — Nerve-grafting: — II. — A  (to  left),  Showing  ulnar  and  median 
nerves  divided  at  different  heights;  B  (to  right),  Union  of  upper  end  of  median  to  lower  end  of 
ulnar; — followed  by  engrafting  of  upper  end  of  ulnar  and  lower  end  of  median  into  this  new 
trunk. 

the  original  incision,  expose  the  neighboring  nerve  upon  which  the  grafting 
or  implantation  is  to  be  made.  By  means  of  curved  scissors,  remove  a  limited 
portion  of  its  sheath,  on  the  lateral  aspect  of  the  nerve,  at  the  sites  where 
the  upper  and  lower  severed  nerve-ends  are  to  be  grafted.     The  obliquely 


NERVE- ANASTOMOSIS;    NERVE-GRAFTING;    NERVE-IMPLANTATION.    167 

or  transversely  divided  ends  of  the  involved  nerve  are  to  be  sutured  to  the 
denuded  lateral  aspect  of  the  intact  nerve,  above  and  below,  by  fine  chromic 


B  C  D 

Figs.  145,  146,  147,  and  148. — Nerve-graftixg: — III. — A,  The  darker,  smaller  nerve 
has  lost  all  function, — B,  Is  divided  transversely  and  its  distal  end  sutured  into  the  sound  nerve. 
G,  The  darker  nerve  has  lost  all  function, — D,  Is  divided  and  sutured  to  the  split  portion  of  the 
sound  nerve. 

sutures  passing   through    the   sheath   of  the  nerve-ends,   on   the  one  hand, 
and  through  the  sheath  and  part  of  the  thickness  of  the  intact  nerve  at  the 


Figs.  149,  150,  151,  and  152. — Nerve-graftixg: — IV. — E,  The  darker,  smaller  nerve  has 
retained  part  of  its  function, — F,  Is  split  and  its  split  end  sutured  to  the  split  end  of  the  sound 
nerve.  G,  The  darker  nerve  has  retained  part  of  its  function, — H,  Is  divided  transversely,  and 
its  proximal  end  sutured  to  the  distal  split  portion  of  the  sound  nerve,  while  its  distal  end  is 
sutured  to  the  proximal  split  portion  of  the  sound  nerve. 

bared  sites,  on  the  other  hand.  Having  completed  the  nerve-suturing,  if 
the  neighboring  parts  have  been  disarranged,  these  should  be  rearranged — 
by  buried  catgut  sutures,  if  necessary.     The  wound  is  then  closed  throughout. 


168       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

The  part  should  be  immobilized  in  a  position  of  relaxation  of  nerve-tension 
until  union  has  occurred — and  subsequently  treated  as  described  under 
neurorrhaphy.  It  sometimes  happens  that  an  adjacent  nerve  has,  through 
degenerative  changes,  sustained  a  total  or  partial  loss  of  function.  Where 
the  loss  is  complete  (Fig.  145,  A),  the  involved  nerve  is  divided  transversely 
and  its  distal  end  sutured  laterally  to  the  adjacent  sound  nerve  (Fig.  146,  B); — 
or  the  distal  end  may  be  sutured  end-to-end  to  split  portion  of  the  sound  nerve 
(Figs.  147  and  148,  C  and  D).  Where  the  loss  of  function  in  the  involved 
nerve  is  not  complete,  a  cross-anastomosis  may  be  done,  thus  preserving  all 
of  each  nerve, — that  is,  both  nerves  may  be  split,  and  the  split  portions  sutured, 
leaving  the  main  trunks  continuous  (Figs.  149  and  150,  E  and  F); — or  the 
involved  nerve  may  be  divided  transversely  and  the  sound  nerve  split  longi- 
tudinally in  both  directions,  after  which  the  proximal  end  of  the  impaired  nerve 
is  sutured  to  the  distal  split  portion  of  the  sound  nerve,  and  the  distal  end  of 
the  impaired  nerve  is  sutured  to  the  proximal  split  portion  of  the  sound  nerve 
(Figs.   151  and  152,  G  and  H). 

Comment. — (i)  The  severed  distal  end  of  the  involved  nerve  is  sometimes 
bevelled  and  implanted  within  the  incised  substance  of  the  sound  nerve 
(Fig.  153).  It  may  happen,  in  extensive  injuries,  that  the  lower  portion  of 
one  nerve  is  destroyed,  and -the  upper  end,  or  ends,  of  one  or  two  adjacent 


Fig.  153. — Implantation  of  Bevelled  End  of  Divided  Nerve  into  Longitudinal 
Slit  in  Sound  Nerve. 

Fig.  154. — Anastomosis  of  Divided  Distal  Ends  of  Two  Nerves  whose  Proximal 
Portions  have  been  Destroyed,  into  Proximal  Trunk  of  Adjacent  Nerve  whose  Distal 
Portion  has  been  Destroyed. 

nerves.  In  such  unusual  cases,  and  in  the  rare  localities  where  such  a  pro- 
cedure is  possible,  the  divided  distal  ends  of  the  latter  may  be  sutured  into 
the  transversely  divided  proximal  end  of  the  former  (Fig.  154).  (2)  It 
seems  to  make  no  difference  whether  a  sensory  nerve  be  grafted  to  a  motor 
or  to  a  mixed  nerve— or  vice  versa. 


INTRANEURAL    INFILTRATION    FOR    REGIONAL    ANESTHESIA.       169 

NEUROLYSIS,  OR  AN  OPERATION  FOR  RELIEF  OF  NERVE  COM- 
PRESSED BY  BONY  OR  FIBROUS  CICATRICIAL  TISSUE  OR  BY 
ADHESIONS. 

Description. — Nerves  are  sometimes  involved  and  pressed  upon  in  the 
processes  of  repair  following  injury  of  bones  and  soft  parts,  or  in  the  processes 
of  disease,  or  by  adhesions,  and  eventually  become  so  firmly  compressed  as 
to  have  their  function  impaired — in  which  case  an  operation  to  free  them  for 
pressure  is  indicated. 

Position — Landmarks — Incision. — Dependent  upon   nerve  involved. 

Operation. — The  steps  of  the  operation  will  be  determined  by  the  position 
and  nature  of  the  compression.  Where  fibrous  cicatricial  tissue  surrounds 
the  nerve,  the  mass  is  to  be  exposed  by  dissection — the  nerve  is  to  be  isolated 
either  above  or  below  the  mass  and  is  to  be  followed  through  it  and  dissected 
out  from  it.  The  cause  of  compression,  as  far  as  possible,  is  to  be  removed, 
so  as  to  avoid  a  recurrence.  Where  a  bony  callus  surrounds  the  nerve,  this 
is  to  be  reached  by  the  safest  route  through  the  muscular  planes — the  nerve 
being  similarly  isolated  above  and  below  the  mass — and  freed  through  it. 
It  is  often  necessary  to  chisel  away  as  much  of  the  callus  as  imprisons  the 
nerve — and  in  order  to  render  a  recurrence  of  compression  unlikely.  The 
wound  is  closed  as  usual.  Cargile  membrane  has  been  used  to  prevent 
re-adhesion. 

Comment. — Nerves  may  be  compressed  by  growing  tumors — their  relief 
being  determined  by  the  treatment  adopted  for  the  tumor,  or  nerves  may  be 
compressed  by  their  thickened  sheaths,  which  require  longitudinal  incision. 

INTRANEURAL   INFILTRATION  FOR  REGIONAL  ANESTHESIA. 

OPERATION    OF    MAT  AS    AND   CRILE. 

Description. — -The  injection  of  a  sterilized  anesthetic  solution  directly 
into  a  nerve-trunk.  The  injection  may  be  made  at  the  site  of  the  proposed 
operation,  or  above  the  site. 

Indications. — To  produce  anesthesia  in  the  region  supplied  by  the  nerve, 
for  the  purpose  of  major  or  minor  operations.  Especially  indicated  in  those 
portions  of  the  body  in  which  nerve-trunks  may  be  isolated, — and  in  those 
cases  in  which  general  anesthesia  is  contraindicated. 

Position — Landmarks— Incision. — Determined  by  the  special  operation. 

Nature  of  the  Anesthetic  Solutions. — These  have  been  of  various  con- 
stitutions and  percentages — there  being  no  recognized  standard  solution 
universally  employed  in  this  comparatively  new  field  of  surgery.  Sterilized 
solutions  of  cocain,  of  eucain  B,  of  nirvanin,  of  Schleich's  solution,  and  others, 
have  been  used.  Almost  any  suitable  syringe  may  be  employed,  though  a 
special  instrument  is  more  appropriate.  Matas  (whose  writing  upon  local 
anesthesia  this  article  largely  follows)  uses  from  5  to  40  min.  (according 
to  the  size  of  the  nerve)  of  Schleich's  solution  No.  1.  (One  tablet  of  Schleich 
No.  1  dissolved  in  100  minims  of  water,  represents  -5^  part  of  cocain  hydro- 
chlorid,  4  0V0  Part  of  morphin  hydrochlorid,  and  -5-^-,-  part  of  sodium  chlorid.) 

Operation. — The  anesthetic  fluid  may  be  injected  at  the  site  of  operation 
or  above  it; — (a)  Where  the  Injection  is  made  into  the  Nerve-trunk  above 
the  site  of  Operation — the  anesthesia  being  produced  in  the  region  supplied 
by  the  nerve: — (Suppose  the  injection  be  made  into  the  sciatic  nerve,  .for 
amputation  of  the  leg);  To  prepare  the  way  for  the  incision,  anesthetize  the 
skin  by   intradermal  infiltration — and  the  connective  tissue   by  subdermal 


170       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

(subcutaneous)  infiltration — both  with  the  Schleich  solution.  Expose  the 
sciatic  nerve  above  the  bifurcation  into  internal  and  external  popliteal  and 
isolate  it  sufficiently  for  manipulation.  Insert  the  needle  of  the  syringe 
through  the  sheath  of  the  nerve  and  into  and  among  its  fibers — and  slowly 
inject  the  anesthetizing  fluid  (the  amount  determined  by  the  nature  of  the 
solution  and  size  of  the  nerve)  until  the  entire  extent  of  a  transverse  section 
of  the  nerve  has  been  infiltrated  or  "blocked"  (Fig.  155).  If  this  single 
injection  be  considered  sufficient  to  last  throughout  the  operation,  the  wound 
may  be  at  once  closed — otherwise  it  is  temporarily  packed  with  gauze.  The 
limb  is  elevated  and  exsanguinated  by  gravity.  A  circular  constrictor  is 
applied  above  the  site  at  which  the  nerve  was  infiltrated.  Within  a  few 
minutes  of  the  infiltration,  the  distal  regions  supplied  by  the  nerve  will  be 


Fig.  155. — Intraneural  Infiltration  for  Regional  Anesthesia: — The  great  sciatic  nerve 

being  here  infiltrated. 

completely  anesthetic,  and  any  operation  may  be  performed  thereon,  as  long 
as  the  constrictor  remains  in  situ,  (b)  Where  Infiltration  is  made  into 
Nerve-trunks  as  exposed  in  the  course  of  an  Operation: — Anesthetize  the  skin 
by  intradermal  infiltration,  and  the  connective  tissue  by  subdermal  infiltration. 
As  each  nerve  is  exposed  it  is  isolated,  taken  up,  and  infiltrated,  as  in  the 
above  method.  Where  the  case  is  a  limb,  a  circular  constrictor  is  used  as 
above.  Where  the  region  is  such  an  one  as  is  involved  in  the  radical  operation 
for  inguinal  hernia,  no  arrest  of  circulation  is  attempted.  In  this  method 
the  anesthesia  is  complete  not  only  at  the  site  infiltrated,  but  in  the  regions 
supplied  by  the  infiltrated  nerves — but  lasts  a  shorter  time,  unless  the  infiltra- 
tion be  repeated,  than  where  a  constrictor  can  be  applied. 

Comment. — If  the  site  of  operation  be  supplied  entirely  by  one  nerve, 
that  nerve  alone  need  be  infiltrated,  at  some  convenient  point  proximal  to  the 
site  of  intended  operation.     If  the  site  of  operation,  however,  be  supplied  by 


PARANEURAL    INFILTRATION    FOR    REGIONAL    ANESTHESIA.         171 

several  nerves,  each  has  to  be  separately  infiltrated; — for  example,  in  the 
operation  of  amputation  of  the  leg  described  above,  if  the  operation  is  to  be 
above  the  level  of  the  tuberosity  of  the  tibia,  the  anterior  crural  nerve  is  to  be 
also  injected, — if  below  that  level,  the  long  saphenous  nerve  is  to  be  injected 
instead  of  the  anterior  crural — the  sciatic  being,  of  course,  infiltrated  in  both 
instances.  The  entire  upper  limb  can  be  anesthetized  by  infiltrating  the 
brachial  plexus  above  the  clavicle. 

PARANEURAL  INFILTRATION  FOR  REGIONAL  ANESTHESIA. 

MATAS'    METHOD. 

Description. — The  injection  of  a  sterilized  anesthetic  solution  into  the 
tissues  immediately  surrounding  a  nerve-trunk,  so  planned  as  to  envelop  the 
nerve  as  closely  as  possible  in  an  anesthetic  atmosphere,  as  it  were. 

Indications. — To  produce  anesthesia  in  the  region  of  the  infiltration  and 
as  far  beyond  as  the  solution  is  diffused. 

Position — Landmarks. — Determined  by  the  special  operation. 

Operation. — Without  making  any  incision  for  the  exposure  of  the  nerve, 
the  anesthetic  solution  is  injected  first  intra dermally,  to  deaden  the  site  super- 
ficiallv,  and  then  into  the  tissues  immediately  in  the  neighborhood  of  the 
nerve',  and  as  near  to  the  nerve  as  possible.  This  infiltration  of  the  tissues 
alongside  of  the  nerve  is  done  upon  a  knowledge  of  the  anatomy  of  the  nerve 
and  its  relation — and  is  meant  to  "envelop  the  nerve  in  an  anesthetic  atmos- 
phere." In  the  case  of  dealing  with  an  extremity,  a  few  minutes  after  the 
infiltration  the  part  is  elevated,  exsanguinated  by  gravity,  and  a  circular  con- 
strictor applied  above  the  region  of  infiltration — subsequently  to  which  the 
parts  below  the  infiltration  will  be  anesthetized  by  the  diffusion  of  the  anesthetic 
solution  (Fig.  158).  In  other  localities  no  attempt  to  control  the  circulation 
is  made.  The  anesthetic  solutions  and  the  special  syringe  for  injection  are 
mentioned  under  Intraneural  Infiltration.  Matas  uses  the  Schleich's  solution 
No.  1,  calculating  in  this,  as  in  other  forms  of  regional  anesthesia,  not  to 
leave  more  than  1  gr.  of  cocain  in  the  tissues.  To  illustrate  the  paraneural 
method  (copying  from  Matas'  writing  upon  the  subject)  let  the  anesthetization 
of  the  finger,  for  the  removal  of  a  nail  or  the  opening  of  a  felon,  be  taken. 
"The  skin  at  the  root  of  the  finger,  on  its  dorsal  aspect,  is  infiltrated  over 
two  spots  on  each  side  of  the  phalanx  nearest  the  carpometacarpal  joint, 
and  on  a  level  with  the  web  of  the  hand.  The  needle  is  then  thrust  into  each 
spot  and  directed  toward  the  known  situation  of  the  digital  nerves,  which  are 
deeply  situated  in  the  lateral  aspect  of  the  digits.  From  10  to  15  minims  of 
the  anesthetizing  solution  are  diffused  in  the  region  of  each  nerve,  with  the  view 
of  creating  a  cocain  atmosphere  around  it.  After  a  few  minutes'  delay  to  allow 
the  capillary  circulation  to  diffuse  the  fluid,  the  hand  is  exsanguinated  by 
elevation,  and  an  elastic  constrictor  is  carried  around  the  root  of  the  finger 
below  the  seat  of  the  infiltration.  The  finger  will  then  become  numb  and 
dead  to  all  painful  impressions,  and  it  will  be  possible  to  perform  any  operation 
upon  the  digit,  at  any  point  beyond  the  line  of  constriction." 

Comment. — This  method  is  more  applicable  to  smaller  extremities  and 
parts — while  the  intraneural  method  to  the  larger.  The  paraneural  infiltration 
for  regional  anesthesia  differs  from  local  infiltration  for  regional  anesthesia 
(which  may  be  represented  by  the  common  use  of  cocain  hypodermatically) 
in  that  in  the  latter  no  attempt  is  made  to  infiltrate  along  the  anatomical 
course  of  the  nerves,  but  the  injection  is  made  almost  at  random  into  the 
cutaneous   and   subcutaneous   tissue. 


172       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

MASSIVE  INFILTRATION  ANESTHESIA  WITH  WEAK  ANALGESIC 

SOLUTIONS. 

MATAS'    MODIFICATION"    OF    SCHLEICH'S    METHOD. 

Description. — By  infiltration  anesthesia  is  meant  ihe  production  of 
diminished  or  suppressed  sensibility  of  a  part  by  means  of  edematization  of 
the  tissues  through  the  injection  of  weak  analgesic  solutions.  The  fluid 
(from  one  to  thirty  ounces)  is  thrown  into  the  tissues  without  reference  to  the 
nerves  of  the  part — the  needle  avoiding  important  structures.  (The  author, 
however,  has  seen  a  quantity  of  the  solution  thrown  into  the  internal  jugular 
vein,  toward  the  heart,  in  operating  upon  the  neck,  without  appreciable 
result.)  The  analgesia  thus  produced  is  accomplished  partly,  and  chiefly, 
by  the  physical  effect  of  the  pressure  exercised  upon  the  conductivity  of  the 
sensory  nerves  by  the  infiltrated  fluid,  and  partly  by  the  paralyzation  of  the 
sensitive  structures  by  the  chemical  action  of  the  agents  used.  Several 
analgesic  solutions  are  in  use,  and  almost  any  syringe  may  be  employed  for 
their  introduction.  Matas,  whose  writings  on  this  subject  have  been  largely 
followed,  uses  a  special  form  of  instrument  and  a  special  solution. 


Fig.  156. — The  Latest  Model  of  Matas'  Infiltrator  :- 

thesia. 


-Used  In  massive  infiltration  anes- 


Apparatus. — The  infiltrator  devised  by  Matas  (Fig.  156)  ''consists  of 
a  glass  receptacle  with  space  for  7  oz.  of  fluid  and  2  oz.  of  air.  The  fluid  is 
introduced  through  the  bottom  (or  the  part  which  becomes  the  bottom  when 
the  apparatus  is  inverted  and  ready  for  use)  which  is  closed  by  screw-cap 
over  a  rubber  washer  which  makes  an  air-tight  joint.  The  bottle  is  graduated, 
which  enables  the  operator  to  see  the  amount  of  fluid  that  is  being  used  during 
an  operation.  The  top  is  provided  with  a  T-tube,  with  two  stop-cocks,  one 
for  the  introduction  of  air,  and  the  other  for  the  egress  of  the  fluid.  A  rubber 
bulb  for  compressing  the  air  is  attached  to  the  bottle  by  means  of  rubber 
tubing   and   suitable   connections    (Fig.   156).     Eight    needles,    straight    and 


MASSIVE    INFILTRATION    ANESTHESIA. 


173 


curved,  are  provided  with  the  outfit,  varying  in  size  from  a  fine  hypodermic 
needle  to  a  large  aspirating  needle.  The  needles  are  connected  to  reservoir 
by  rubber  tubing  of  sufficient  length  to  give  the  operator  freedom  of  movement 
iii  handling  the  needle.  After  the  sterilized  solution  has  been  placed  in  the 
receptacle  this  is  charged  with  air  until  marked  resistance  is  felt  in  compressing 
the  bulb,  when  the  bulb  and  its  tubing  are  detached  from  their  special  stop-cock. 
The  apparatus  is  now  ready  for  infiltration.  The  chief  advantages  of  this 
apparatus  over  the  ordinary  syringes  used  for  infiltration  anesthesia  are: — 
(a )  That  it  allows  the  operator  to  infiltrate  and  edematize  large  areas  rapidly, 
continuously,  or  interruptedly  without  the  delay  caused  by  recharging  or 
exchanging  svringes; — (b)  That  by  the  use  of  long  needles  it  tends  to  diminish 
the  traumatism  caused  by  frequent  punctures  made  necessary  by  shorter 
needles  used  with  the  ordinary  quickly  exhausted  syringes." 

Solutions. — The  solution  used  by  Matas  for  routine  work  is  a  sterilized 
j^j-  of  1  per  cent,  eucain  B  solution  in  normal  salt  solution  (T8o-  of  1  per 
cent.) — with  10  to  15  minims  of  1  :  1000  adrenalin  chlorid  solution  added 
to  the  total  amount  injected.  This  solution  is  used  in  bulk,  up  to  5  or  6 
ounces  for  injection  into  the  tissues  where  the  bulk  of  it  will  flow  out — and 


Fig.  157. — The  Original  Type  of  Matas'  Infiltrator: — Shown  here  to  illustrate  the 
manner  of  charging  the  receptacle  with  compressed  air,  which  is  done  on  the  same  general 
principle  in  the  latest  instrument. 


up  to  2  ounces  where  this  amount  will  be  retained.  The  adrenalin  is  added 
for  the  purpose  of  producing  ischaemia  of  the  parts,  especially  where  no  form 
of  constrictor  can  be  used,  and  may  be  of  benefit  additionally  because  of  its 
action  upon  the  circulation.  For  preliminary  intradermal  injection  i  of  1  per 
cent,  eucain  B  solution  is  used. 

Indications. — "In  a  general  way,  this  method  of  infiltration  is  indicated 
in  all  operations  in  which  the  circulation  cannot  be  controlled,  and  in  which 
the  major  part  of  the  infiltrating  solution  must  remain  in  the  tissues.  By  this 
method  extensive  extirpation  of  tumors,  excision  of  malignant  growths,  ligation 
of  all  the  important  vessels  of  the  neck  and  extremities,  resection  of  nerves 
for  neuralgia,  excision  of  tongue,  extirpation  of  thyroid  gland,  amputations, 
operations  for  hernia  and  other  abdominal  operations  on  debilitated  patients, 
thoracotomy  with  resection  of  ribs,  and  other  operations  have  been  successfully 
performed  in  the  clinics  of  the  author  of  this  method  by  combining  the  intra- 
neural method  with  local  infiltration." 

Preparation; — Position; — Landmarks. — Dependent  upon  the  special 
operation. 

Operation. — "In  this,  as  in  all  other  methods  of  local  anesthesia,  it  is 


174       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

most  important  to  remember  that  the  derm  proper,  and  especially  its  papillary 
layer,  must  be  first  edematized  by  intraarticular  infiltration  before  beginning 
the  infiltration  of  the  deeper  planes;  the  same  rule  applies  to  mucous  surfaces." 
For  this  purpose  the  weaker  solution  above  mentioned  is  used,  carried  through 
a  fine  needle.  "The  field  of  the  operation  can  then  be  edematized,  (I)  in  toto; 
i.  e.,  by  infiltration  en  bloc  without  reference  to  nerves  or  other  anatomical 
elements  (as  in  the  extirpation  of  a  benign  tumor  of  the  breast);  or  (2)  by 
circumferential  infiltration;  i.  e.,  by  enclosing  the  field  of  operation  within  a 
wall  of  anesthetizing  edema,  thus  cutting  off  the  enclosed  space  from  all  nerve 
communication  with  the  surrounding  parts  (e.  g.,  the  extirpation  of  a  pedicu- 


Fig.  158. — Matas'  Older  Form  of  Infiltrator: — Shown  here  to  illustrate  the  manner 
of  accomplishing  massive  infiltration,  after  filling  the  space  in  the  bottle  with  compressed  air — 
the  same  general  technic  being  used  with  the  latest  instrument. 

lated  tumor,  or  sebaceous  cyst),"  or  the  amputation  of  a  limb.  Where  it  is 
possible  to  control  the  circulation  by  a  constrictor,  and  where  exsanguination 
can  be  practised,  these  should  be  done.  "The  solutions  are  injected  tepid 
or  cold  into  the  tissues;  after  the  infiltration  is  completed  the  entire  field  is 
covered  with  a  sterilized  ice-bag  for  three  to  five  minutes,  which  by  refrigera- 
ting the  solution,  greatly  intensifies  the  anesthetic  action."  Having  obtained 
loss  of  sensation,  the  operation  is  proceeded  with  as  indicated  in  the  special 
instance.  During  the  course  of  an  operation  begun  by  infiltration,  individual 
nerves  may  be  taken  up  and  injected  intraneurally — or  the  infiltrating  solu- 
tion may  be  deposited  among  the  deeper  tissues  (Fig.  158). 


EXPOSURE    OF    GASSERIAN    GANGLION.  1 75 


SURGICAL  ANATOMY  OF  GASSERIAN  GANGLION  OF  TRIFACIAL 

NERVE. 

Description  and  Relations. — (a)  Both  sensory  and  motor  root  of  the 
trifacial  pass  downward  and  forward  through  an  aperture  in  dura  mater, 
which  lies  under  cover  of  tentorium  cerebelli  and  a  little  to  outer  side  of  apex 
of  petrous  portion  of  temporal  bone,  to  enter  Meckel's  space,  between  the 
supporting  and  periosteal  layers  of  dura  mater,  in  which  space  the  sensory 
portion  enlarges  into  the  gasserian  ganglion,  (b)  The  gasserian  ganglion,  of 
somewhat  semilunar  form,  with  convexity  forward,  rests  in  depression  upon 
upper  surface  of  petrous  portion  of  temporal  bone,  near  its  apex — and  also  to  a 
slight  extent  upon  cartilage  which  occupies  foramen  lacerum  medium.  Its 
upper  surface  is  firmly  attached  to  dura  mater  (roof  of  Meckel's  space) — its 
lower  surface,  less  firmly  (to  floor  of  Meckel's  space).  Its  inner  part  lies 
near  posterior  extremity  of  cavernous  sinus  and  internal  carotid  artery. 
The  motor  root  and  the  large  superficial  petrosal  nerve  lie  beneath  the  ganglion. 
From  its  convex  antero-external  border  are  given  off  the  following  main 
divisions; — Ophthalmic,  passing  out  through  sphenoidal  fissure;  Superior 
Maxillary,  passing  through  foramen  rotundum;  Inferior  Maxillary,  passing 
through  foramen  ovale  and  being  joined  immediately  after  its  exit  by  the 
motor  root,  which  also  passes  through  foramen  ovale  separately. 


EXPOSURE   OF  GASSERIAN  GANGLION  AND  THREE  DIVISIONS  OF 
FIFTH  NERVE  BY  THE  DIRECT  INFRA- ARTERIAL  ROUTE. 

cushing's  method. 

Description. — A  flap  of  soft  parts,  including  the  temporarily  resected 
zygoma,  is  turned  down,  thus  exposing  the  zygomatic  and  pterygomaxillary 
fossae.  An  opening  is  then  made,  with  trephine  or  special  instrument,  through 
the  most  prominent  portion  of  the  great  wing  of  the  sphenoid,  near,  or  including, 
the  zygomatic  ridge  (infratemporal  crest).  The  dura  is  thus  reached  below 
the  middle  meningeal  artery  and  the  ganglion  exposed  extra-durallv,  in 
Meckel's  space.  The  route  of  approach  is  more  direct,  the  hemorrhage  less, 
and  the  amount  of  handling  of  the  brain  less  than  in  most  of  the  methods  of 
reaching  the  ganglion. 

Preparation. — Head  shaved. 

Position. — Patient  on  back,  head  on  one  side  and  supported  by  firm 
pillow.  Surgeon  at  side  of  head,  either  in  front  of  or  behind  patient.  Assis- 
tant opposite. 

Landmarks. — Outline  of  zygomatic  arch. 

Incision. — Horse-shoe  in  shape,  the  ends  of  the  two  limbs  being  upon 
the  outer  and  inner  ends  of  the  zygomatic  arch,  about  4  cm.  (ij  inches)  apart, 
and  the  upper  part  of  the  convexity  extending  about  5  cm.  (4  inches)  above 
the  zygoma. 

Operation. — (1)  A  skin-flap  of  the  parts  overlying  the  temporal  fascia 
is  turned  down  to  a  level  just  below  the  zygoma.  The  temporal  vessels  are 
secured.  (2)  A  second  horse-shoe  incision,  like  the  first  but  slightly  smaller, 
is  made  through  the  temporal  fascia,  the  base  of  the  incision  passing  through 
the  periosteum  along  the  middle  of  the  outer  aspect  of  the  zygoma.  Through 
this  periosteal  incision  free  the  zygoma  of  its  periosteum  except  along  the 
attachment  of  the  masseter  muscle.     Divide  the  zygomatic  arch  at  its  inner 


176       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

and  outer  ends  with  a  Gigli  saw  conducted  beneath  it — having  first  drilled  on 
each  side  of  each  saw-cut,  for  future  ligaturing.  (3)  Along  the  line  of  the 
limbs  and  convexity  of  the  preceding  horse-shoe  incision  divide  the  temporal 
muscle  down  to  the  bone.  Turn  the  flap  of  soft  parts,  with  zygoma  adherent, 
downward,  firmly  retracting  it — so  as  to  expose  the  zygomatic  crest  (infra- 
temporal ridge),  the  lower  part  of  the  temporal  fossa  and  the  beginning  of  the 
pterygomaxillary  fossa.  (4)  An  opening  is  now  made  through  the  prominent 
part  of  the  wing  of  the  sphenoid,  either  by  a  trephine  of  about  3  cm.  (i\  inches), 
or  by  means  of  some  special  instrument,  with  or  without  previous  burr-openings. 
The  dura  in  the  middle  fossa  of  the  base  of  the  skull  is  thus  exposed  at  a  point 
to  the  outer  side  of  and  about  midway  between  the  foramina  ovale  and  rotun- 
dum — very  near  the  foramina  and  below  and  to  the  outer  side  of  the  middle 
meningeal  artery  emerging  from  the  foramen  spinosum.  (5)  The  Gasserian 
ganglion  and  its  three  branches  are  thus  exposed,  after  gently  separating  the 
dura  from  the  bony  wall  of  the  middle  fossa — these  structures  being  still 
covered  by  their  special  investment  of  the  dura,  constituting  Meckel's  cavity 
or  space  (Fig.   159).     This  cavity  of  Meckel,  which  it  is  very  important  to 


S  BC  D 


Fir.  159. — Cushing's  Operation  for  Exposure  of  Gasserian  Ganglion  and  Three 
Branches  of  Trifacial  Nerve: — A,  Gasserian  ganglion;  B,  Ophthalmic  division  of  fifth  nerve; 
C,  Superior  maxillary  division;  D,  Inferior  maxillary  division;  E,  Floor  of  Meckel's  space;  F, 
Dural  arch  and  roof  of  Meckel's  space;  G,  Middle  meningeal  artery.    (Modified  from  Cushing.) 

recognize,  and  which  it  is  necessary  to  open  before  coming  into  direct  contact 
with  the  structures  sought,  is  incised  along  its  outer  aspect,  between  the  second 
and  third  nerves,  at  their  entrance  into  their  foramina.  By  careful  blunt 
dissection  the  superior  portion  of  the  roof  of  Meckel',s  space  is  further  opened 
up,  leaving  the  ganglion  and  the  second  and  third  branches  exposed  upon  the 
floor,  or  lower  aspect,  of  Meckel's  space.  The  floor  of  Meckel's  space  is  now 
separated  from  these  structures  by  blunt  dissection,  until  the  ganglion  is 


EXPOSURE    OF    GASSERIAX    GAXGLIOX.  177 

raised  from  it.  The  dura  is  then  separated  on  the  inner  side,  where  it  lies 
in  contact  with  the  sixth  nerve  and  cavernous  sinus,  the  separation  being 
accomplished  toward  the  first  division.  The  second  and  third  divisions 
are  put  on  the  stretch  gently  by  means  of  blunt  hooks  and  divided  close  to  their 
foramina.  The  body  of  the  ganglion  is  seized  with  forceps  and  torn  out, 
together  with  the  origins  of  the  second  and  third  divisions  and  the  first  division. 
(6)  Wounding  of  the  middle  meningeal  artery  is  generally  avoided.  Hemor- 
rhage from  small  arteries  and  veins,  and  the  cavernous  sinus,  if  wounded,  is 
controlled  by  packing  temporarily.  Where  continuous  packing  is  not  neces- 
sitated, the  wound  is  closed  throughout,  without  drainage — suturing  back 
the  structures,  including  the  zygoma,  into  normal  position.  The  eye  is  covered 
with  rubber  protective — avoiding  all  pressure. 

Comment. — (1)  Hemorrhage  from  the  middle  meningeal  artery,  the 
chief  source  of  serious  hemorrhage,  is  avoided  by  approaching  the  ganglion 
from  below  the  artery.  (2)  The  small  size  and  protected  locality  of  the 
opening  through  the  skull  makes  the  necessity  of  a  bone-covering  less  than 
in  the  operations  which  reach  the  ganglion  through  the  temporal  fossa.  (3) 
No  attempt  should  be  made  to  remove  the  ganglion  until  it  has  been  freed 
from  its  special  envelope  of  reflected  dura — which  should  be  accomplished 
from  above  first,  thus  lessening  the  hemorrhage  which  often  accompanies  the 
freeing  of  the  ganglion  from  its  bed.  (4)  The  sixth  nerve  is  often  injured 
in  freeing  the  ophthalmic  division  of  the  nerve — and  the  sympathetic  always 
is,  because  of  its  intimate  relation — but  these  occurrences  are  generallv  not 
permanently  serious.  (5)  The  zygoma  is  sometimes  not  sutured  back  into 
position — but  is  allowed  to  sink  into  a  less  prominent  position  as  the  muscles 
of  mastication  atrophy.  (6)  It  may  be  necessary  to  ligate  the  middle  menin- 
geal artery. 


EXPOSURE  OF  GASSERIAN  GANGLION  AND  THREE  DIVISIONS  OF 
FIFTH  NERVE  THROUGH  TEMPORAL  FOSSA  BY  OSTEOPLASTIC 
FLAP. 

HARTLEY-KRAUSE    OPERATION. 

Description. — Osteoplastic  resection  of  temporal  region  with  temporary 
turning  down  of  flap  of  bone  and  soft  parts  and  separation  of  dura  mater 
from  middle  fossa  of  skull — the  three  divisions  of  the  fifth  nerve  being  exposed 
and  traced  to  the  Gasserian  ganglion,  in  Meckel's  space,  outside  of  the  dura 
proper. 

Preparation. — Head  shaved. 

Position. — Patient  on  back;  head  to  one  side  and  supported  by  firm 
pillow.  Surgeon  at  side  of  head,  either  in  front  of  or  behind  patient.  Assist- 
ant opposite. 

Landmarks. — External  angular  process  of  frontal;  tragus  of  ear;  supra- 
temporal  ridge. 

Incision. — A  horseshoe-shaped  incision  is  made  over  the  temporal 
region,  its  anterior  extremity  being  near  the  external  angular  process  of  the 
frontal  bone,  its  posterior  extremity  near  the  tragus  of  the  ear,  and  the  highest 
part  of  the  curve  reaching  the  supratemporal  ridge  (Fig.  160). 

Operation. — (1)  The  above  incision  passes  through  all  the  soft  tissues 
and  periosteum  directly  to  the  bone,  along  the  entire  line.  (2)  With  periosteal 
elevator,  the  soft  parts  of  *'  flap  are  freed  from  the  bone  to  a  slight  extent 
only,  around  the  entire  i       .    n  line — the  freeing  at  the  two  ends  of  the  base- 


178       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

line  being  a  little  more  extensive.  Throughout  the  rest  of  its  extent,  the 
flap  remains  adherent  to  the  underlying  bone.  (3)  With  a  trephine  of  about 
1.3  cm.  (J  inch)  diameter,  two  discs  of  bone  are  removed,  the  anterior  with 
its  center  over  the  tip  of  the  sphenoid  wing,  the  posterior  having  its  center 
over  a  point  2.5  cm.  (1  inch)  vertically  above  the  external  auditory  meatus. 
From  these  trephine  openings  the  dura  is  separated  as  far  as  possible,  both 


Fig.  160.— Exposure  of  Gasserian  Ganglion  by  Osteoplastic  Flai — Preparatory  to  the 
Hartley-Krause  Operation: — I. — A,  Periosteum;  B,  Horseshoe  flap  broken  back  and  turned 
down  ;  C,  Dura  mater,  with  anterior  and  posterior  branches  of  middle  meningeal  artery. 

along  the  straight  basal  line  connecting  the  two  openings,  and  in  the  direction 
in  which  the  convex  bone-section  is  to  be  made.  (4)  A  section  of  bone  similar 
in  shape  to  the  skin  incision,  but  smaller  in  size,  is  now  made.  This  section 
is  made  from  the  squamous  portion  of  the  temporal  and  greater  wing  of  the 
sphenoid — the  basal  attachment  being  somewhat  narrower  than  the  greatest 


EXPOSURE    OF    GASSERIAN    GANGLION. 


179 


transverse  measurement  of  the  convex  portion.  This  bone-section  was 
formerly  made  by  a  special  chisel  cutting  a  triangular  groove- — but  is  now 
made  by  a  motor  or  other  saw — the  section  beginning  at  one  trephine-opening 
and  ending  at  the  other,  care  being  taken  to  do  no  damage  to  the  dura.  (5) 
The  bone  being  thus  cut  through  everywhere  except  across  its  basal  line, 
some  stout  instrument  (such  as  an  osteotome  or  elevator)  is  inserted  into  the 
groove  at  its  greatest  convexity,  resting  against  the  parietal  bone  as  a  fulcrum 
— then,  with  a  sharp,  sudden  movement,  this  flap  of  skin,  muscle,  periosteum, 


Fig.  161. — Exposure  of  Gasserian  Ganglion"  and  Roots  of  Trifacial  Nerve  by 
Osteoplastic  Flap,  by  the  Hartley-Krause  Method: — II. — A,  Retractor  elevating  brain 
and  exposing  middle  fossa  of  skull;  B,  Gasserian  ganglion,  with  first  division  of  trifacial  nerve 
passing  through  sphenoidal  fissure,  second  division  through  foramen  rotundum,  and  third 
division  through  foramen  ovale;  C,  Middle  meningeal  artery  entering  through  foramen  spinosum; 
D,  Position  of  cavernous  sinus  and  internal  carotid  artery;  the  third,  fourth,  and  sixth  nerves 
are  seen  between  the  cavernous  sinus  and  the  first  division  of  the  fifth  nerve.  The  lamina  of 
dura  forming  Meckel's  space  has  been  incised  over  the  ganglion  and  the  third  division,  but  is 
not  accurately  shown  in  its  reflection  forming  the  roof  of  Meckel's  cavity.  Note: — the  ganglion 
and  branches  are  represented  somewhat  disproportionately  large  and  prominent,  as  well  as 
upon  too  high  a  plane. 

and  bone  is  prized  outward  and  downward,  generally  snapping  directlv  and 
evenly  across  the  basal  line  just  above  the  zygomatic  arch,  and  remaining 
hinged  by  the  soft  parts — and  exposing  an  area  of  brain  (covered  by  dura 
mater)  of  about  5  to  7.5  cm.  (2  to  3  inches)  in  diameter  (Fig.  161).     (6)  If 


180       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

the  middle  meningeal  artery  is  found  injured,  it  is  tied  as  near  the  foramen 
spinosum  as  possible.  (7)  The  dura  mater  and  temporosphenoidal  lobe  of 
the  brain  are  now  separated  from  the  middle  fossa  of  the  skull.  This  is  done 
in  the  direction  toward  the  apex  of  the  petrous  portion  of  the  temporal  bone, 
and  is  accomplished  by  the  fingers  or  a  piece  of  gauze,  or  by  a  curved,  blunt 
elevator.  Sometimes  the  dura  is  considerably  torn,  and  sometimes  the 
artery  is  torn  whether  the  dura  is  or  not,  requiring  temporary  packing  of 
the  bony  groove  to  control  the  hemorrhage,  where  ligature  is  impossible. 
Injured  dura  should  be  sutured  wherever  possible.  (8)  The  three  divisions 
of  the  nerve  are  now  seen  and  are  traced  back  from  their  foramina.  The 
positions  of  the  carotid  artery  and  cavernous  sinus  are  located  as  nearly  as 
possible,  for  the  purpose  of  guarding  them.  (9)  Isolate  and  cut  the  first, 
second,  and  third  divisions  close  to  the  sphenoidal  fissure,  foramen  rotundum, 
and  foramen  ovale,  respectively.  Secure  the  proximal  ends  of  the  severed 
nerves  with  forceps  or  silk,  and,  practising  traction  upon  them,  trace  them 
back  to  the  gasserian  ganglion — after  incising  the  dura  mater  over  them. 
Then,  raising  the  ganglion  from  its  bed,  sever  its  connections  with  the  brain 
close  to  the  dura  mater,  and,  if  possible,  without  including  or  injuring  the 
motor  root.  (10)  At  the  end  of  the  operation  the  dura  and  unexposed  cerebral 
convolutions  are  allowed  to  fall  into  place — the  flap  of  bone  and  soft  parts  is 
turned  up — and  sutures  applied  to  skin  and  muscles. 

Comment. — (1)  The  width  of  the  basal  line  of  bone  may  be  decreased 
by  rongeur  forceps,  thus  increasing  the  likelihood  of  a  clean,  transverse 
breakage — or  a  Gigli  saw  may  be  conducted  under  the  bone  at  its  base  and 
made  partly  to  divide  it.  (2)  In  the  use  of  either  chisel  or  saw,  the  inner 
tablet  of  the  skull  may  be  left  uncut  in  two  or  three  places,  over  a  limited 
extent,  so  that  when  the  flap  is  broken  back,  these  parts  of  the  vitreous  are 
left  as  shelves  for  the  flap  to  rest  upon  when  turned  back  into  place.  (3) 
Bleeding  may  be  so  great  as  compel  one  to  pack  and  finish  the  operation  in 
two  stages.  (4)  The  advisability  of  removing  the  first  division  is  doubtful, 
because  of  the  trophic  changes  which  follow  in  the  eye.  The  first  division 
is  never  involved  alone.  (5)  The  motor  root  should  always  be  left  undisturbed, 
if  possible — to  avoid  paralysis  of  the  muscles  of  mastication.  It  is  more  apt  to 
be  injured  if  the  dura  of  Meckel's  space  be  opened  over  the  ganglion  and  the 
sensory  root  be  cut  between  the  ganglion  and  the  pons.  When  possible  it  is 
best  to  cut  the  second  and  third  divisions  close  to  the  foramen  rotundum  and 
foramen  ovale  respectively — dissect  them  back  to  the  ganglion,  and  remove  the 
parts  of  the  ganglion  corresponding  to  these  divisions,  leaving  untouched  the 
first  division,  with  its  corresponding  ganglion  and  the  motor  root.  (6)  If  the 
first  division  be  removed,  with  the  corresponding  part  of  the  ganglion,  especial 
care  is  needed  not  to  harm  the  cavernous  sinus  and  the  nerves  to  the  eye — 
to  aid  in  avoiding  which,  the  second  and  third  divisions  should  be  removed 
first  to  give  more  room.  If  the  first  division  be  accidentally  severed,  leave 
the  lacerated  end  as  near  the  remains  of  the  ganglion  as  possible.  (7)  If 
much  oozing  follows  packing,  wick  or  gauze  drainage  is  indicated  for  twenty- 
four  or  forty-eight  hours.  (8)  The  chief  dangers  of  the  operations  are — ■ 
injury  to  internal  carotid  and  cavernous  sinus;  laceration  of  brain;  injury 
to  nerves  of  eye  (third,  fourth,  and  ophthalmic  division) ;  hemorrhage  from 
middle  meningeal  artery.  (9)  In  Horsley's  method  of  intracranial  exposure 
of  the  gasserian  ganglion  a  large  soft  flap  is  turned  down  from  the  temporal 
region,  the  underlying  bone  is  removed  by  trephine  and  bone  forceps  (not 
to  be  returned),  the  temporosphenoidal  lobe  exposed,  the  dura  incised,  the 
ganglion  exposed,  and  the  root  cut  on  the  proximal  side  of  the  ganglion. 


EXPOSURE    OF    GASSERIAN    GANGLION.  181 

EXPOSURE  OF  GASSERIAN  GANGLION  AND  THREE  DIVISIONS  OF 
FIFTH  NERVE  BY  TREPHINING  THROUGH  PTERYGOMAXILLARY 
FOSSA. 

rose's  method. 

Description. — The  ganglion  is  approached  through  the  pterygomaxillary 
fossa,  the  zygoma  being  temporarily  and  the  coronoid  process  of  the  inferior 
maxilla  permanently  resected,  and  the  trephine  applied  to  include  the  anterior 
and  outer  portion  of  the  foramen  ovale.     The  dura  proper  is  not  opened. 

Preparation. — Head  shaved;  eyelids  stitched  together  with  temporary 
sutures. 

Position. — As  in  preceding  operation. 

Landmarks. — ( >uter  canthus  of  eye;  zygomatic  arch;  meatus  auditorius 
externus;  angle  and  horizontal  ramus  of  lower  jaw. 

Incision. — Begins  near  outer  canthus  of  eye,  about  1.3  cm.  (h  inch) 
below  the  external  angular  process  of  the  frontal — passes  backward  along 
the  upper  border  of  the  zygoma  to  its  posterior  extremity — thence  downward 
just  in  front  of  ear  to  the  angle  of  the  jaw — thence  forward  along  the  horizontal 
ramus  of  the  jaw  to  the  facial  vessels. 

Operation. — (1)  Reflection  of  the  Skin  Flap; — Incise  through  skin  and 
fascia  only,  along  the  above  line.  Raise  this  semicircular  skin  flap  without 
harming  the  facial  nerve  or  Stenson's  duct.  (2)  Exposure  of  the  Pterygoid 
Space; — Incise  down  through  the  periosteum  for  the  entire  length  of  the 
zygoma,  and  detach  the  periosteum.  Drill  (for  later  wiring  of  the  bones) 
two  holes  through  the  zygomatic  process  of  the  malar,  and  two  through  the 
root  of  the  zygoma.  Divide  the  bone  (downward  and  forward)  between  the 
two  anterior  holes — and  also  between  the  two  posterior  holes.  Displace  the 
zygoma  downward  and  backward,  bringing  the  masseter  with  it  (dividing 
the  necessary  muscle-fibers).  The  coronoid  process  is  exposed  and  cut 
obliquely  downward  and  forward,  as  low  as  possible,  then  turned  upward, 
and,  together  with  tendon,  cut  away  (there  being  no  object  in  retaining  it, 
as  it  would  waste  with  the  other  muscles  of  mastication  supplied  by  the 
motor  fibers  of  the  third  division).  (3)  Exposure  of  the  Foramen  Ovale; — 
Expose  the  internal  pterygoid  by  removing  the  overlying  fat  and  connective 
tissue.  The  internal  maxillary  artery,  which  is  generally  found  upon  the 
muscle,  is  divided  between  two  ligatures.  The  inferior  dental  and  lingual 
gustatory  nerves  are  sought  at  the  lower  border  of  the  external  pterygoid, 
cut,  and  their  proximal  ends  tied  with  silk,  to  serve  as  guides.  Expose  the 
foramen  ovale  on  the  under  surface  of  the  great  wing  of  the  sphenoid,  by 
partly  cutting  away  and  partly  retracting  away  (by  scraping)  the  external 
pterygoid — thus  exposing  both  the  great  wing  of  the  sphenoid  and  the  external 
pterygoid  plate.  The  foramen  ovale  is  sought  by  following  up  the  silk  liga- 
ture, drawing  the  nerves  of  the  third  division  taut,  and  also  by  the  finger 
feeling  in  its  known  position,  a  little  behind  and  external  to  the  external 
pterygoid  plate,  remembering  that  just  to  the  inner  side  and  behind  the 
foramen  ovale  lie  the  eustachian  tube  and  the  middle  meningeal  artery  about 
to  enter  the  foramen  ovale.  Bleeding  is  apt  to  be  considerable  here,  espe- 
cially from  the  veins  of  the  pterygoid  plexus  and  from  veins  passing  through 
the  foramen  ovale  between  the  pterygoid  plexus  and  the  cavernous  sinus. 
This  hemorrhage  is  controlled  by  gauze  packing.  (4)  Opening  the  Base 
of  the  Skull; — A  small,  long-handled  trephine  is  placed  just  in  front  and 
to  the  outer  side  of  the  foramen  ovale,  so  that  the  margin  of  the  foramen  is 
included  in  the  disc  of  the  bone  to  be  removed.  (5)  Division  of  Nerve- 
trunks  and  Partial  Removal  of  the  Ganglion; — The  trephine-opening  having 


182       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

been  cleared  and  sufficiently  enlarged  by  chisel  or  forceps,  the  surgeon  follows, 
by  means  of  the  silk  ligature,  the  third  division  up  to  the  ganglion,  which  is 
Loosened  from  its  bed  and  its  second  and  third  divisions  freely  resected — 
the  first  being  left  undisturbed.  (6)  Closure  of  the  Wound;— The  wound 
having  been  irrigated  with  i  :  4000  bichlorid,  dried  and  dusted  with  iodoform, 
the  previously  drilled  zygoma  is  wired,  the  temporal  fascia  sutured  to  the  cut 
margin  of  the  fascia  over  the  zygoma,  and  the  wound  closed  without  drainage. 
The  eyelid  stitches  are  removed  in  three  or  four  days. 

Comment. — (1)  The  operation   may   be  performed  in  two  stages.     (2) 
The  coronoid  process  may  be  drilled  (for  wiring)  before  cutting. 


SURGICAL  ANATOMY  OF  SUPRAORBITAL  BRANCH  OF  FRONTAL 

NERVE. 

Description. — Passes  forward  from  bifurcation  of  frontal  nerve  and 
leaves  orbit  through  supraorbital  notch  (or  foramen) — and,  giving  off  palpebral 
branches,  ascends  vertically  upward  close  to  bone,  beneath  orbicularis  pal- 
pebrarum and  occipitofrontalis  to  forehead,  where  it  divides  into  cutaneous 
and  pericranial  branches.     The  supraorbital  vessels  lie  on  its  outer  side. 


EXPOSURE  OF  SUPRAORBITAL  BRANCH  OF  FRONTAL  AT 
SUPRAORBITAL  FORAMEN. 

Position. — Patient  supine;  head  slightly  elevated.  Surgeon  on  side  of 
operation,  or  above  head. 

Landmarks. — Supraorbital  notch  (or  foramen) — which,  if  not  easily 
felt,  lies  at  junction  of  inner  and  middle  thirds  of  supraorbital  margin. 

Incision. — Transverse,  about  2.5  cm.  (1  inch)  in  length,  along  supra- 
orbital margin,  with  center  over  position  of  supraorbital  notch  (or  foramen) 
— the  evebrow  having  been  previously  shaved. 

Operation. — Having  steadied  the  brow  by  the  first  finger  of  left  hand 
(which  also  draws  up  the  soft  parts  so  as  to  hide  subsequent  scar)  and  de- 
pressed lid  with  left  thumb,  carry  the  above  incision  through  skin,  fascia, 
and  orbicularis  palpebrarum — when  the  nerve  will  be  found  upon  the  peri- 
osteum, accompanied  by  its  vessels.     (Fig.   104). 


SURGICAL  ANATOMY  OF  SUPERIOR  MAXILLARY  BRANCH  OF  TRI- 
FACIAL AND  MECKEL'S  GANGLION. 

Description. — Arises  from  center  of  gasserian  ganglion — runs  forward 
through  foramen  rotund  urn — traverses  upper  part  of  sphenomaxillary  fossa 
— enters  orbit  through  sphenomaxillary  fissure — thence  courses  forward  along 
infraorbital  groove,  accompanied  by  infraorbital  artery,  to  infraorbital  canal 
— along  which  it  passes  to  emerge  upon  face  through  infraorbital  foramen, 
as  the  infraorbital  nerve,  terminating  beneath  levator  labii  superioris  muscle 
in  a  leash  of  branches.  The  distance  of  infraorbital  foramen  from  foramen 
rotundum  is  about  5  cm.  (2  inches). 

Sphenopalatine  or  Meckel's  Ganglion. — Placed  deeply  in  spheno- 
maxillary fossa,  beneath  superior  maxillary  nerve,  near  sphenopalatine 
foramen.     Its   relations   are: — Superiorly,    superior   maxillary   nerve;   Poste- 


EXPOSURE    OF    SURERIOR    MAXILLARY    XERVE. 


I83 


riorly,  sphenoid  bone  and  Vidian  canal;  Externally,  internal  maxillary  artery 
and  external  pterygoid  muscle;  Internally,  vertical  plate  of  palate  and  spheno- 
palatine foramen. 

Comment. — The  posterior  superior  dental  is  given  off  from  the  superior 
maxillary  just  before  the  nerve  enters  the  infraorbital  canal — the  middle 
superior  dental,  at  the  back  part  of  the  canal — and  the  anterior  superior 
dental  just  before  its  exit  upon  the  face.  To  insure,  therefore,  the  removal 
of  the  origin  of  the  posterior  superior  dental  nerve,  the  trunk  has  to  be 
removed  as  far  back  as  Meckel's  ganglion. . 


EXPOSURE  OF  SUPERIOR  MAXILLARY  NERVE  AT  FORAMEN  RO- 
TUNDUM  BY  OSTEOPLASTIC  RESECTION  OF  MALAR  AND  ADJA- 
CENT BONES. 

kocher's  operation. 

Description. — Having  temporarily  raised  a  bony  flap  (composed  of  the 
parts  mentioned  below),  the  infraorbital  nerve  is  liberated  and  traced  back  to 
the  superior  maxillary  nerve  and  Meckel's  ganglion,  at  the  foramen  rotundum 
in  the  sphenomaxillary  fossa. 


Fig.  162. — Skin*  Incisions  for  Exposure  of  Superior  and  Inferior  M\xillary 
Nerves: — A,  Kocher's  incision  for  osteoplastic  exposure  of  superior  maxillary  nerve  at  foramen 
rotundum;  B,  Kocher's  incision  for  osteoplastic  exposure  of  inferior  nerve  at  foramen  ovale. 


Position. — Patient  supine;  head  elevated  and  turned  to  opposite  side. 
Surgeon  on  side  of  operation. 

Landmarks. — Infraorbital  foramen;  infraorbital  margin  of  orbit;  malar 
bone. 

Incision. — Begins  1  cm.  (nearly  h  inch)  internal  to  the  infraorbital 
foramen,  and  \  cm.  (about  \  inch)  below  the  inner  end  of  the  infraorbital 
margin — -and  runs  almost  horizontally  outward,  with  slight  downward  inclina- 
tion, over  the  inferior  aspect  of  the  malar,  to  end  over  the  zygoma  (Fig.   162,  A). 

Operation. — This  incision  exposes  the  angular  artery  at  it-  inner  end, 
enabling  the  vessel  to  be  displaced  further  inward  or  ligated.  Steno's  duct 
lies  below  the  incision.     The  inner  end  of  the  incision  passes  down  to  the  bone 


184      OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

between  the  fibers  of  the  orbicularis  palpebrarum  and  the  levator  labii 
superioris.  The  orbicularis,  together  with  the  periosteum,  is  raised  from  the 
bone  as  far  upward  as  the  orbit.  The  levator  labii  superioris  is  dissected 
subperiosteal! v  down  to  the  infraorbital  foramen,  where  the  infraorbital 
nerve  is  secured  with  a  tenaculum  or  ligature.  The  outer  portion  of  the 
incision  runs  above  the  origins  of  the  zygomatici — these  are  detached  down- 
ward— and  the  anterior  fibers  of  the  masseter  are  separated  from  the  inferior 
and  internal  aspects  of  the  malar.  The  external  and  internal  surfaces  of  the 
malar  are  thus  bared.  The  malar  process  of  the  superior  maxilla  is  bared, 
upon  its  anterior  surface,  up  to  the  infraorbital  foramen — and,  upon  its 
superior  surface,  as  far  posteriorly  as  the  sphenomaxillary  fissure.  Retract 
the  upper  edge  of  the  wound  upward  sufficiently  to  expose  the  frontomalar 
suture,  which  is  so  chiseled  through  toward  the  posterior  part  of  the  spheno- 
maxillary fissure  that  its  superior  border,  the  orbital  process  of  the  malar, 
part  of  the  orbital  plate  of  the  sphenoid,  and  part  of  the  zygomatic  process 
can  be  raised  (Fig.    163).      Anteriorly,  the  bone    is    chiseled  through  from 


Fig.   163. 


-Bone  Sections  in  Kocher's  Osteoplastic  Exposure  of  Superior  Maxillary 
Nerve  at  Foramen  Rotundum. 


above  the  infraorbital  nerve  (in  such  a  manner  that  the  roof  of  the  infraorbital 
canal  is  carried  away)  downward  and  outward,  to  below  the  anterior  border 
of  the  origin  of  the  masseter — and  then  upw7ard  through  the  external  wall  of 
the  antrum  until  it  meets,  posteriorly,  the  section  through  the  orbital  structures. 
Thus  the  external  part  of  the  orbital  plate  and  the  supero-external  wall  of  the 
antrum,  along  with  its  posterior  angle,  remain  connected  with  the  malar  bone, 
when  the  latter  is  levered  out.  Having  raised  the  orbital  fat  with  a  special 
elevator  and  protected  the  globe  of  the  eye,  the  mass  of  bone  is  dislodged 
upward  and  outward  from  the  wound  by  means  of  a  stout  hook  or  periosteal 


EXPOSURE    OF    SUPERIOR    MAXILLARY    NERVE.  185 

elevator.  The  infraorbital  nerve,  which  is  kept  taut  by  the  ligature  attached 
to  it,  is  now  traced  through  the  upper  part  of  the  opened  antrum  to  the  foramen 
rotundum.  A  small,  blunt  hook  is  carried  behind  the  descending  spheno- 
palatine nerves  and  made  to  grasp  the  main  trunk,  which  is  then  divided  or 
wrenched  out.  The  accompanying  infraorbital  artery  is  either  retracted  or 
ligated.  The  malar  bone,  with  its  attached  bony  fragments,  is  now  put  back 
into  its  normal  position — where  it  will  generally  remain  without  sutures, 
although  fixation  sutures  may  be  used  if  desired.  The  soft  parts  are  closed 
without  drainage.  No  harm  is  ordinarily  done  by  opening  the  antrum — 
and  verv  little  disfigurement  results. 


EXPOSURE  OF  SUPERIOR  MAXILLARY  NERVE  AND  MECKEL'S 
GANGLION  BY  THE  ANTRAL  ROUTE. 

CARXOCHAN'S  OPERATION. 

Description. — The  superior  maxillary  nerve  is  removed  from  the  infra- 
orbital foramen  to  the  foramen  rotundum,  together  with  Meckel's  ganglion— 
by  following  the  course  of  the  infraorbital  canal,  and  removing  parts  of  the 
anterior  wall,  roof,  and  posterior  wall  of  the  antrum  of  Highmore. 

Position. — Patient  supine;  head  elevated  and  turned  slightly  to  one  side. 
Surgeon  on  side  of  operation. 

Landmarks. — Infraorbital  foramen  (which  is  about  S  mm. — J  inch — 
below  the  infraorbital  margin,  and  on  a  line  drawn  from  the  supraorbital 
foramen  to  a  point  between  the  two  bicuspids  of  both  jaws). 

Incision. — -V-shaped  (two  sides  of  an  equilateral  triangle,  each  side 
being  about  2.5  cm. — 1  inch — long),  placed  with  its  center  over  the  infraorbital 
foramen  and  its  two  limbs  upward. 

Operation. — (1)  This  incision  is  carried  to  the  bone.  The  flap  is  then 
turned  up  over  the  closed  eye  and  its  apex  stitched  to  the  forehead.  (2) 
The  infraorbital  nerve  is  isolated  at  the  foramen,  cut  as  long  as  possible, 
and  tied  with  silk — to  serve  as  a  guide  and  means  of  traction.  (3)  A  trephine 
of  about  1.3  to  2  cm.  (§  to  f  inch)  in  diameter,  or  a  chisel,  is  now  applied  to 
the  cleared  bone,  and  a  portion  of  bone  removed  including  the  foramen  in  its 
upper  half — and  the  mucous  membrane  of  the  antrum  is  incised.  (4)  The 
upper  portion  of  the  posterior  wall  of  the  antrum  is  similarly  removed  over 
an  area  of  about  6  mm.  (\  inch),  either  by  trephine  or  chisel.  (5)  The  mucous 
membrane  covering  the  roof  of  the  antrum  is  now  divided  in  the  direction 
of  the  infraorbital  canal,  followed  by  breaking  away  the  bony  floor  of  the 
canal,  which  may  be  done  by  chisel  or  stout  scissors,  while  practising  traction 
upon  the  nerve  as  a  guide.  (6)  By  this  means,  and  by  the  use  of  long  slender 
scissors  and  dissecting  forceps,  the  nerve  is  freed  back  across  the  spheno- 
maxillary  fossa   to   the   foramen   rotundum,   until   it   hangs   freely  exposed. 

(7)  Effort  should  be  made  to  recognize  Meckel's  ganglion  at  this  stage,  locating 
it  as  definitely  as  possible.  Considerable  bleeding  may  be  expected  at  this 
period  of  the  operation — hemorrhage  being  controlled  chiefly  by  pressure. 
Artificial  illumination  should  be  used.  The  nerve,  while  slight  traction  is 
being  applied,  should  be  divided  at  the  foramen  rotundum  and  from  its 
sphenopalatine   branches.     The    nerve    and    ganglion    are   then    withdrawn. 

(8)  The  soft  parts  are  now  sutured — and,  if  much  oozing  occur,  temporary 
drainage  is  to  be  provided  for  through  the  lower  angle  of  the  wound,  or  tem- 
porary packing  may  be  necessary,  with  subsequent  suturing  of  the  lower 
part  of  the  wound. 


186      OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

Comment. — (i)  A  T-shaped  incision  may  be  used — the  horizontal 
portion  being  placed  under  the  lower  margin  of  the  orbit,  and  the  vertical 
portion  running  down  on  the  cheek  to  near  the  mouth.  Or  a  r  -shaped 
incision  may  be  used — the  horizontal  portion  along  the  orbit,  and  the  vertical 
portion  in  the  nasolabial  groove.  Probably  the  best  incision  is  a  long  trans- 
verse one  below  the  orbital  margin,  with  strong  retraction.  (2)  When 
Meckel's  ganglion  is  removed,  the  vidian  nerve  is  paralyzed  and  therefore 
the  motor  branches  to  the  palate  muscles. 


EXPOSURE  OF  SUPERIOR  MAXILLARY  NERVE  AND  MECKEL'S 
GANGLION  BY  THE  ORBITAL  ROUTE. 

Description. — After  subperiosteally  displacing  the  contents  of  the  orbit 
from  the  infraorbital  canal  and  removing  the  roof  of  the  canal,  the  nerve 
is  followed  back  to  and  beyond  Meckel's  ganglion  and  cut  at  the  foramen 
rotundum. 

Position. — As  in  the  above  operation. 

Landmarks. — Infraorbital  margin  and  infraorbital  foramen. 

Incision. — Curved  incision  along  lower  margin  of  orbit  over  infraorbital 
foramen — extending  from  near  internal  angular  process  to  external  angular 
process  of  frontal. 

Operation. — Carry  the  incision  to  the  bone  throughout.  Isolate  the 
nerve — cut  as  long  as  possible — and  attach  a  stout  piece  of  silk  to  the  proximal 
end  as  a  guide  and  means  of  traction.  The  bone  between  the  infraorbital 
foramen  and  infraorbital  margin  is  removed  by  trephine  or  chisel,  exposing 
the  anterior  portion  of  the  infraorbital  canal.  The  periosteum  of  the  floor 
of  the  orbit  is  raised  along  the  orbital  margin  with  a  periosteal  elevator — 
a  spatula  or  retractor  is  placed  beneath  this  and  the  tissues  of  the  orbit  are 
held  out  of  the  way.  The  roof  of  the  canal  is  next  broken  down  with  a  fine 
chisel,  or  other  instrument — bleeding  being  controlled  by  pressure— and  the 
nerve  lifted  out  of  its  bed  by  traction  on  the  ligature — and  is  then  traced 
back  with  delicate  instruments  to  the  foramen  rotundum  and  removed, 
together  with  Meckel's  ganglion  and  its  terminal  filaments.  The  orbital 
contents  are  then  allowed  to  fall  back  into  place  and  the  skin  incision  sutured. 

Comment. — It  is  exceedingly  difficult,  and  probably  impossible,  actually 
to  leach  the  ganglion  by  this  method,  especially  without  wounding  the  eye- 
structures.  It  is  also  difficult  to  make  the  section  far  enough  back  to  include 
all  the  dental  nerves. 


EXPOSURE  OF  SUPERIOR  MAXILLARY  NERVE  AND  MECKEL'S 
GANGLION  BY  THE  PTERYGOMAXILLARY  ROUTE. 

BRAUN-LOESSEN  OPERATION. 

Description. — The  nerve  and  ganglion  are  reached  in  the  pterygo- 
maxillary  fossa  by  temporarily  resecting  the  zygoma,  turning  it  and  the 
masseter  muscle  downward,  firmly  retracting  the  temporal  muscle  backward, 
and  following  the  posterior  surface  of  the  superior  maxillary  bone  into  the 
pterygomaxillary  fossa. 

Position. — Patient  supine;  head  on  one  side  and  elevated;  surgeon  to 
right  for  both  sides. 


EXPOSURE    OF    SUPERIOR    MAXILLARY    NERVE.  187 

Landmarks. — External  angular  process  of  frontal;  zygoma;  posterior 
border  of  ascending  ramus  of  lower  jaw. 

Incision. — Begins  at  external  angular  process  of  frontal,  passes  downward 
and  backward  along  upper  border  of  zygoma  to  tragus  of  ear,  thence  down- 
ward in  front  of  ear  along  posterior  margin  of  inferior  maxilla  to  angle  of 
lower  jaw. 

Operation. — (1)  This  incision  (the  region  having  been  shaved)  passes 
only  through  skin  and  superficial  fascia — and  the  flap  of  integumentary 
tissues  thus  raised  by  dissection  is  turned  forward  and  temporarily  attached 
to  the  nose  by  suture.  (2)  An  incision  is  made  along  the  zygoma,  passing 
to  the  bone,  which  is  then  exposed  subperiosteally.  Two  holes  are  drilled 
(for  wiring  the  bone  later)  through  the  malar  bone  on  a  line  with  a  continua- 
tion of  the  upper  part  of  its  posterior  border,  and  two  through  the  zygoma 
near  its  root.  The  zygomatic  arch  is  then  sawed  through  between  the  two 
anterior  drill-holes  and  between  the  two  posterior  drill-holes,  directing  the 
saw  from  without  inward  at  the  two  ends  (forming  a  beveled  shelf  for  the 
arch  to  rest  upon  when  replaced).  The  temporal  fascia  has  been  freed 
along  its  upper  border  in  exposing  the  arch — and  now  the  entire  arch  is 
turned  down,  with  its  attached  masseter,  cutting  whatever  fibers  of  that 
muscle  are  still  holding  the  arch  in  place.  (3)  At  this  stage  the  mouth  is 
opened  with  a  gag  and  the  lower  jaw  depressed,  to  carry  downward  and 
backward  the  coronoid  process,  with  its  temporal  attachment — at  the  same 
time  drawing  backward  with  retractors  the  temporal  muscle  and  tendon 
from  the  anterior  portion  of  the  temporal  fossa.  If  this  do  not  give  sufficient 
exposure,  the  anterior  part  of  the  muscle  and  tendon  is  divided  transversely. 
(4)  The  pterygomaxillary  fissure  is  thereby  exposed — and  the  internal  maxil- 
lary artery  and  vein  are  seen  entering  and  leaving  the  pterygomaxillary 
fossa  through  this  fissure  and  are  both  ligated.  The  superior  maxillary 
nerve  is  found  leaving  the  foramen  rotundum  and  is  brought  forward  by 
means  of  a  nerve-hook.  The  nerve  and  Meckel's  ganglion  can  be  more 
thoroughly  exposed,  at  this  stage  of  the  operation,  by  chiseling  away  the 
spur  of  bone  at  the  base  of  the  external  pterygoid  plate,  projecting  outward 
and  forward  across  the  pterygomaxillary  fissure  and  partially  blocking  the 
entrance  to  the  pterygomaxillary  fossa — and  then  both  nerve  and  ganglion 
can  be  hooked  forward.  (5)  In  concluding  the  operation,  the  temporarily 
removed  zygomatic  arch  is  wired  at  both  ends  where  previously  drilled.  If 
the  temporal  muscle  have  been  partly  severed,  this  is  sutured.  The  temporal 
fascia  is  sutured  to  the  cut  margin  of  fascia  over  the  zygoma.  The  skin 
incision  is  closed  as  usual. 

Comment. — (i)  If  the  infraorbital  nerve  be  exposed  at  its  emergence 
upon  the  face  from  the  infraorbital  foramen  and  be  severed,  then  by  traction 
upon  the  nerve  hooked  up  in  the  sphenomaxillary  fossa  the  entire  length 
of  the  infraorbital  nerve  may  be  drawn  out  of  the  canal  backward  and  all  its 
dental  branches  torn  across  in  their  bony  canals.  (2)  This  operation  is 
similar,  in  principle,  to  Rose's  method  of  exposing  the  gasserian  ganglion— 
and  the  chief  indication  for  its  use  is  where  it  is  found  desirable  to  expose 
the  inferior  maxillary  at  the  foramen  ovale,  as  well  as  the  superior  maxillary, 
with  Meckel's  ganglion,  at  the  foramen  rotundum.  To  expose  the  superior 
maxillary  and  Meckel's  ganglion  alone,  the  antral  or  the  orbital  route  would 
be  preferable; — and  to  expose  all  three  roots,  or  the  second  and  third,  the 
Hartley-Krause  or  the  Rose  operation,  especially  the  former,  would  be  better. 


1 88       OPERATIONS    UPON   THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

EXPOSURE  OF  INFRAORBITAL  NERVE  AT  INFRAORBITAL 

FORAMEN. 

Position. — Patient's  head  slightly  elevated.     Surgeon  to  side  of  operation. 

Landmarks. —Infraorbital  foramen — which,  if  not  palpable,  lies  about  8 
mm.  (J  inch)  below  infraorbital  margin,  and  on  line  from  supraorbital  foramen 
to  a  point  between  the  two  bicuspids  in  both  jaws. 

Incision. — About  2  cm.  (f  inch)  in  length,  over  the  infraorbital  foramen, 
parallel  with  the  margin  of  the  orbit. 

Operation. — Skin,  fat,  and  orbicularis  palpebrarum  are  incised.  The 
levator  labii  superioris  is  exposed  and  also  incised.  The  nerve  is  found  at 
its  emergence  from  the  foramen.     (Fig.   106). 

Comment. — The  infraorbital  nerve  may  be  exposed  through  the  mouth, 
without  scarring.  Having  made  the  gingivolabial  fold  tense,  an  incision  is 
made  through  the  mucous  membrane  and  periosteum  along  the  line  of  reflec- 
tion from  the  upper  lip  to  the  superior  maxilla.  The  soft  parts  are  then 
dissected  away  from  the  bone  along  the  canine  fossa,  subperiosteally,  and 
firmly  retracted  upward — until  the  infraorbital  foramen  is  reached. 

Note. — For  the  Anatomy  of  the  Infraorbital,  see  the  Superior  Maxillary 
nerve. 

SURGICAL  ANATOMY  OF  INFERIOR  MAXILLARY  BRANCH  OF  TRI- 
FACIAL AND  THE  OTIC  AND  SUBMAXILLARY  GANGLIA. 

Description  of  Inferior  Maxillary. — Formed  of  two  roots — a  large 
sensory  root  from  the  inferior  angle  of  gasserian  ganglion — and  a  small 
motor  root  which  passes  under  the  ganglion  and  unites  with  the  sensory  root 
just  after  it  has  passed  through  the  foramen  ovale — both  roots  passing  through 
the  foramen  separately.  The  nerve  divides  into  anterior  and  posterior  divi- 
sions 3  to  4  mm.  Q  inch,  about)  beneath  the  base  of  skull  and  under  cover 
of  the  external  pterygoid — the  former  receiving  the  greater  part  of  the  motor 
root  and  the  latter  the  greater  part  of  the  sensory  root. 

Ganglia. — (1)  Otic  (Arnold's)  Ganglion; — situated  immediately  beneath 
foramen  ovale,  having  inferior  maxillary  nerve  on  its  outer  side,  the  eustachian 
tube  on  its  inner  side,  and  the  middle  meningeal  artery  on  its  posterior  side. 
(2)  Submaxillary  Ganglion; — placed  between  mylohyoid  and  hyoglossus 
muscles,  above  deep  portion  of  submaxillary  gland,  and  at  outer  side  of 
Wharton's  duct. 

Note. — Foramen  ovale  lies  on  a  line  connecting  the  eminentia  articularis, 
at  root  of  zygoma,  of  one  side,  with  that  of  the  other,  and  about  3  cm.  (if 
inches)  from  the  eminentia — and  is  directly  posterior  and  a  little  external 
to  the  external  pterygoid  plate.  The  middle  meningeal  artery  enters  the 
foramen  spinosum  just  behind  the  foramen  ovale.  (3)  The  internal  maxillary 
artery,  in  its  second  part,  runs  forward  and  upward  on  outer  surface  of  external 
pterygoid  muscle.  (4)  The  pterygoid  plexus  of  veins  lies  on  the  external 
pterygoid  muscle. 

EXPOSURE  OF  INFERIOR  MAXILLARY  NERVE  AT  FORAMEN  OVALE 
BY   OSTEOPLASTIC  RESECTION  OF    MALOZYGOMATIC  ARCH. 

kocher's   operation. 

Description.— Having  temporarily  resected  the  malozygomatic  arch, 
the  pterygomaxillary  fossa  is  exposed,  and  the  third  division  of  the  fifth  nerve 
traced  to  its  exit  from  the  foramen  ovale. 


EXPOSURE    OF    INFERIOR    MAXILLARY    NERVE. 


189 


Position. — Patient  supine;  head  elevated  and  turned  to  opposite  side. 
Surgeon  on  side  of  operation. 

Landmarks. — Frontal  process  of  malar;  posterior  extremity  of  zygoma; 
pinna  of  ear. 

Incision. — Begins  just  posterior  to  the  frontal  process  of  the  malar — 
passes  thence  obliquely  downward  and  backward  to  the  posterior  end  of  the 
zygoma — and  is  carried  thence  upward  and  backward,  in  front  of  the  ear, 
at  right  angles  to  the  first  portion  of  the  incision  (Fig.   162,  B). 

Operation. — The  first  part  of  this  incision  is  superficial — the  latter 
portion,  passing  upward  in  front  of  the  ear,  is  carried  down  to  the  bone, 
and  the  temporal  vessels  ligated.  More  anteriorly  the  incision  divides  the 
skin,  superficial  fascia,  dense  temporal  fascia,  and  some  fibers  of  the  orbicularis 
palpebrarum — all  of  which  are  displaced  downward,  together  with  branches 
of  the  facial  nerve  going  to  the  orbicularis  and  frontal  muscles.  The  malar 
bone  is  exposed  just  behind  its  frontal  process  and  divided  vertically  with  a 


Fig.  164. — Bone  Sections  for  Kocher's  Osteoplastic  Exposure  of  Inferior  Maxillary 
Nerve  at  Foramen  Ovale,  at  Malar  and  Zygoma. 


saw  (Fig.  164).  The  zygoma  is  similarly  divided  transversely  near  its 
posterior  root.  The  malozygomatic  arch  is  then  displaced  downward  with  a 
strong  hook.  The  external  aspect  of  the  temporal  muscle  is  thus  exposed — 
and  its  posterior  and  inferior  borders  are  separated  from  the  skull  and  retracted 
firmly  forward.  If  necessary  to  afford  freer  access — which  is  rarely  the 
case — the  temporal  insertion  into  the  coronoid  may  be  divided,  or  the  coronoid 
itself  be  removed.  Forward  retraction  of  the  temporal,  however,  is  usually 
sufficient — together  with  the  forward  displacement,  by  retraction,  of  the 
structures  of  the  retromaxillary  fossa.  All  the  soft  parts,  together  with  the 
periosteum,  are  thus  liberated  and  retracted  forward  and  inward — thereby 
exposing  the  external  aspect  of  the  pterygoid  process — just  posterior  to  the 
sharp  edge  of  which  the  foramen  is  readily  palpable,  lying  about  3  cm.  (ij 
inches)  internal  to  the  zygomatic  process.  The  middle  meningeal  artery, 
entering  the  foramen  spinosum,  lies  just  behind.  The  branches  of  the  max- 
illary lie  in  the  parts  already  retracted  downward.  The  sometimes  severe 
hemorrhage  can  be  controlled  by  packing  temporarily.     The  inferior  maxillary 


190      OPERATIONS    UPON   THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

nerve  is  seized  near  its  exit  with  a  small,  blunt  hook  and  drawn  forward — and 
is  then  grasped  with  forceps  and  removed  entire.  If  the  hemorrhage  have 
ceased,  and  it  is  certain  all  the  nerve  has  been  removed,  the  malozygomatic 
arch  is  replaced  and  sutured  into  position  and  the  wound  closed  throughout. 
If,  on  the  other  hand,  hemorrhage  persist,  and  there  is  uncertainty  as  to  the 
nerve,  the  wound  is  packed  for  a  time — and  reopened  in  one  or  two  days — 
and  then  secondarily  sutured.  The  scar  following  the  operation  is  not  promi- 
nent. 


EXPOSURE  OF  INFERIOR  MAXILLARY  NERVE   AT  FORAMEN  OVALE 
—OR  OF  SUPERIOR  MAXILLARY  NERVE  AT  FORAMEN  ROTUNDUM. 

MIXTER'S  OPERATION. 

Description. — Mixter's  operation  consists  in  a  temporary  excision  and 
downward  displacement  of  the  zygomatic  arch,  with  the  attached  masseter 
— followed  bv  a  backward  displacement  of  the  temporal  muscle,  to  reach 
the  superior  maxillary  nerve  and  foramen  rotundum — and  a  forward  dis- 
placement of  the  muscle  to  reach  the  inferior  maxillary  and  foramen  ovale. 
The  inferior  maxillary  nerve  may  be  exposed  at  its  origin  by  any  of  the  opera- 
tions exposing  the  gasserian  ganglion,  either  intracranially  or  extracranially. 

Position. — Patient  on  back;  head  elevated  and  turned  to  one  side.  Surgeon 
on  side  of  operation,  or  to  right  for  both  operations. 

Landmarks. — Zygoma;  temporal  ridge. 

Incision. — Curved,  with  convexity  upward — beginning  about  1.3  cm. 
{\  inch)  below  malar  portion  of  zygomatic  arch  and  passing  upward  along 
posterior  margin  of  malar  bone  and  external  angular  process  of  frontal  bone, 
to  commencement  of  temporal  ridge — thence  follows  lower  temporal  ridge 
to  opposite  anterior  margin  of  ear — and  then  curves  downward  to  pass  in 
front  of  ear  and  ends  about  1.3  cm.  (J  inch)  below  root  of  zygoma. 

Operation. — The  above  incision  is  made  through  the  shaved  skin  and 
through  the  fascia — and  this  flap  is  turned  downward,  guarding  Steno's  duct. 
The  temporal  artery  is  ligated,  unless  it  can  be  displaced  backward.  The 
zygomatic  arch  is  exposed  subperiosteal!}-  and  sawed  through  in  front  and 
behind,  beveling  from  without  inward — and  guarding  against  opening  the 
inferior  maxillary  articulation  behind.  The  zygoma,  attached  masseter,  and 
fatty  connective  tissue  are  now  well  retracted  downward.  The  temporal 
muscle  and  its  attachment  to  the  coronoid  process  become  thereby  well  exposed 
— and  are  manipulated  in  accordance  with  the  structure  sought: — (a)  To 
Expose  the  Superior  Maxillary  Nerve  and  the  Foramen  Rotundum: — The 
temporal  muscle  and  tendon  are  firmly  retracted  posteriorly,  by  a  broad, 
smooth  retractor,  aided  by  an  assistant's  depressing  the  jaw — the  surgeon 
being  guided  by  the  posterior  wall  of  the  superior  maxillary  bone  and  the 
spur  of  bone  projecting  forward  and  outward  from  the  base  of  the  external 
pterygoid  plate.  This  spur  is  chiseled  away  to  better  expose  the  foramen 
rotundum,  if  necessary — the  chiseling  being  done  in  a  forward  and  slightly 
inward  direction,  to  avoid  going  into  the  middle  fossa  of  the  skull.  Having 
removed  this  spur,  the  superior  maxillary  nerve  is  to  be  found  crossing  the 
pterygomaxillary  fossa  from  the  foramen  rotundum  to  the  infraorbital  foramen, 
with  Meckel's  ganglion  beneath  it,  and  near  the  sphenopalatine  foramen, 
(b)  To  Expose  the  Inferior  Maxillary  Nerve  and  Foramen  Ovale: — The 
temporal  muscle  and  tendon  are  now  firmly  retracted  forward  (the  jaw 
being  now  closed  to  carry  the  coronoid  process  forward) — the  surgeon  being 


EXPOSURE  OF  INFERIOR  DENTAL  NERVE  IN  MOUTH.      191 

guided  to  the  foramen  ovale  by  its  position  just  posterior  and  external  to  the 
base  of  the  external  pterygoid  plate,  at  a  distance  of  about  3  cm.  (1^  inches) 
internal  to  the  anterior  margin  of  the  posterior  attachment  of  the  zygoma 
and  slightly  posterior  to  this  line  drawn  directly  inward.  On  the  way  inward 
the  internal  maxillary  artery  is  met  on  the  external  pterygoid  muscle  and 
ligated.  The  pterygoid  plexus  of  veins  also  lies  upon  this  muscle.  The 
external  and  internal  pterygoid  muscles  can  generally  be  displaced  by  retrac- 
tion without  necessitating  their  incision.  The  foramen  ovale  is  usually 
recognized  by  the  tip  of  the  finger  and  the  nerve  is  exposed  emerging  from 
it  and  drawn  forward  by  a  hook.  Free  hemorrhage  may  necessitate  packing 
one  part  of  the  wound  while  working  in  another.  In  concluding  the  operation 
for  exposure  of  either  structure,  the  zygoma  is  replaced  and  the  flap  turned 
back  into  position. 

Comment. — (I)  If  the  zygoma  be  drilled  anteriorly  and  posteriorly 
and  then  sawed  between  each  pair  of  drill-holes,  it  may  be  subsequently 
wired.  (2)  If  sufficient  room  cannot  be  gotten  by  retraction  of  the  temporal 
muscle  and  tendon,  it  may  be  divided  in  part,  transversely — the  anterior 
portion  being  cut  to  reach  the  foramen  rotundum — and  the  posterior  portion 
in  order  to  reach  the  foramen  ovale.  The  muscle  should  be  sutured  on 
completing  the  operation.  (3)  The  coronoid  process  could  be  drilled,  sawed 
between  the  drill-holes,  and  the  coronoid  tip  and  temporal  attachment  turned 
upward — to  be  afterward  sutured  back  in  place.  (4)  As  much  of  the  pterygoid 
muscles  (especially  the  external)  may  be  divided,  or  drawn  away  from  its 
origin  at  the  sphenoid,  as  needed.  But  the  less  the  detachment  of  the  tem- 
poral and  pterygoid  muscles,  the  less  the  involvement  of  the  jaw  articulation 
subsequently — except  that  caused  by  paralytic  atrophy  if  the  motor  part  of 
the  third  division  be  cut.  (5)  The  motor  part  of  the  inferior  maxillary  is 
to  be  avoided  if  possible — but  is  generally  unavoidably  included  in  the  destruc- 
tion of  the  sensory  portion. 

SURGICAL  ANATOMY  OF  INFERIOR  DENTAL  NERVE. 

Description  and  Relations. — A  sensory  nerve — a  branch  of  inferior 
maxillary  nerve,  passing  down  under  cover  of  external  pterygoid  muscle,  it 
descends  to  outer  side  of  internal  pterygoid,  to  interval  between  ramus  of 
inferior  maxilla  and  internal  lateral  ligament,  to  dental  foramen — accom- 
panied by  inferior  dental  artery  and  having  lingual  nerve  in  front  and  internal 
to  it.  The  mylohyoid  branch  is  given  off  just  before  the  nerve  enters  the 
dental  canal,  and  the  mental  branch  at  its  exit  at  the  mental  foramen.  The 
dental  foramen  is  surrounded  by  the  lingula  of  Spix,  to  which  is  attached 
the  internal  lateral  ligament,  the  groove  for  the  mylohyoid  nerve  being  just 
behind  it  and  the  attachment  of  the  internal  pterygoid  muscle  reaching  to 
its  base.  The  inferior  dental  vessels  pass  along  behind  and  outside  the 
nerve.     The  internal  maxillary  artery  passes  safely  above  the  dental  foramen. 


EXPOSURE  OF  INFERIOR  DENTAL  NERVE  IN  MOUTH 

PARAVICINI'S  INTRABUCCAL  METHOD. 

Position. — Patient  supine;  head  slightly  raised;  gag  in  opposite  side  of 
mouth;  cheek  of  operated  side  held  open  by  retractors  and  commissure  of 
mouth  drawn  backward.  Surgeon  faces  patient  and  stands  on  his  right  for 
both  operations.     A  head-mirror  should  be  used. 


192       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

Landmarks. — Ascending  ramus  of  jaw;  spine  of  Spix;  internal  pterygoid 
muscle. 

Incision. — About  2.5  cm.  (1  inch)  in  length — along  anterior  border  of 
ascending  ramus  of  inferior  maxilla,  about  7  mm.  (^  inch)  to  inner  side 
of  sharp  anterior  border  of  coronoid  process,  and  ending  over  the  spine  of 
Spix. 

Operation. — Having  incised  and  detached  the  mucous  membrane  and 
periosteum,  feel  for  the  spine  of  Spix — cutting  the  internal  lateral  ligament 
with  scissors  if  necessary  in  order  to  expose  the  nerve  entering  the  foramen — 
which  is  then  isolated  and  drawn  forward.  The  inferior  dental  artery  lies 
in  close  contact  and  should  be  avoided.  In  completing  the  operation,  it  is 
better  to  close  the  incision  with  sutures — though  these  are  often  omitted. 

Comment. — Expose  the  dental  foramen  that  the  lingual  may  not  be 
taken  for  the  inferior  dental  nerve.  If  possible,  avoid  injuring  the  internal 
lateral  ligament,  which  is  attached  to  the  spine  of  Spix. 

EXPOSURE   OF    INFERIOR   DENTAL    THROUGH   ASCENDING    RAMUS 
OF  INFERIOR  MAXILLA. 

Description. — The  outer  aspect  of  the  lower  jaw  is  exposed  and  the 
nerve  reached  by  trephining  the  bone. 

Position. — Patient's  head  turned  to  one  side  and  slightly  elevated. 
Surgeon  on  side  of  operation. 

Landmarks. — The  four  borders  of  the  ascending  ramus  of  the  inferior 
maxilla. 

Incision. — Curved,  circumscribing  the  angle  and  lower  half  of  ascending 
ramus  of  lower  jaw — the  transverse  curve  being  just  above  the  lower  margin 
— and  the  vertical  limbs  corresponding  with  the  anterior  and  posterior  borders. 
Thus  Stenson's  duct  escapes  and  but  few  branches  of  the  facial  nerve  are 
injured. 

Operation. — This  incision  is  first  carried  through  skin  and  superficial 
fascia,  when  whatever  nerves  are  in  line  of  incision  are  retracted  (especially 
the  buccal  and  supramaxillary) — then  through  masseter  and  periosteum  to 
bone.  The  soft  parts  are  now  freed  from  bone  subperiosteally  and  retracted 
strongly  upward,  gaining  room  by  this  upward  retraction  without  harm  to 
the  facial  nerve  or  Stenson's  duct.  A  window  of  bone,  having  its  center 
corresponding  with  this  quadrilateral  surface  of  bone,  is  then  removed  with 
the  trephine  or  chisel  (a  disc  about  1.3  to  2  cm. — h  to  f  inch — in  diameter), 
remembering  that  the  lower  and  anterior  part  of  the  ascending  ramus  is 
much  thicker  than  the  upper  and  posterior.  Approach  the  nerve  and  accom- 
panying artery  with  care,  elevating,  rather  than  chiseling  or  trephining,  the 
last  thickness  of  bone.     The  nerve  is  then  isolated  in  its  canal. 

Comment. — (1)  The  nerve  can  be  reached  at  its  entrance  into  the  dental 
canal  and  traced  up  to  the  foramen  ovale  by  an  extension  of  this  operation, 
by  widening  the  sigmoid  notch.  The  incision  passes  through  skin  and 
superficial  fascia  only — beginning  at  the  middle  of  the  zygoma,  passing 
backward  and  downward  in  front  of  the  tragus  to  the  angle  of  the  jaw,  and 
thence  forward  to  a  point  just  posterior  to  the  facial  artery.  Raise  this  flap 
of  skin  and  superficial  fascia  as  far  as  the  anterior  border  of  the  masseter 
and  turn  it  forward.  Expose  Stenson's  duct  and  edge  of  the  parotid  gland 
(sufficiently  to  guard  them).  Divide  the  masseter  and  overlying  deep  fascia 
down  to  the  bone  in  a  transverse  direction,  and  between  Stenson's  duct  above 
and  the  highest  branch  of  the  facial  nerve  below.     Free  the  muscle  from 


SURGICAL    ANATOMY    OF    LINGUAL    NERVE.  193 

the  bone  at  the  sigmoid  notch  and  just  below.  Apply  the  trephine  so  as 
to  leave  a  slight  bridge  of  bone  between  the  sigmoid  notch  and  the  trephine- 
opening — and  subsequently  cut  this  bridge  away  with  bone-forceps.  Expose 
the  inferior  dental  nerve  and  artery — ligate  the  artery  and  also  the  internal 
maxillary  artery  (upon  the  external  pterygoid  muscle)  if  necessary.  Secure 
the  nerve  with  silk  ligature,  and,  by  traction  on  silk,  follow  the  nerve  to  the 
foramen  ovale,  retracting  the  external  pterygoid  upward  (or  divide  it).  Sever 
the  nerve  as  high  and  as  low  as  possible.  The  lingual  nerve,  lying  further 
forward  and  inward,  may  be  also  reached  at  the  same  time.  (2)  The  entrance 
to  the  inferior  dental  canal  may  also  be  reached  from  the  inner  aspect  of  the 
inferior  maxilla — by  making  an  incision  around  the  angle  of  the  jaw,  corre- 
sponding with  the  insertion  of  the  masseter,  and  raising  the  soft  parts  from 
the  inner  surface  of  the  bones  subperiosteally  to  the  dental  foramen — the 
mouth  cavity  not  being  opened  (Liicke-Sonnenburg  operation).  (3)  The 
operation  of  exposing  the  inferior  dental  nerve  through  the  mouth  is  to  be 
preferred,  as  being  less  disfiguring — although  probably  more  difficult. 


EXPOSURE   OF   INFERIOR   DENTAL  NERVE   AT  MENTAL   FORAMEN, 
FROM  WITHIN  MOUTH. 

Description. — The  lower  lip  is  everted  and  an  incision  made  over  the 
site  of  the  mental  foramen. 

Position. — Patient  supine;  head  supported  and  to  one  side.  Surgeon 
on  side  of  operation,  or  on  right  for  both  operations.  Assistant  draws  lower 
lip  well  downward. 

Landmarks. — A  line  drawn  over  the  supraorbital  foramen  and  between 
the  two  bicuspids  of  both  jaws  will  cross  the  infraorbital  and  mental  foramina 
— the  mental  foramen,  in  the  adult,  generally  lying  midway  between  the  upper 
and  lower  borders  of  the  jaw  proper  (exclusive  of  teeth). 

Incision. — Transverse,  through  mucous  membrane  along  line  of  its 
reflection  from  lower  lip  to  inferior  maxilla,  with  its  center  between  the  two 
bicuspids,  the  lower  lip  being  firmly  drawn  downward.  A  vertical  incision 
may  be  made  instead  of  the  transverse. 

Operation. — This  incision  passes  through  periosteum  to  bone,  upon 
slight  downward  freeing  of  which  the  nerve  is  found  emerging  from  the 
mental  foramen. 

Comment. — An  incision  could  be  made  from  without,  through  the 
tissues  of  the  chin,  over  the  position  of  the  foramen,  in  the  direction  of  the 
fibers  of  the  facial  nerve,  if  the  matter  of  scarring  be  not  taken  into  account. 


SURGICAL  ANATOMY  OF  LINGUAL  (GUSTATORY)  NERVE. 

Description  and  Relations. — A  nerve  of  common  sensation — branch 
of  posterior  division  of  inferior  maxillary  nerve.  Descends  under  external 
pterygoid,  to  inner  side  and  anterior  to  dental  nerve,  a  cord  generally  con- 
necting the  two,  and  being  joined  near  origin  by  chorda  tympani.  The 
nerve  then  passes  between  internal  pterygoid  muscle  and  ramus  of  lower 
jaw — inclining  inward  to  side  of  tongue,  and,  passing  over  attachment  of 
superior  constrictor  of  pharynx  to  the  lower  jaw  and  the  styloglossus  muscle, 
above  the  deep  part  of  submaxillary  gland,  is  continued  forward  between 
mucous  membrane  of  mouth  and  mvlohvoid  muscle  and  lies  on  its  origin 
13 


194       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

close  to  bone — then  runs  between  mylohyoid  and  hyoglossus — crosses  below 
Wharton's  duct,  and  passes  along  side  of  tongue,  under  mucous  membrane, 
to  apex. 

Comment. — On  widely  opening  the  mouth,  one  can  feel  the  pterygo- 
maxillarv  ligament,  as  a  prominent  ridge  behind  the  last  molar.  The  nerve 
is  generally  to  be  felt  behind  the  ptervgomaxillary  ligament,  about  1.3  cm. 
(\  inch)  posterior  and  inferior  to  the  last  molar,  lying  just  beneath  the  mucous 
membrane. 


EXPOSURE  OF  LINGUAL  (GUSTATORY)  NERVE  IN  THE  MOUTH. 

Position. — Patient  on  back;  head  slightly  raised;  gag  in  opposite  side 
of  mouth;  cheek  of  operated  side  held  open  by  retractors;  tongue  of  patient 
drawn  out  and  to  opposite  side  by  assistant.  Surgeon  stands  on  patient's 
right  for  both  operations,  and  uses  a  head-mirror. 

Landmarks. — Ramus  of  jaw;  pterygomaxillary  ligament;  last  molar 
tooth. 

Incision. — Vertical,  about  2.5  cm.  (1  inch)  in  length,  placed  in  fold  of 
mucous  membrane  midway  between  tongue  and  gum,  with  center  on  level 
with  last  molar.  The  nerve  lies  about  at  the  junction  of  the  upper  and 
middle  thirds  of  a  line  from  the  crown  of  the  last  molar  to  the  angle  of  the 
jaw. 

Operation. — Having  incised  in  the  above  line,  the  nerve  is  found  just 
beneath  the  mucous  membrane,  prior  to  dipping  under  the  mylohyoid  muscle 
— and  is  isolated  and  drawn  forward  by  a  hook. 

Comment. — The  lingual  nerve  may  be  reached  from  outside  the  mouth 
by  excising  a  part  of  the  inferior  maxilla,  at  the  junction  of  the  alveolar  process 
and  the  ascending  ramus  (Loebker).  Or  it  may  be  reached  by  dissecting 
up  under  the  internal  surface  of  the  inferior  maxilla,  displacing  the  sub- 
maxillary gland,  dividing  the  posterior  portion  of  the  mylohyoid  and  finding 
the  nerve  under  the  posterior  portion  of  the  sublingual  gland  (Luschka). 


SURGICAL  ANATOMY  OF  FACIAL  NERVE. 

Description. — Arises,  superficially,  at  upper  end  of  medulla  oblongata, 
in  groove  between  olivary  and  restiform  bodies — passes,  in  company  with 
auditory  nerve-,  forward  and  outward  to  internal  auditory  meatus,  which  it 
enters  with  auditory  nerve,  the  pars  intermedia  intervening  between  the 
nerves.  At  the  bottom  of  meatus,  the  facial  nerve  enters  aqueductus  Fallopii, 
which  it  follows  to  its  emergence  at  the  stylomastoid  foramen — thence  passes 
downward  and  forward  through  substance  of  parotid  gland — crosses  external 
carotid  artery  and  divides  behind  ramus  of  inferior  maxilla,  opposite  upper 
margin  of  digastric  muscle,  into  two  chief  branches: — (1)  Temporofacial, 
running  upward  and  forward  through  parotid  gland,  crossing  external  carotid 
artery  and  temporomaxillary  vein  and  passing  over  neck  of  condyle  of  jaw, 
and  dividing  into  temporal,  malar,  and  infraorbital  branches, — and  (2) 
Cervicofacial,  running  downward  and  forward,  through  parotid  gland, 
crossing  external  carotid  artery,  and  dividing,  opposite  angle  of  jaw,  into 
buccal,  supramaxillary,  and  inframaxillary  branches. 


EXPOSURE    OF    SPINAL    ACCESSORY    NERVE.  1 95 

EXPOSURE  OF  FACIAL  NERVE  IN  FRONT  OF  MASTOID  PROCESS. 

BAUM'S   OPERATION'. 

Position. — Patient  supine;  head  elevated  and  to  one  side.  Surgeon  to 
right  for  both  operations. 

Landmarks. — Anterior  border  of  mastoid  process;  posterior  border  of 
ascending  ramus  of  inferior  maxilla.  The  point  at  which  the  nerve  is  sought 
being  from  6  mm.  to  1.3  cm.  (J  to  \  inch)  in  front  of  center  of  anterior  border 
of  mastoid  process. 

Incision. — Begins  close  behind  pinna  of  ear,  opposite  meatus — passes 
downward  to  opposite  lobule  of  ear,  and  then  downward  and  forward  almost 
to  angle  of  inferior  maxilla. 

Operation. — This  incision  is  deepened  through  skin  and  fascia,  with 
care.  The  parotid  fascia  is  incised  and  the  parotid  gland  is  retracted  forward. 
The  anterior  edge  of  the  sternomastoid  is  exposed  and  drawn  backward. 
The  posterior  belly  of  the  digastric  is  exposed  and  the  nerve  is  sought  on  a 
line  with  the  upper  border  of  the  posterior  belly  of  this  muscle  and  at  the 
point  above  mentioned — coming  from  the  stylomastoid  foramen  toward  the 
surface.  The  posterior  auricular  artery  and  vein  will  probably  need  ligating, 
and  some  fibers  of  the  great  auricular  nerve  will  be  cut.  The  internal  jugular 
vein  is  near  the  deep  part  of  the  wound,  but  there  are  no  other  important  vessels 
anterior  to  the  plane  of  the  digastric  (behind  which  is  the  external  carotid). 
If  necessary,  especially  in  stout  subjects,  a  small  transverse  incision,  passing 
forward  from  below  the  pinna,  may  be  added. 


SURGICAL  ANATOMY  OF  SPINAL  ACCESSORY  NERVE. 

Description  and  Relations. — (i)  Accessory  portion  passes  outward  to 
jugular  foramen,  where  it  unites  with  spinal  portion,  and  is  joined  to  upper 
ganglion  of  the  vagus  and  sends  fibers  into  its  pharyngeal  and  superior  laryn- 
geal branches  and  into  the  trunk  of  that  nerve  below  the  ganglion.  (2) 
Spinal  portion,  after  issuing  from  jugular  foramen  (where  it  unites  with 
accessorv  portion),  passes  backward,  crossing  in  front  of  (sometimes  behind) 
the  internal  jugular  vein,  descends  obliquely  behind  digastric  and  stylo- 
hyoid muscles  and  occipital  artery  to  enter  upper  third  of  sternomastoid 
about  5  cm.  (2  inches)  below  tip  of  mastoid  process — perforates  this  muscle 
in  its  second  fourth  and  emerges  on  level  with  center  of  its  posterior  border 
— and  runs  thence  obliquely  across  the  occipital  triangle,  and,  entering 
upper  part  of  lower  third  of  its  anterior  border,  terminates  in  the  deep  surface 
of  the  trapezius. 


EXPOSURE  OF   SPINAL  ACCESSORY  NERVE   AT   ANTERIOR  BORDER 
OF  STERNOMASTOID  MUSCLE. 

Position.— Patient  supine;  shoulders  slightly  elevated;  head  to  opposite 
side;  neck  supported.     Surgeon  on  right,  for  either  operation. 

Landmarks. — Anterior  border  of  upper  portion  of  sternomastoid. 

Incision. — About  7.5  cm.  (3  inches)  in  length,  following  the  anterior 
border  of  the  sternomastoid,  with  its  center  opposite  a  point  about  5  cm. 
(2  inches)  below  the  tip  of  the  mastoid  process. 

Operation. — Having  cut  through  skin  and  superficial  fascia,  and  opened 


196       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 


up  the  cervical  fascia,  avoiding  the  external  jugular  vein  and  great  auricular 
nerve,  expose  the  anterior  border  of  the  sternomastoid  and  draw  the  muscle 
firmly  backward.     Recognize  the  inferior  border  of   the  posterior  belly  of 

the  digastric — the  nerve  will  be  found  pass- 
ing from  beneath  it  to  the  sternomastoid, 
crossing  the  transverse  process  of  the  atlas. 
Avoid  branches  of  the  facial  nerve  (at  the 
upper  edge  of  the  wound)  and  the  occipital 
artery  (lying  over  the  nerve). 

Comment. — If  only  that  portion  of  the 
spinal  accessory  be  involved  which  is  distal 
to  the  sternomastoid,  the  nerve  may  be  ex- 
posed by  an  incision  placed  along  the  poste- 
rior border  of  the  sternomastoid,  with  its 
center  opposite  the  center  of  the  posterior 
border  of  the  muscle. 


FACIO-ACCESSORY  OR  FACIO-HYPOGLOS- 

SAL  ANASTOMOSIS  FOR  PERIPHERAL 

FACIAL  PARALYSIS. 

Description. — The  operation  consists  in 
anastomosing  the  paralyzed  facial  nerve  with 
some  neighboring  intact  nerve.  The  anasto- 
mosis is  usually  made  with  either  spinal  ac- 
cessory or  the  hypoglossal.  While  each 
method  has  its  advantages  and  disadvant- 
ages— and  each  method  its  adherents — it 
would  seem  that  the  greater  advantages  lie 
in  favor  of  severing  the  spinal  accessory 
nerve,  and  uniting  its  central  end  to  the 
impaired  peripheral  end  of  the  facial.  The 
glossopharyngeal  has  also  been  used. 

Position. — Patient  supine;  shoulders 
slightly  elevated;  head  to  opposite  side; 
neck  supported.  Surgeon  on  side  of  oper- 
ation. 

Landmarks. — Anterior  border  of  sterno- 
mastoid muscle;  mastoid  process;  upper  bor- 
der of  thyroid  cartilage. 

Incision. — Along    the    anterior    border 
of     the     sternomastoid  —  beginning     2     cm. 
(about  I  inch)  above  the  tip  of  the  mastoid  process — and  ending  opposite 
the  upper  border  of  the  thyroid  cartilage. 

Operation. — (1)  To  Expose  the  Facial  Nerve; — Having  incised  through 
skin  and  fascia,  the  sternomastoid  is  exposed  and  retracted  posteriorly,  and 
the  parotid  gland  exposed  and  displaced  anteriorly.  The  nerve  is  sought 
as  it  emerges  from  the  gland  at  a  point  approximately  1  cm.  (about  J  inch) 
above,  and  1  cm.  (about  J  inch)  internal  to  the  tip  of  the  mastoid  process. 
Just  distal  to  the  point  selected  for  division,  which  should  be  as  near  the 
stylomastoid  foramen  as  possible,  two  fine  silk  sutures  should  be  carried  through 
the  sheath  of  the  nerve,  after  which  the  nerve  is  divided  (Fig.   165).     (2) 


Fig.  165. — F  acid-accessory  An- 
astomosis:— A,  Mastoid  process;  B, 
Parotid  gland;  C,  Sternomastoid 
muscle;  D,  Stylohyoid  and  posterior 
belly  of  digastric  muscles;  E,  E,  Di- 
vided ends  of  facial  nerve;  F,  Spinal 
portion  of  spinal  accessory  nerve;  G, 
Divided  end  of  spinal  accessory  anasto- 
mosed with  distal  end  of  facial  nerve. 
(Modified  from  Berger  and  Hart- 
mann.) 


EXPOSURE    OF    POSTERIOR    DIVISIONS    OF    CERVICAL    NERVES.      197 

To  Expose  the  Spinal  Accessory  Nerve; — The  nerve  enters  the  deep  surface 
of  the  sternomastoid  about  5  cm.  (2  inches)  below  the  mastoid  process.  It  is 
covered  by  the  posterior  belly  of  the  digastric  and  the  deep  fascia,  and  lies 
just  below  the  transverse  process  of  the  atlas.  Here  also  two  fine  silk  sutures 
are  passed  through  the  sheath  of  the  nerve  just  proximal,  in  this  case,  to  the 
line  where  the  nerve  is  to  be  divided.  The  nerve  is  then  divided  transversely, 
with  a  sharp  knife  (and  not  with  scissors,  which  also  crush) — and  is  dissected 
up  sufficiently  to  enable  it  to  reach  the  severed  distal  end  of  the  facial  without 
tension — and  here  the  facial  and  spinal  accessory  stumps  are  united  end-to- 
end  by  means  of  fine  silk  interrupted  sutures  passing  through  their  sheaths 
only.  The  spinal  accessory  may  be  used  in  three  ways — the  entire  nerve 
may  be  taken;  the  branch  to  the  trapezius  may  be  used;  or  the  trunk  may  be 
split  and  one  of  the  split  portions  be  employed.  (3)  To  Expose  the  Hypo- 
glossal Nerve; — This  is  accomplished  through  the  same  incision.  The  pos- 
terior belly  of  the  digastric  lies  just  above  the  nerve,  which  is  isolated  as  it  runs 
forward  from  under  the  occipital  artery  to  cross  the  external  carotid.  The 
technic  of  anastomosis  is  carried  out  as  in  the  above  instance. 


EXPOSURE  OF  POSTERIOR   DIVISIONS  OF  FIRST,  SECOND,  AND 
THIRD  CERVICAL   NERVES. 

KEEN'S   OPERATION. 

Description. — The  posterior  divisions  of  the  first,  second,  and  third 
cervical  nerves  have  been  exposed  and  excised  in  spasmodic  torticollis- 
supplying,  as  they  do,  the  posterior  rotator  muscles  of  the  neck. 

Position. — Patient  turned  to  one  side;  neck  made  prominent.  Surgeon 
at  patient's  back. 

Landmarks. — Middle  line  of  neck;  external  occipital  protuberance. 

Incision. — From  6  to  7.5  cm.  (2^  to  3  inches)  in  length  and  transverse 
in  direction — passing  outward  from  the  middle  line  of  the  neck,  at  a  point 
about  4  cm.  (1^  inches)  below  the  external  occipital  protuberance. 

Operation. — Divide,  in  the  line  of  incision,  the  skin,  fascia,  trapezius, 
and  posterior  border  of  the  splenitis  capitis,  until  the  complexus  is  reached, 
after  which  the  nerves  are  separately  isolated: — (1)  Find  the  occipitalis  major 
nerve  (internal  branch  of  posterior  division  of  second  cervical  nerve)  emerging 
from  the  complexus  and  about  to  enter  the  trapezius.  Divide  the  complexus 
transversely,  on  a  level  with  the  nerve.  Follow  the  nerve  to  the  common 
trunk  of  the  posterior  division  (before  the  external  and  internal  branches 
are  given  off).  Thus  the  second  cervical  nerve  is  exposed.  (2)  Recognize 
the  suboccipital  triangle, — bounded,  above  and  internally,  by  the  rectus 
capitis  posticus  major  (from  spinous  process  of  axis  to  superior  curved  line 
of  occiput), — above  and  externally,  by  obliquus  capitis  superior  (from  upper 
surface  of  transverse  process  of  atlas  to  occipital  bone,  between  curved  lines, 
and  external  to  complexus), — below  and  externally,  bv  obliquus  capitis 
inferior  (from  apex  of  spinous  process  of  axis  to  lower  and  back  part  of  trans- 
verse process  of  atlas).  Within  this  triangle  lies  the  suboccipital  nerve 
(posterior  division  of  first  cervical  nerve),  which  does  not  divide  into  internal 
and  external  branches — lying  close  to  the  occiput  and  behind  the  vertebral 
artery.  Trace  it  as  near  to  the  spine  as  possible.  Thus  the  first  cervical 
nerve  is  exposed.  (3)  The  external  branch  of  the  posterior  division  of 
the  third  cervical  nerve  is  found  about  2.5  cm.  (1  inch)  lower  down  than 
the    occipitalis    major   and    upder    the    complexus.     It   is    to   be    followed 


198      OPERATIONS    UPON   THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

to  the  common  trunk  of  the  posterior  division.     And  thus  the  third  cervical 
nerve  is  exposed. 

Comment. — This  operation  has  been  modified  by  making  a  vertical 
incision  from  the  occiput  downward,  about  4  cm.  (1^  inches)  outside  of 
the  median  line — passing  through  the  trapezius,  edge  of  the  splenius,  and 
then  through  the  complexus.  Also,  the  second  and  third  divisions  may  be 
divided  without  the  first. 


SURGICAL  ANATOMY  OF  BRACHIAL  PLEXUS  OF  NERVES. 

Formed  by. — Fasciculus  from  anterior  branch  of  fourth  cervical,  anterior 
branches  of  fifth,  sixth,  seventh,  and  eighth  cervical,  and  greater  part  of 
anterior  branch  of  first  dorsal. 

Extent  and  Position. — From  lower  part  of  side  of  neck  to  lower  part 
of  axillary  space,  dividing,  opposite  the  coracoid  process,  into  numerous 
trunks,  and  giving  off  its  terminal  nerves  at  the  lower  axillary  boundary, 

Relations. — (1)  In  neck : — First,  lies  between  anterior  and  middle 
scaleni  and  at  outer  border  of  former  muscle; — then  parti}-  behind  and  partly 
above  and  external  to  third  part  of  subclavian  artery,  in  the  posterior  triangle 
of  neck,  crossed  by  posterior  belly  of  omohyoid; — then  behind  clavicle  and 
subclavius  muscle,  upon  first  serration  of  serratus  magnus  and  subscapularis 
muscles.  (2)  In  axilla  : — Lies  to  outer  side  of  first  portion  of  axillary  artery, 
being  covered  by  pectoralis  major — then  surrounds  second  portion  of  artery, 
covered  by  the  pectoralis  minor  and  resting  upon  subscapularis  muscle,  one 
cord  lying  to  inner  side,  one  behind,  and  one  to  outer  side  of  vessel.  The 
third  part  of  the  artery  has  the  internal  cutaneous  and  inner  head  of  median 
nerve  in  front;  circumflex  and  musculospiral  behind;  ulnar  and  lesser  internal 
cutaneous  on  inner  side;  and  trunk  of  median  and  musculocutaneous  on 
outer  side. 


EXPOSURE  OF  BRACHIAL  PLEXUS  IN   NECK. 

Position. — Patient  upon  back,  near  edge  of  table;  thorax  raised;  head 
extended  and  turned  to  opposite  side;  arm  drawn  downward  and  behind 
back.  Surgeon  stands  in  front  of  right  shoulder,  in  operating  upon  either 
side. 

Landmarks. — Sternomastoid ;  trapezius. 

Incision. — Vertical,  in  posterior  triangle  of  neck — beginning  about  9 
cm.  (3^  inches)  above  clavicle  and  passing  downward  to  within  about  1.3 
cm.  (J  inch)  of  middle  of  clavicle,  parallel  with  anterior  border  of  trapezius, 
but  nearer  posterior  border  of  sternomastoid. 

Operation. — Having  divided  skin  and  platysma,  the  external  jugular 
vein  is  either  ligated  and  cut  between  two  ligatures,  or  retracted.  Some  of 
the  descending  branches  of  the  cervical  plexus  are  apt  to  be  incised,  generally 
the  supraclavicular.  Incise  the  deep  cervical  fascia.  Recognize  the  outer 
border  of  the  anterior  scalenus  and  retract  inward.  Retract  the  posterior 
belly  of  the  omohyoid  downward  and  expose  the  brachial  plexus  by  dissection. 
Avoid  the  transversalis  colli  artery  and  vein  crossing  the  middle  of  the  plexus. 
Identify  the  cords  of  the  plexus  by  following  with  finger  to  the  interval  between 
the  anterior  and  middle  scalenus  muscles. 


OPERATION    FOR    BRACHIAL    BIRTH    PALSY. 


199 


OPERATION  FOR  BRACHIAL  BIRTH  PALSY. 

Description. — The  brachial  plexus  as  a  whole,  or  its  constituent  roots 
individually,  is  subject  to  the  injuries  which  may  involve  nerve  structures  in 
general,  resulting  in  a  partial  or  general  paralysis.  A  special  form  of  paralysis, 
termed  brachial  birth  palsy,  is  especially  apt  to  occur  at  birth  in  those  cases 
where  the  head  and  neck  have  been  forced  away  from  the  shoulder,  thus 
overstretching  or  lacerating  nerve-roots  of  the  brachial  plexus,  especially  the 
upper  roots.  This  subject  has  been  extensively  and  creditably  worked  up 
by  Clark,  Taylor,  and  Prout,  through  whose  courtesy  the  following  writing  is 
taken  from  Keen's  "  Surgery,"  Vol.  II. 

"One  of  the  most  common  and  interesting  forms  of  brachial  palsy  are 
the  brachial  birth  palsies,  usually  of  the  upper  arm  type,  very  rarely  the  total 


Fig.  166. — Dissection*  of  the  Operative  Field  in  Brachial  Birth  Palsy  (Clark, 
Taylor,  and  Prout): — A,  Scalenus  amicus  muscle;  B,  Phrenic  nerve;  C,  Internal  jugular  vein; 
D,  Transversalis  colli  artery,  divided;  E,  \'II  Cervical  root;  F,  Omohyoid  muscle;  G,  V  Cervical 
root;  H,  Scalenus  medius  muscle;  I,  VI  Cervical  root;  J,  Transversalis  colli  artery;  K,  Supra- 
scapular nerve;  L,  Nerve  to  subclavian  muscle;  M,  Clavicle;  N,  Nerve  to  scalenus  anticus  muscle. 

arm  palsy.  They  may  occur  in  either  vertex  or  breech  presentation,  when 
traction  is  exerted  and  the  head  pulled  away  from  the  shoulder.  The  attitude 
is  very  characteristic  in  severe  cases;  the  arm  hangs  limp  by  the  side,  as  it 
cannot  be  abducted  at  the  shoulder  or  flexed  at  the  elbow,  and,  as  it  cannot  be 
rotated  out  at  the  shoulder  or  supinated  in  the  forearm,  the  whole  arm  is 
rotated  in  and  the  hand  is  pronated  so  that  it  looks  backward  and  sometimes 
even  outward.  They  should  be  operated  on  as  described  below.  Kennedv 
and  Taylor  have  reported  several  operations  with  good  results,  and  among 
them  were  cases  ten  and  eleven  years  old.  In  mild  cases  nothing  is  required 
except  massage,  passive  motion,  electricity,  and  apparatus — and  in  all  cases, 
unless  there  is  neuritis,  these  measures  should  be  faithfully  employed  until 
recovery  results  or  it  becomes  necessary  to  operate.  When  there  is  neuritis, 
complete  rest  in  the  normal  position  is  demanded  until  inflammation  has 
subsided.    The  only  treatment  for  cases  of  permanent  paralysis  is  the  excision 


200      OPERATIONS    UPON    THE    XERXES,    PLEXUSES,    AND    GANGLIA. 

of  the  scar  tissue  replacing  and  surrounding  the  injured  nerve  and  suture  of 
the  freshened  nerve-ends.  The  time  at  which  to  undertake  this  treatment 
is  still  a  matter  of  dispute.  Kennedy  advises  early  operation — in  two  or  three 
months  if  the  muscles  give  no  response  to  the  faradic  current.  If  the  muscles 
re-pond  and  continue  to  improve  in  response  to  the  faradic  current,  he  does 
not  operate  but  expects  spontaneous  recovery.  Taylor  advises  delay  for 
a  year  in  most  cases  of  brachial  birth  palsies.  The  advantages  of  this  delay 
are  a  more  definite  localization  of  the  lesion,  larger  size  of  the  field  of  operation, 
and  diminished  danger  from  shock  and  hemorrhage. 


Fig.  167. — Dissection  of  the  Operative  Field  in  Brachial  Birth  Palsy  (Clark, 
Taylor,  and  Prout): — A,  Phrenic  nerve;  B,  Scalenus  anticus  muscle;  C,  Internal  jugular  vein; 
D,  Transversalis  colli  artery;  E,  Omohyoid  muscle,  divided;  F,  Suprascapular  artery,  divided; 
(j,  YIII  Cervical  and  I  dorsal  roots;  H,  External  anterior  thoracic  nerve;  I,  Subclavian  artery; 
J,  V  Cervical  root;  K,  VI  Cervical  root;  L,  Scalenus  medius  muscle;  M,  Nerve  to  scalenus  anticus 
muscle;  X,  Suprascapular  nerve;  O,  Transversalis  colli  artery;  P,  VII  Cervical  root;  Q,  Omo- 
hyoid muscle,  divided;  R,  Suprascapular  artery;  S,  Clavicle  and  subclavius  muscle,  divided  and 
retracted;  T,  Deltoid,  pectoralis  minor,  pectoralis  major  (muscles);  U,  Nerve  to  subclavius 
muscle. 


"  The  incision  extends  from  the  posterior  border  of  the  sternomastoid  at 
the  junction  of  its  middle  and  lower  third,  to  the  junction  of  the  middle  and 
outer  thirds  of  the  clavicle  through  the  skin,  platysma,  and  deep  fascia.  The 
omohyoid  muscle,  exposed  near  the  clavicle,  with  the  suprascapular  vessels 
beneath  it,  is  retracted  downward,  or,  if  necessary,  divided.  Beneath  the 
layer  of  fat  at  this  level  the  deep  fascia,  usually  thickened,  covering  the  plexus 
is  divided  and  dissected  away  from  it.  The  injured  portion  of  the  nerve  or 
nerves,  determined  beforehand  from  the  paralysis,  is  felt  to  be  thickened  or 


EXPOSURE    OF    MEDIAN    NERVE    IN    MIDDLE    OF    ARM.  201 

indurated.     This  area  is  excised  by  a  sharp  scalpel  through  healthy  nerve- 
tissue  and  the  ends  sutured  (Figs.  166  and  167). 

"  This  incision  suffices  for  the  common  type  where  the  lesion  is  confined 
to  the  fifth  or  fifth  and  sixth  nerve-roots  and  their  junction.  When,  however, 
the  lesion  extends  to  the  lower  roots  of  the  plexus,  or  lies  in  the  lower  part  of 
the  plexus,  the  incision  should  be  extended  downward  and  the  clavicle,  sub- 
clavius  muscle,  and,  if  necessary,  the  pectoral  muscles  divided  to  give  a 
better  exposure.  If  thought  best,  the  operation  may  be  done  in  two  stages 
to  avoid  too  long  an  operation  and  too  much  shock.  The  clavicle  is  afterward 
sutured  periosteally.  An  immobolizing  dressing  approximating  the  head 
and  shoulder  to  relieve  any  tension  on  the  plexus  should  be  applied  and  this 
position  maintained  for  two  or  three  weeks.  After-treatment  by  massage, 
electricity,  and  the  use  and  education  of  the  muscles  is  very  important.  The 
results  of  these  operations  have  been  very  encouraging.  The  improvement 
is  slow  and  continuous  through  a  number  of  vears." 


SURGICAL  ANATOMY  OF  MEDIAN  NERVE. 

Description. — (a)  In  Arm;  Arises  by  a  root  from  inner  and  one  from 
outer  cords  of  brachial  plexus,  which  embrace  axillary  artery,  uniting  either 
in  front  or  to  outer  side  of  the  vessel.  Descends  arm  on  outer  side  of  brachial 
artery  at  first — then  crosses  in  front  of  the  middle  of  artery  (though  some- 
times passing  behind) — thence  downward  on  inner  side  of  artery  to  elbow — 
where  it  is  separated  from  elbow-joint  by  brachialis  anticus  muscle  and  is 
covered  by  bicipital  fascia,  (b)  In  Forearm;  Passes  between  two  heads  of 
pronator  radii  teres  and  descends  between  flexor  sublimis  and  profundus 
digitorum  to  about  5  cm.  (2  inches)  above  the  annular  ligament  of  wrist, 
where  it  lies  beneath  the  fascia,  between  the  tendons  of  the  flexor  sublimis 
digitorum  below,  the  palmaris  longus  internally,  and  the  flexor  carpi  radialis 
externally  (or  rather  more  under  the  palmaris  longus).  (c)  In  Hand;  It 
enters  palm  beneath  the  annular  ligament  and  rests  upon  flexor  tendons, 
covered  by  fascia  and  superficial  palmar  arch. 


EXPOSURE  OF  MEDIAN  NERVE  IN  MIDDLE  OF  ARM. 

Position. — Patient's  arm  is  extended  and  abducted,  with  hand  supine. 
Surgeon  stands  on  outer  side  of  right  limb,  cutting  from  above  downward; 
and  between  body  and  left  limb,  cutting  from  above  downward  (or  on  outside 
of  left  limb,  cutting  from  below  upward). 

Landmarks. — Inner  edge  of  bicipital  muscle. 

Incision. — Along  inner  edge  of  biceps,  in  middle  of  arm — about  4  cm. 
(2^  inches)  in  length. 

Operation. — Divide  skin  and  connective  tissue.  Avoid  internal  cutaneous 
nerve  and  basilic  vein.  Clearly  expose  inner  edge  of  biceps  muscle  and 
draw  the  muscle  to  the  outer  side,  when  the  median  nerve  is  found  crossing 
the  brachial  artery  from  the  outer  toward  the  inner  side  (or  sometimes  passing 
beneath  the  artery). 


202       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 


EXPOSURE  OF  MEDIAN  NERVE  AT  BEND  OF  ELBOW. 

Position. — As  above. 

Landmarks. — Groove  between  biceps  and  pronator  radii  teres  muscles. 

Incision. — Between  inner  margin  of  biceps  and  outer  margin  of  pronator 
radii  teres,  somewhat  nearer  the  former,  with  center  of  incision  opposite 
the  fold  of  the  elbow,  and  being  about  5  cm.  (2  inches)  in  length. 

Operation. — This  incision  will,  in  the  usual  disposition  of  the  veins 
at  the  elbow,  pass  to  the  outer  side  and  nearly  parallel  with  the  median  basilic 
vein,  which  should  be  retracted  inward.  Incise  the  bicipital  fascia  in  a  line 
with  the  skin-cut.  The  median  nerve  lies  just  to  the  inner  side  of  the  brachial 
artery  and  its  vena?  comites — all  lying  upon  the  brachialis  anticus.  Gut- 
suture  the  bicipital  fascia  in  closing  the  wound. 


SURGICAL  ANATOMY  OF  ULNAR  NERVE. 

Description. — (a)  In  Arm;  Arises  from  inner  cord  of  brachial  plexus, 
between  axillary  artery  and  vein,  and  passes  down  arm  on  inner  side  of 
axillary  and  brachial  arteries  to  middle  of  arm,  covered  only  by  skin  and 
fascia — thence  diverges  to  cross  inner  head  of  triceps  obliquely — pierces 
interna]  intermuscular  septum  and  descends  posterior  to  that  structure, 
together  with  inferior  profunda  artery,  which  is  upon  its  outer  side,  (b) 
At  Elbow;  Occupies  groove  between  olecranon  and  internal  condyle,  resting 
upon  posterior  surface  of  latter  (rarely  upon  anterior  surface),  and  enters 
forearm  between  two  heads  of  flexor  carpi  ulnaris.  (c)  In  Forearm;  Passes 
vertically  down  ulnar  side,  upon. flexor  profundus  digitorum,  its  upper  half 
covered  by  flexor  carpi  ulnaris,  its  lower  half  by  skin  and  fascia  (the  nerve 
here  lying  external  to  flexor  carpi  ulnaris).  The  ulnar  nerve  lies,  throughout, 
to  the  ulnar  side  of  the  ulnar  artery — the  upper  third  lying  considerably  to 
the  inner  side,  and  the  lower  two-thirds  near  to  the  inner  side.  The  dorsal 
cutaneous  branch  passes  posteriorly  between  5  and  7.5  cm.  (2  and  3  inches) 
above  the  wrist,  (d)  At  Wrist;  Crosses  front  of  annular  ligament  between 
ulnar  artery  and  pisiform  bone,  a  little  internal  and  posterior  to  the  artery, 
and  immediately  divides  into  superficial  and  deep  palmar  branches. 


EXPOSURE  OF  ULNAR  NERVE  ABOVE  MIDDLE  OF  ARM. 

Position. — As  for  median  nerve  in  middle  of  arm  (page  201). 

Landmarks. — Brachial  artery,  which  is  parallel  with  and  to  outer  side 
of  the  nerve  for  the  upper  half  of  the  arm. 

Incision. — From  5  to  7.5  cm.  (2  to  3  inches)  in  length,  with  its  center 
just  above  the  middle  of  the  arm — running  parallel  with  and  about  1.3  cm. 
(^  inch)  to  inner  side  of  line  of  brachial  artery  (the  line  for  the  ligation  of 
the  middle  third  of  the  brachial  artery  passing  along  the  inner  margin  of  the 
biceps  muscle). 

Operation. — Incise  skin  and  fascia,  which  here  alone  cover  the  nerve. 
Avoid  the  basilic  vein  and  the  vena?  comites  of  the  brachial  artery — also  the 
internal  cutaneous  nerve  to  the  outer,  and  the  lesser  internal  cutaneous  nerve 
to  the  inner  side.  The  ulnar  nerve  is  found  diverging  from  its  course  parallel 
with  the  inner  side  of  the  brachial  artery  to  pass  obliquely  across  the  inner 
head  of  the  triceps  to  pierce  the  internal  intermuscular  septum. 


EXPOSURE    OF    MUSCULOSPIRAL    NERVE.  203 

EXPOSURE  OF  ULNAR  NERVE  JUST  ABOVE  INTERNAL  CONDYLE  OF 

HUMERUS. 

Position. — Patient  upon  back  at  edge  of  table.  Assistant  stands  on 
side  opposite  one  to  be  operated,  and,  grasping  patient's  wrist,  with  patient's 
hand  prone,  draws  his  (patient's)  arm  and  forearm  across  the  chest,  thus 
exposing  its  posterior  surface  to  the  operator — who  stands  upon  the  side  to 
be  operated,  cutting  from  elbow  toward  shoulder  on  both  sides. 

Landmarks. — Olecranon;  internal  condyle  of  humerus. 

Incision. — About  5  cm.  (2  inches)  in  length,  extending  from  a  point 
about  1.3  cm.  (h  inch)  above  (to  proximal  side  of)  internal  condyle  and  midway 
between  internal  condyle  and  olecranon,  upward  toward  a  point  at  inner 
side  of  brachial  artery  opposite  the  insertion  of  the  coracobrachialis  muscle 
(about  center  of  arm). 

Operation. — Incise  skin  and  fascia  in  above  line — when  the  nerve  will 
be  found  upon  the  posterior  surface  of  the  internal  intermuscular  septum, 
with  the  inferior  profunda  artery  upon  its  outer  side. 

Comment. — If  the  incision  were  to  extend  over  the  internal  condyle, 
the  nerve  would  be  found  lying  upon  the  posterior  surface  of  the  base  of  the 
inner  condyle  of  the  humerus,  close  to  the  bone  and  along  the  inner  edge 
of  the  triceps. 


SURGICAL  ANATOMY  OF  MUSCULOSPIRAL  NERVE. 

Description. — Arises,  in  common  with  circumflex  nerve,  from  posterior 
cord  of  brachial  plexus — descends  arm  behind  axillary  and  brachial  arteries 
and  in  front  of  tendons  of  latissimus  dorsi  and  teres  major,  and  winds  around 
humerus  in  musculospiral  groove,  from  inner  to  outer  side,  with  superior 
profunda  artery,  lying  between  the  internal  and  external  heads  of  the  triceps. 
Arriving  at  outer  side  of  arm,  it  pierces  the  external  intermuscular  septum 
about  midway  between  insertion  of  deltoid  and  tip  of  external  condyle  (namely, 
at  lower  third)  and  descends  between  supinator  longus  and  brachialis  anticus 
to  front  of  external  condyle,  where  it  divides  into  radial  and  posterior  inter- 
osseous nerves. 


EXPOSURE  OF  MUSCULOSPIRAL  NERVE   BELOW  MIDDLE  OF  ARM. 

Description. — The  exposure  is  here  made  upon  the  external  aspect  of 
the  arm  and  the  nerve  is  reached  anterior  to  the  external  intermuscular 
septum. 

Position. — Same  as  for  ulnar  nerve  just  above  internal  condyle  (page 
203).     The  surgeon  may  also  stand  so  as  to  cut  from  shoulder  toward  elbow. 

Landmarks. — Insertion  of  deltoid  (about  middle  of  arm);  external 
condyle  of  humerus;  upper  border  of  supinator  longus. 

Incision. — About  6  to  7.5  cm.  (2%  to  3  inches)  in  length — crossing  obliquely 
the  outer  surface  of  the  lower  third  of  the  arm — so  placed  that  its  center 
will  be  midway  between  the  deltoid  and  the  external  condyle — and  so  that 
its  obliquity  will  follow  the  line  of  the  upper  border  of  the  supinator  longus. 

Operation. — Having  incised  skin  and  fascia,  avoiding  cephalic  and 
median  cephalic  veins,  identify  the  internal  border  of  the  supinator  longus. 
Draw  this  muscle  to  the  outer  side,  so  as  to  expose  the  interval  between  it 


204       OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

and  the  brachialis  anticus — where  the  nerve  will  be  found  close  to  the  bone, 
accompanied  by  a  branch  of  the  superior  profunda  artery. 

Comment. — Exposure  of  the  nerve  at  its  bifurcation  into  radial  and 
posterior  interosseous  may  be  accomplished  (if  not  performed  as  a  separate 
operation)  by  continuing  the  above  incision  downward. 


SURGICAL  ANATOMY  OF  THE  INTERCOSTAL  NERVES. 

Description. — (a)  Pectoral  Intercostal  Nerves  : — Pass  outward,  as 
the  anterior  divisions  of  the  dorsal  nerves,  in  front  of  superior  costotransverse 
ligaments,  levatores  costarum,  external  intercostal  muscles,  covered  (to  angle 
of  ribs)  by  pleura  and  endothoracic  fascia.  They  then  approach  upper 
part  of  each  intercostal  space  to  accompany  intercostal  vessels,  in  groove  of 
rib  above,  to  front  of  chest — the  nerve  lying  below  the  vessels.  Between 
angle  of  rib  and  middle  of  rib  they  lie  between  internal  and  external  inter- 
costal muscles,  giving  off,  a  little  posterior  to  middle  of  the  ribs,  the  lateral 
cutaneous  branches — which  latter  branches  pass  through  external  intercostal 
and  serratus  magnus  muscles  about  center  of  ribs  and  divide  into  anterior 
and  posterior  branches.  The  main  trunk  of  the  intercostal  nerve  continues 
forward  among  fibers  of  internal  intercostal  muscles  to  costal  cartilages — ■ 
thence  passes  between  internal  intercostal  muscles  and  pleura,  crossing  in 
front  of  internal  mammary  artery  and  triangularis  sterni  muscle — to  pierce 
internal  intercostal  muscles  and  pectoralis  major  and  end  in  the  anterior 
cutaneous  branches,  (b)  Abdominal  Intercostal  Nerves : — Take  the  same 
course  (as  the  anterior  divisions  of  the  dorsal  nerves)  as  the  pectoral  inter- 
costals,  from  their  origin  to  ends  of  intercostal  spaces  in  which  they  lie — 
thence  they  run  between  the  slips  of  origin  of  diaphragm  to  enter  the  abdominal 
wall,  each  nerve  (from  seventh  to  ninth,  inclusive)  crossing  behind  cartilage 
of  rib  below.  In  the  abdominal  wall  they  pass  between  internal  oblique 
and  transversalis,  diverging  from  each  other  as  they  go  forward,  to  outer 
edge  of  the  rectus — and,  piercing  posterior  layer  of  rectal  sheath,  rectus  itself, 
and  anterior  layer  of  sheath,  they  supply  rectus  and  sheath  and  end  in  the 
anterior  cutaneous  nerves  near  the  linea  alba. 

Comment. — (i)  The  exceptions  in  the  distribution  of  the  anterior  divi- 
sions of  the  first,  second,  and  twelfth  nerves  are  not  mentioned  in  the  above 
descriptions.  (2)  The  upper  six  dorsal  nerves  form  the  pectoral  intercostal 
nerves — the  lower  six,  the  abdominal  intercostals.  (3)  The  final  distribution 
of  the  lower  dorsal  nerves  is  as  follows; — sixth,  to  pit  of  stomach;  seventh,  to 
lower  end  of  ensiform  cartilage;  eighth,  over  the  middle  linea  transversa; 
tenth,  to  the  umbilicus;  twelfth,  midway  between  umbilicus  and  pubis. 

EXPOSURE  OF  INTERCOSTAL  NERVE  BETWEEN  ANGLE  AND  MIDDLE 

OF  RIB. 

Position. — Patient  on  side.     Surgeon  either  in  front  or  at  back  of  patient. 

Landmarks. — Angle  and  lower  border  of  rib. 

Incision. — Parallel  with  and  just  below  lower  border  of  rib,  and  lying 
between  the  angle  and  middle  of  rib. 

Operation. — Having  incised  skin,  fascia,  and  external  intercostal  muscle, 
separate  the  cut  edges  of  the  external  intercostal  muscle  and  seek  for  nerve 
in  the  intermuscular  plane  between  external  and  internal  intercostals,  near 
the  lower  border  of  the  rib  above.  The  nerve  may  be  drawn  down  into  view 
from  the  groove  in  the  lower  border  of  the  rib  by  means  of  a  nerve-hook.     If 


SURGICAL    ANATOMY    OF    GREAT    SCIATIC    NERVE.  205 

necessary,  bite  out  a  half-button  of  rib  subperiosteally  with  rongeur  forceps, 
fully  exposing  the  nerve  and  intercostal  vessels,  when  the  latter  may  be 
divided  between  ligatures,  if  necessary. 

SURGICAL  ANATOMY  OF  ANTERIOR  CRURAL  NERVE. 

Arises  from  second,  third,  and  fourth  lumbar  nerves  and  descends  through 
fibers  of  psoas  muscle — emerging  from  lower  part  of  its  outer  border,  and 
descending  beneath  Poupart's  ligament  into  thigh,  beneath  the  iliac  fascia, 
in  groove  between  psoas  and  iliacus,  being  separated  from  femoral  artery 
on  its  inner  side  by  the  psoas.  It  divides  below  Poupart's  ligament  into  an 
anterior  division,  passing  in  front  of  the  external  circumflex  vessels — and  a 
posterior  division,  passing  behind  these  vessels. 

EXPOSURE  OF  ANTERIOR  CRURAL   NERVE,  BELOW  POUPART'S 

LIGAMENT. 

Position. — Patient  on  back;  limb  extended  and  rotated  slightly  outward. 
Surgeon  to  outer  side  of  right  limb,  and  to  inner  side  of  left  or  on  right, 
leaning  over  body;  or  on  outer  side  of  left  limb,  cutting  from  below  up- 
ward). 

Landmarks. — Middle  of  Poupart's  ligament. 

Incision. — Vertical,  about  5  cm.  (2  inches)  in  length,  carried  downward 
from  a  point  about  1.3  cm.  (h  inch)  external  to  center  of  Poupart's  ligament. 

Operation. — Incise  skin  and  superficial  fascia.  Crural  branch  of  genito- 
crural  nerve  may  be  met  running  down  the  thigh.  The  superficial  circumflex 
iliac  vessels  will  lie  across  the  incision.  Flex  the  thigh  to  relax  the  muscles. 
The  nerve  will  be  found  lying  to  the  outer  side  of  the  femoral  artery,  in  the 
groove  between  the  iliacus  and  psoas  muscle-. 

EXPOSURE  OF     OBTURATOR,  SUPERIOR  GLUTEAL.  AND  PUDIC 

NERVES. 

The  operations  for  the  exposure  of  the  obturator  nerve  at  the  thyroid 
foramen,  the  superior  gluteal  nerve  upon  the  buttock,  the  pudic  nerve  upon 
the  buttock,  and  the  pudic  nerve  in  the  perineum,  are.  practically,  the  same 
as  the  operations  for  the  ligation  of  the  obturator  artery  at  the  thyroid  foramen, 
the  gluteal  artery  upon  the  buttock  (page  87),  the  internal  pudic  artery  upon 
the  buttock  (page  87),  and  the  internal  pudic  artery  in  the  perineum  (page 
87),  respectively. 

SURGICAL  ANATOMY  OF  GREAT  SCIATIC  NERVE. 

Description. — Continuation  of  lower  cord  of  sacral  plexus — leaves  pelvis 
by  great  sacrosciatic  foramen,  below  pyriformis — descends  from  hollow 
between  great  trochanter  and  tuberosity  of  ischium  down  back  of  thigh,  to 
about  its  lower  third,  where  it  divides  into  external  and  internal  popliteal 
nerves  (the  division  often  occurring  higher).  The  great  sciatic  nerve  rests, 
from  above  downward,  upon  the  ischium,  gemellus  superior,  obturator 
internus,  gemellus  inferior,  quadratus  femoris  and  adductor  magnus, — and 
is  covered  by,  from  above  downward,  the  skin,  fascia,  gluteus  maximus, 
biceps,  and  small  sciatic  nerve.  It  has  the  sciatic  artery  to  its  inner  side, 
and  small  sciatic  nerve  superficial  to  it  above,  and  to  its  inner  side  as  it  (the 
small  sciatic  nerve)  descends  the  thigh. 


2o6       OPERATIONS    UPON   THE    NERVES,    PLEXUSES,    AND    GANGLIA. 


EXPOSURE  OF  GREAT  SCIATIC  NERVE  AT  LOWER  BORDER  OF 
GLUTEUS  MAXIMUS. 

Position. — Patient  turned  upon  side  sufficiently  to  expose  field  of  opera- 
tion. Surgeon  on  side  of  operation,  cutting  downward  on  left  side,  and 
upward  on  right. 

Landmarks. — Lower  margin  of  gluteus,  which  is  below  fold  of  buttock; 
tuberosity  of  ischium;  great  trochanter. 

Incision. — Begins  over  gluteal  fold  and  passes  vertically  downward  for 
a  distance  of  7.5  to  10  cm.  (3  to  4  inches),  with  center  of  incision  over  lower 
margin  of  gluteus  maximus  and  placed  midway  between  tuberosity  of  ischium 
and  great  trochanter — although  the  nerve  lies  a'  little  nearer  the  former  than 
the  latter,  for  by  this  incision  the  hamstring  muscles  are  more  easily  retracted. 

Operation. — Having  incised  skin  and  fatty  areolar  tissue,  the  small 
sciatic  nerve  and  cutaneous  vessels  are  encountered.  Expose  the  lower  edge 
of  the  gluteus  maximus,  running  downward  and  outward,  and  retract  upward. 
Find  and  retract  the  hamstring  muscles  inward,  bending  the  knee  to  aid  the 
retraction.  The  nerve  is  found  a  little  nearer  the  tuberosity  of  the  ischium 
than  the  great  trochanter  and  under  the  outer  edge  of  the  biceps  muscle. 


SURGICAL  ANATOMY  OF  INTERNAL  POPLITEAL  BRANCH  OF  GREAT 

SCIATIC  NERVE. 

Description. — The  larger  branch  of  the  great  sciatic.  Extends  from 
bifurcation,  at  lower  third  of  thigh,  through  middle  of  popliteal  space  to 
lower  border  of  popliteus  muscle,  where  it  becomes  the  posterior  tibial  nerve. 
It  is  covered,  above,  by  hamstring  muscles;  in  the  middle,  by  skin  and  fascia; 
and  below,  by  heads  of  gastrocnemii.  The  popliteal  vein  intervenes  between 
the  nerve  superficially,  and  the  artery  deeply.  In  the  upper  popliteal  space 
the  nerve  lies  external  to  the  popliteal  artery  and  vein;  at  the  level  of  the 
knee,  the  nerve  crosses  these  vessels;  and  in  the  lower  popliteal  space  the 
nerve  lies  to  the  inner  side  of  the  vessels. 


EXPOSURE  OF  INTERNAL   POPLITEAL  NERVE  AT  LOWER  PART  OF 

POPLITEAL  SPACE. 

Position. — Patient  rests  on  shoulder  and  side  of  chest,  as  nearly  prone 
as  anesthesia  will  allow;  limb  extended.  Surgeon  to  outer  side  of  left,  cutting 
downward;  and  to  inner  side  of  right,  cutting  downward  (or  to  outer  side, 
cutting  upward). 

Landmarks. — Heads  of  gastrocnemii  muscles. 

Incision. — Begins  opposite  the  center  of  the  popliteal  space  and  passes 
vertically  downward  for  about  9  cm.  (3^  inches),  between  the  two  heads  of 
the  gastrocnemii. 

Operation. — Having  divided  skin  and  superficial  fascia,  avoid  external 
saphenous  vein  and  nerve  at  the  outer  and  lower  part  of  the  wound.  Expose 
the  heads  of  the  gastrocnemii  and  open  up,  by  blunt  dissection,  the  interval 
between  them,  retracting  the  heads  of  the  muscle  to  their  respective  sides. 
The  nerve  will  be  found  the  most  superficial  of  the  important  structures  in 
the  popliteal  space. 


EXPOSURE    OF    EXTERNAL    POPLITEAL    NERVE.  207 

SURGICAL  ANATOMY  OF  POSTERIOR  TIBIAL  NERVE. 

Description. — The  direct  continuation  of  internal  popliteal  nerve. 
Extends  from  lower  border  of  popliteus  muscle  to  interval  between  internal 
malleolus  and  heel,  where  it  divides  into  internal  and  external  plantar  nerves. 
It  is  covered,  above,  by  gastrocnemius,  plantaris,  soleus,  and  intermuscular 
deep  fascia;  and,  below,  by  only  skin  and  fascia.  It  rests  upon  (its  anterior 
relations  are),  above,  tibialis  posticus;  and,  below,  flexor  longus  digitorum. 
It  lies  to  inner  side  of  posterior  tibial  artery  above,  but  soon  crosses  it  and 
runs  on  its  fibular  side  to  ankle. 


EXPOSURE  OF  POSTERIOR   TIBIAL   BETWEEN   ORIGIN  AND  ANKLE. 

The  operation  for  the  exposure  of  the  posterior  tibial  nerve  at  its  origin 
is,  practically,  the  same  as  that  for  the  exposure  of  the  internal  popliteal  at 
the  lower  part  of  the  popliteal  space  (page  206).  The  posterior  tibial  nerve 
in  the  leg  may  be  exposed  by  the  same  operation  as  would  expose  the  poste- 
rior tibial  artery  at  the  same  level  (pages  109  and  no). 

EXPOSURE  OF  POSTERIOR  TIBIAL  NERVE  BEHIND  INTERNAL 

MALLEOLUS. 

Position. — Patient  on  back;  knee  flexed;  leg  resting  on  outer  side.  Sur- 
geon stands  facing  either  foot,  cutting  from  above  downward. 

Landmarks. — Internal  malleolus;  tendo  Achillis. 

Incision. — Curved,  about  5  cm.  (2  inches)  in  length,  made  about  1.3 
cm.  (^  inch)  behind  and  parallel  with  the  internal  malleolus,  beginning  just 
in  front  of  tip  of  malleolus  and  extending  upward  in  a  line  midway  between 
internal  malleolus  and  tendo  Achillis. 

Operation. — Directing  the  knife  toward  the  tibia,  divide  skin,  superficial 
fascia,  and  annular  ligament.  The  order  of  the  structures  met  behind  the 
internal  malleolus,  from  within  outward,  is,  tibialis  posticus;  flexor  longus 
digitorum;  posterior  tibial  artery,  vein  and  nerve;  flexor  longus  hallucis. 
The  nerve  is  therefore  sought  between  the  tendons  of  the  flexor  longus  digi- 
torum and  flexor  longus  hallucis. 


SURGICAL  ANATOMY  OF  EXTERNAL  POPLITEAL  (PERONEAL) 
BRANCH  OF  GREAT  SCIATIC. 

Description. — Smaller  branch  of  great  sciatic.  Enters  superior  angle 
of  popliteal  space  and  passes  obliquely  along  outer  side  of  this  space  to  head 
of  fibula,  lying  near  inner  border  of  biceps  (lying  beneath  skin  and  fascia, 
behind  head  of  fibula,  to  inner  side  of  biceps  tendon).  The  nerve  leaves 
the  popliteal  space  in  interval  between  biceps  tendon  and  outer  head  of 
gastrocnemius — winds  around  neck  of  fibula  between  bone  and  peroneus 
longus  muscle — and,  piercing  origin  of  latter  muscle,  divides  into  anterior 
tibial,  musculocutaneous,  and  recurrent  articular  nerves. 

EXPOSURE  OF  EXTERNAL  POPLITEAL  BEHIND  TENDON  OF  BICEPS. 

Position. — Patient  on  uninvolved  side,  rolled  into  slightly  prone  position; 
leg  extended.     Surgeon  stands  facing  back  of  patient's  knee. 
Landmarks. — Tendon  of  biceps;  head  of  fibula. 


208      OPERATIONS    UPON    THE    NERVES,    PLEXUSES,    AND    GANGLIA. 

Incision. — About  4  to  5  cm.  (i£  to  2  inches),  along  posterior  edge  of 
tendon  of  biceps,  extending  from  over  the  prominence  of  the  external  condyle 
of  the  femur  toward  the  posterior  border  of  the  head  of  the  fibula. 

Operation. — Divide  skin  and  deep  fascia.  Expose  the  biceps  tendon. 
Flex  the  knee  to  relax  the  tendon  and  search  for  the  nerve  near  the  attachment 
of  the  biceps  tendon  to  the  head  of  the  fibula,  near  the  outer  edge  of  the 
gastrocnemius. 


SURGICAL  ANATOMY  OF  ANTERIOR  TIBIAL  BRANCH  OF  EXTERNAL 

POPLITEAL. 

Description. — One  of  the  terminal  branches  of  the  external  popliteal. 
Commences  between  fibula  and  peroneus  longus — pierces  septum  between 
peronei  and  extensors — passing  obliquely  beneath  extensor  longus  digitorum 
to  forepart  of  interosseous  membrane.  Runs  forward  on  interosseous  mem- 
brane between  extensor  longus  digitorum  and  tibialis  anticus,  in  upper  part 
of  leg — and  between  tibialis  anticus  and  extensor  longus  hallucis,  lower 
down.  Passes  under  anterior  annular  ligament  and  ends  in  front  of  bend 
of  ankle  in  external  and  internal  branches.  The  anterior  tibial  nerve  reaches 
the  fibular  side  of  the  tibial  artery  at  the  junction  of  the  upper  and  second 
fourths  of  the  leg,  thence  lies  in  front  of  the  artery  to  the  ankle,  and  thence 
generally  lies  to  its  outer  side. 


EXPOSURE  OF  ANTERIOR  TIBIAL  NERVE  NEAR  ORIGIN. 

Position. — Patient  supine  and  inclined  to  uninvolved  side;  hip  slightly 
flexed  and  rotated  inward,  so  that  knee  rests  upon  inner  aspect.  Surgeon 
stands  behind  either  limb,  cutting  from  above  on  the  right,  and  from  below 
on  the  left. 

Landmarks. — Outer  tuberosity  of  tibia;  head  of  fibula. 

Incision. — Begins  opposite  the  most  external  part  of  the  tibial  tuberosity, 
and  about  1.3  cm.  (|  inch)  anterior  to  the  head  of  the  fibula,  and  passes 
downward  for  5  to  7.5  cm.  (2  to  3  inches). 

Operation. — Having  incised  skin  and  fascia,  the  intermuscular  septum 
between  peroneus  longus  and  extensor  longus  digitorum  is  sought,  running 
obliquely  downward  and  forward,  and  is  opened  up  by  blunt  dissection. 
The  anterior  tibial  nerve  (and  also  the  musculocutaneous  nerve)  is  found 
deep  in  this  intermuscular  interval,  running  downward  and  inward,  below 
the  fibular  head  and  covered  by  the  extensor  longus  digitorum  (the  musculo- 
cutaneous running  vertically  downward). 

Comment. — The  anterior  tibial  nerve  may  be  exposed  at  any  point  on 
the  leg  below  its  upper  fourth,  by  the  same  operation  as  would  expose  the 
anterior  tibial  artery  at  the  corresponding  level  (pages  104,  105,  and  106). 


SURGICAL    ANATOMY    OF    THE    CERVICAL    SYMPATHETIC    GANGLIA 

AND   CORD. 

Description. — The  cervical  portion  of  the  gangliated  cord  lies  deeply 
in  the  neck,  embedded  in  the  fascia  between  the  muscles  covering  the  front 
of  the  vertebral  column  behind,  and  the  carotid  sheath  in  front — and  consists 
of  three  ganglia,  together  with  the  connecting  cord: — (a)  Superior  Cervical 


TOTAL    EXCISION    OF    CERVICAL    SYMPATHETIC.  209 

Ganglion  (largest) — lies  opposite  second  and  third  cervical  vertebrae  (some- 
times, fourth  and  fifth) — rests  upon  rectus  capitis  anticus  major,  posteriorly, 
— has  internal  carotid  artery  and  internal  jugular  vein,  anteriorly, — and 
pneumogastric  nerve,  externally,  (b)  Middle  Cervical  Ganglion  (sometimes 
wanting) — opposite  sixth  (or  seventh)  cervical  vertebra — upon,  or  close  to, 
where  the  cord  crosses  the  inferior  thyroid  artery,  (c)  Inferior  Cervical 
Ganglion — between  base  of  transverse  process  of  seventh  cervical  vertebra 
and  neck  of  first  rib,  lying  between  subclavian  and  vertebral  arteries. 


TOTAL  EXCISION  OF  CERVICAL  SYMPATHETIC  GANGLIA  AND  CORD. 

JONNESCO'S  OPERATION. 

Description. — -The  cervical  sympathetic  ganglia  and  cord  have  been 
incised,  partially  excised,  and  totally  excised — chiefly  for  exophthalmic  goiter 
and  epilepsy — and  also  in  hysteria,  chorea,  tumors  of  the  brain,  and  glau- 
coma. The  cord  and  one  or  both  upper  ganglia  of  one  or  both  sides  have 
been  removed, — or  both  upper  ganglia  of  both  sides,  with  intervening  cords, 
— or  both  cords  with  all  the  ganglia  of  one  or  both  sides.  The  removal  of 
the  cord  and  ganglia  of  one  side  will  be  described  below. 

Position. — Patient  supine;  shoulders  and  head  raised  and  latter  turned 
to  opposite  side;  neck,  shaved,  rests  upon  a  narrow  support  (to  render  promi- 
nent).    Surgeon  to  right,  for  both  sides. 

Landmarks. — Mastoid  process;  posterior  border  of  sternomastoid; 
clavicle. 

Incision. — Beginning  opposite  the  posterior  margin  of  the  mastoid  pro- 
cess, passes  downward  along  the  posterior  border  of  the  sternomastoid  to 
just  below  the  clavicle. 

Operation. — Incise  skin,  superficial  fascia,  and  platysma.  Divide  the 
external  jugular  vein  between  two  ligatures.  Displace  the  sternomastoid 
inward  (or  it  may  be  split  longitudinally  near  its  posterior  border  and  the 
parts  retracted  laterally).  Expose  the  common  sheath  of  the  vessels  by  blunt 
dissection.  Lift  the  carotid  sheath,  unopened,  upward  and  retract  it  inward 
— when  the  cervical  cord  and  superior  and  middle  cervical  ganglia  will  be 
exposed,  lying  upon  the  prevertebral  muscles.  Having  well  retracted  the 
structures  to  that  side  toward  which  most  easily  displaced,  isolate  the  trunk 
of  the  cervical  sympathetic  near  the  center  of  the  incision.  Follow  it  up  to 
the  superior  ganglion,  divide  the  communicating  branches  of  the  ganglion 
with  delicate  scissors,  and  remove  the  ganglion  with  fine  forceps.  Practising 
slight  traction  upon  the  distal  end  of  the  trunk,  trace  the  cord  down  to  the 
middle  ganglion,  which  is  similarly  removed — carefully  guarding,  throughout, 
all  important  adjacent  structures.  Continuing  gentle  traction  upon  the  cord, 
just  sufficient  to  follow  it,  trace  the  main  trunk  down  behind  the  clavicle  to 
the  inferior  ganglion.  Guard  the  spinal  accessory  nerve  in  the  upper  part 
of  the  neck — the  nerves  of  the  cervical  plexus  in  the  middle  of  the  neck — 
the  thyroid  and  vertebral  vessels,  recurrent  laryngeal  and  phrenic  nerves 
and  pleura  in  the  lower  part  of  the  neck — and  the  thoracic  duct  on  the  lower 
left  side.  In  closing  the  operation,  approximate  the  separated  muscles  with 
buried  gut  sutures — and  close  the  superficial  wound  in  the  usual  manner, 
unless  temporary  drainage  be  indicated. 


CHAPTER  V. 

OPERATIONS  UPON  THE  BONES. 

OSTEOTOMY  IN  GENERAL. 

Definition. — Any  division  of  bone  by  cutting  instrument. 

Indications. — Deformities  of  bones  and  joints  (such  as  result  from 
congenital  conditions) ;  diseases  of  bones  and  joints,  followed  by  weakening 
of  bone  and  subsequent  curvature  or  angularity;  malunion  following  fracture; 
ankylosis. 

Varieties. — (a)  Linear  Osteotomy;  Simple  division  of  bone  in  its  con- 
tinuity, by  simple  transverse,  oblique  or  vertical  section-line  (e.  g.,  linear 
osteotomy  of  neck  or  shaft  of  femur  for  faulty  ankylosis),  (b)  Cuneiform 
Osteotomy;  Removal  of  a  wedge-shaped  piece  of  bone  in  its  continuity  (e.  g., 
cuneiform  osteotomy  for  bent  tibia), — or  from,  or  including,  one  of  its  ends 
(e.  g.,  cuneiform  osteotomy  of  a  joint  for  ankylosis),  (c)  Osteo-arthrotomy; 
Though  not  a  distinct  variety  of  osteotomy,  may  be  considered  as  an  inter- 
articular  osteotomy,  linear  or  cuneiform. 

General  Manner  of  Performing  Osteotomy  as  to  the  Instrument. 
—Osteotomy,  in  general,  may  be  performed  with  an  osteotome,  an  instrument 
ground  evenly  from  both  sides,  and  graded  upon  its  blade  to  indicate  depth 
of  section, — with  a  chisel,  an  instrument  beveled  from  one  side  only,  and 
similarly  graded  upon  handle, — or  with  a  special  saw. 

General  Manner  of  Performing  Osteotomy  as  to  Method  of  Opera- 
tion.— (a)  Open  Method;  in  which  the  site  of  the  bone-section  is  exposed 
to  view  by  a  preliminary  operation,  (b)  Subcutaneous  or  Submuscular 
Method;  in  which  the  site  of  bone-section  is  reached  through  the  smallest, 
simplest  incision  and  the  bone  divided  out  of  sight  and  by  the  sense  of  touch. 
Cuneiform  osteotomy  is  nearly  always  done  by  the  open  method.  Linear 
osteotomy  may  be  done  by  the  subcutaneous  or  by  the  open  method — the 
former  being  more  frequently  done — the  latter  being  preferable  where  the 
safety  of  the  parts  can  be  better  preserved  by  first  exposing  them.  Cuneiform 
osteotomy  should  be  done  subperiosteally  where  possible,  and  when  not 
contraindicated  (as  by  disease).  Linear  osteotomy  should  be  done  sub- 
periosteally when  performed  by  the  open  method,  if  possible  and  not  contra- 
indicated.  Linear  osteotomy  is  usually  performed  with  an  osteotome  or  a 
saw.  Cuneiform  osteotomy  is  generally  done  with  a  chisel  (sometimes  with 
a  saw). 

Instruments  Used  in  Osteotomy. — Rubber  tourniquet;  scalpels; 
tenotomy  knives;  hemostatic  forceps;  dissecting  and  toothed  forceps;  scissors, 
curved  and  straight,  sharp  and  blunt;  retractors;  chisels,  various  sizes  and 
widths;  osteotomes,  various  sizes  and  widths;  mallets,  preferably  of  wood; 
saws,  especially  of  the  osteotomy  type  (with  narrow  blade  and  with  cutting 
part  only  at  end,  and  with  blunt  point  and  large  handle),  and  also  chain- 
saws,  Gigli  saws,  and  butcher  saw;  periosteal  elevators,  curved  and  straight; 
rugines;    raspatories;   blunt   dissector;    bone-holding   forceps;    bone-cutting 

2IO 


LIXEAR    OSTEOTOMY    BY    THE    SUBCUTANEOUS    METHOD.  211 

forceps;  needles,  straight  and  curved;  needle-holder;  chromic  and  plain 
gut;  silkworm-gut  and  kangaroo  tendon;  bone-drills;  silver  wire;  pegs  and 
nails,  ivory  and  metallic;  sand-bag  (for  part  to  rest  upon  and  dissipate  the 
jar). 

Preparation  of  Patient. — The  part  shaved. 

Position. — The  position  of  patient,  surgeon,  and  assistant  will  be  deter- 
mined by  the  special  operation. 


LINEAR  OSTEOTOMY  BY  THE  SUBCUTANEOUS  METHOD. 

Steps  of  Operation  Preparatory  to  Division  of  Bone.— Having  ex- 
sanguinated the  limb  by  elevation,  followed  by  the  application  of  a  rubber 
tourniquet  (which  may  generally  be  dispensed  with),  the  portion  of  the  limb 
involved  is  placed 
upon  a  sand-bag 
(previously  damp- 
ened and  covered 
with  several  layers 
of  wet.  sterilized  tow- 
els, to  prevent  the  fly- 
ing of  dust),  which 
forms  a  yielding  bed 
into  which  the  part 
may  be  moulded  and 
in  which  it  may  re- 
ceive the  jar  of  the 
blows  from  the  mal- 
let. An  incision,  just 
long  enough  to  ad- 
mit the  osteotome  or 
saw,  is  made  over 
the  site  of  the  bone- 
section.  The  incision 
is  as  limited  as  pos- 
sible, and  so  placed 
as  to  reach  the  bone 
by  the  most  direct 
and  safest  route,  and 
with  the  least  danger 
to  important  struc- 
tures. It  should  be, 
where  possible,  in  a 
line  with  the  over- 
lying muscle-fibers— 

should  avoid  vessels  and  nerves — and  is  generally  parallel  with  the  bone. 
This  incision  is  usually  made  directly  to  the  bone  with  one  stroke — it  being 
impossible,  from  the  small  size  of  the  wound,  to  recognize  the  intermuscular 
planes,  or  the  bone's  exact  level,  if  at  any  depth  from  the  surface.  Hav- 
ing made  a  path  to  the  bone,  the  remaining  steps  of  the  operation  will  de- 
pend upon  the  instrument  with  which  the  division  of  the  bone  is  to  be  made. 

Division  of  Bone  with  Osteotome. — Having  made  the  incision  through 


Fig.  1 6S.— Linear  Osteotomy  by  the  Sibcutaneois  Method: 
—  A.  Linear  osteotomy  of  anatomical  neck  of  femur  with  saw;  B, 
Linear  osteotomy  of  surgical  neck  of  femur  with  osteotome. 


212  OPERATIONS    UPON    THE    BONES. 

the  soft  parts  with  a  knife,  the  knife  is  not  withdrawn  but  allowed  to  remain 
in  situ  as  a  guide — upon  this  an  osteotome  (somewhat  narrower  than  the 
bone  to  be  divided)  is  introduced,  entering  the  wound  with  the  length  of  its 
cutting  edge  corresponding  to  the  length  of  the  wound.  It  is  carefully  passed 
down,  in  contact  with  the  knife,  to  the  bone,  and  the  knife  withdrawn.  The 
osteotome,  constantly  held  in  contact  with  the  bone,  is  now  turned  with  its 
cutting-edge  in  the  direction  of  the  desired  bone-section  (which  is  generally 
at  a  right  angle  to  the  incision  of  the  soft  parts).  In  the  act  of  turning  the 
osteotome  into  position,  the  soft  parts  are  levered  away  by  the  blunt  sides 
of  the  instrument,  and  the  bone  is  hugged,  but  care  is  used  not  to  detach 
the  periosteum  (which  the  knife-incision  may  have  cut)  (Fig.  168,  B).  The 
osteotome  is  held  in  the  surgeon's  left  hand  near  its  cutting  end — being  grasped 
in  his  full  hand,  the  ulnar  margin  of  his  hand  resting  on  the  patient's  limb 
to  steady  the  instrument.  The  instrument  should  cut  away  from  important 
structures,  and  preferably  toward  the  surgeon.  After  each  stroke  of  the 
mallet,  the  osteotome  should  be  shifted,  traveling  back  and  forth  in  the  line 
of  section,  that  it  may  not  bind  in  any  one  place.  In  section  of  thick  bones, 
if  the  instrument  bind,  it  is  withdrawn  and  a  thinner  (not  narrower)  one  is 
introduced — and  subsequently  a  still  thinner,  if  necessary.  Progress  through 
the  bone  is  determined  by  the  skilled  sense  of  touch.  The  section  should  be 
evenly  made,  as  to  depth,  completely  across  the  width  of  bone,  traveling 
back  and  forth,  no  two  blows  being  made  in  one  site.  Never  remove  the 
instrument  from  the  groove  in  the  bone  when  once  the  section  has  been 
commenced  (unless  a  larger  instrument  catches  in  the  section  and  has  to 
be  replaced  by  a  thinner  one),  for  it  is  often  hard  to  regain  the  groove.  The 
last  portion  of  bone  on  the  far  side  of  the  section,  when  important  structures 
are  just  beyond,  need  not  be  cut  with  the  osteotome,  but  may  be  bent  or 
broken  subsequently  by  manipulation  of  the  limb. 

Division  of  Bone  with  Saw. — A  special  osteotomy  saw,  generally  of 
the  Adams  type,  is  used.  The  operation  is  very  similar  to  that  just  described, 
except  in  the  substitution  of  the  saw  for  the  osteotome.  The  skin  incision 
is  placed  as  in  the  above  operation,  but  is  made  with  a  tenotome  instead 
of  an  ordinary  knife — usually  cutting  in  the  line  of  the  muscle-fibers  and  in 
the  axis  of  the  limb.  When  the  bone  is  reached,  the  blade  of  the  tenotome 
is  turned  so  as  to  cross  the  bone  transversely  and  is  made  to  cut  a  path  for 
the  saw  across  the  bone — the  non-cutting  part  of  the  handle  of  the  tenotome 
doing  no  harm  to  the  soft  parts  between  the  bone  and  wound  of  entrance. 
When  the  way  for  the  saw  has  been  prepared,  the  tenotome  is  left  in  situ 
as  a  guide.  Upon  this  the  blade  of  the  saw  is  introduced  down  to  the  bone 
and  its  cutting  part  pushed  on  across  the  portion  of  bone  to  be  divided  (Fig. 
1 68,  A).  The  bone  is  to  be  sawed  with  short  strokes,  guarding  against 
thrusting  the  point  of  the  saw  into  the  soft  parts,  especially  at  the  beginning 
and  ending  of  the  section.  The  section  may  be  nearly  made  with  the  saw 
and  completed  by  manual  bending  or  breaking. 

After-treatment. — Following  osteotomy,  the  limb,  or  part,  is  in  a  con- 
dition of  compound  fracture  made  under  the  most  favorable  circumstances. 
Some  form  of  splint,  or  a  plaster-dressing,  must  immobilize  the  limb  and 
keep  the  ends  of  the  bones  in  apposition.  The  wound  is  closed  by  suture 
— no  drainage  being  used  in  clean  cases. 

Comment. — (i)  In  division  by  an  osteotome,  the  osteotome  itself  is 
sometimes  used  to  cut  its  way  through  the  soft  parts,  instead  of  knife.  (2) 
When  the  bone-section  is  nearly  complete,  bending  is  especially  applicable 


LINEAR    OSTEOTOMY    BY    THE    OPEN    METHOD. 


213 


in  young  tender  bones.  (3)  The  section  of  the  bone  should  generally  be 
completed  by  instrument,  and  not  by  breaking,  as  a  splinter  of  bone  may 
do  damage  to  adjacent  parts. 


LINEAR  OSTEOTOMY  BY  THE  OPEN  METHOD. 

Steps  of  Operation  Preparatory  to  Division  of  Bone. — The  site  of 
the  bone-section  is  exposed  by  an  incision  so  placed  as  to  reach  the  bone 
most  readily  and  safely,  seeking  an  intermuscular  plane  where  possible. 
Having  passed  through  skin,  fascia — and  through  or  between  muscles — ■ 
the  soft  parts  are  opened  up  and  retracted  to  either  side — and  the  region 
of  bone  fully  exposed  to  view.  Where  it  is  possible  to  do  so,  and  where 
it  is  not  contraindicated,  the  periosteum  is  incised  in  the  long  axis  of  the 
bone,  freed  from  its  circumference,  and  retracted  with  the  soft  parts.  The 
bone-section  may  then  be  made  with  an  osteotome  or  with  a  saw: — ■ 

Division  of  Bone  with  Osteotome. — The  osteotome  is  introduced  at 
once  upon  the  bone,  in  the  direction  the  section  is  to  be  made — after  which  it 
is  manipulated  as  in  the 
subcutaneous  method — 
much  greater  control 
of  the  instrument  being 
possible. 

Division  of  Bone 
with  Saw. — -The  saw- 
is  similarly  introduced 
at  once  upon  the  bone, 
in  the  direction  the  sec- 
tion is  to  be  made. 
The  section  is  then 
made  by  short  strokes, 
while  the  parts  are  well 
retracted  and  the  entire 
operation  exposed  to 
view. 

After  -  treatment. 
— U  n  1  e  s  s  contraindi- 
cated, the  periosteum 
should  be  sutured  with 
gut — the  sutures  at  the 
same  time  passing 
through  the  muscles  and 
quilting  them  together. 
The     wound     is     then 

closed  in  the  usual  way — and  a  retentive  apparatus  applied,  as  described 
in  the  last  operation. 

Comparison. — In  subcutaneous  osteotomy  the  use  of  the  osteotome  is 
safer,  less  damaging,  and  the  section  is  cleaner  than  by  the  saw.  In  open 
osteotomy  the  saw  is  preferable,  especially  the  chain  or  Gigli  saw.  In  the 
open  method,  while  a  larger  wound  of  entrance  is  made,  the  bone-section 
is  more  accuratelv  made  and  less  damage  is  done  to  the  neighboring  tissues. 


Fig.  169, 


-Cuneiform  Osteotomy: — Chisel  is  shown  removing 
wedge-shaped  piece  of  bone  from  bent  tibia. 


214  OPERATIONS    UPON    THE    BONES. 


CUNEIFORM  OSTEOTOMY. 

Description. — A  wedge-shaped  piece  of  bone  is  removed,  the  size  of 
which  is  determined  by  the  needs  of  the  case — the  general  rule  being  that 
the  sides  of  the  wedge  should  be  at  right  angles  to  the  axis  of  the  bone  just 
above  and  below  the  section — ordinarily,  however,  a  smaller  wedge  suffices. 
The  wedge  usually  extends  entirely  through  the  bone,  its  base  being  upon 
one  surface  and  the  apex  upon  the  opposite — but  it  may  extend  only  two- 
thirds  or  three-fourths  of  the  way  through,  the  balance  being  bent  or  broken. 
The  operation  is  nearly  always  done  by  the  open  method. 

Operation. — Having  exsanguinated  the  limb  by  elevation,  followed  by 
the  application  of  a  rubber  tourniquet  (which  is  much  more  frequently  used 
than  in  the  linear  form  of  osteotomy)  the  limb  is  placed  upon  a  sand-bag. 
The  incision  is  placed  over  the  site  of  the  base  of  the  wedge  to  be  removed 
and  is  considerably  longer  than  the  base  of  the  wedge — and  is  so  planned 
as  to  enable  the  bone  to  be  reached  through  the  most  direct  and  safest  route, 
and  to  enable  the  muscles  to  be  separated  rather  than  cut.  The  skin  and 
fascia  are  first  incised — the  muscles  separated  in  their  intermuscular  cleavage 
line  and  retracted — and  the  periosteum  incised  in  the  axis  of  the  bone,  down 
to  the  bone,  and  retracted  with,  and  adherent  to,  the  soft  parts.  This  clearing 
of  the  bone  subperiosteally  is  accomplished  with  a  curved  periosteal  elevator, 
the  clearing  being  done  more  extensively  at  the  site  corresponding  with  the 
base  of  the  wedge.  The  chisel  is  the  best  instrument  with  which  to  perform 
cuneiform  osteotomy — though  a  chain  or  Gigli  saw  may  sometimes  be  used 
advantageously,  and  even  an  ordinarv  saw  may  be  conveniently  used  in 
some  cases  of  angular  ankylosis  (Fig.  169).  The  chisel  is  held  like  an  osteo- 
tome, for  the  sake  of  steadiness.  The  beveled  edge  of  the  chisel  is  directed 
toward  the  wedge  of  bone  to  be  removed.  If  the  wedge  be  of  considerable 
size,  it  cannot  be  removed  with  accuracy  in  one  piece — a  small  wedge,  narrow 
at  its  base,  must  be  first  removed — and  then  slices  may  be  chiseled  from  the 
sides  of  this  until  a  cuneiform  space  representing  a  wedge  of  the  requisite 
size  is  removed.  Having  removed  the  wedge  of  bone,  the  ends  of  the  bone 
are  put  into  position — the  periosteum  is  sutured  with  gut — the  wound  closed 
— and  the  limb  put  up  in  an  immovable  splint. 

Comment. — In  this,  as  in  the  other  forms  of  osteotomy,  additional 
means  may  be  used  for  holding  the  divided  ends  of  the  bone  in  place,  besides 
the  special  form  of  splint — such  as  wiring,  pegging,  suturing,  and  other 
devices  mentioned  under  operations  for  ununited  fractures. 


THE  OPERATIVE  TREATMENT  OF  FRACTURES   IN   GENERAL.1 

Operations  for  ununited  fractures  resolve  themselves,  as  far  as  the  forms 
of  the  bones  are  concerned,  into  three  classes — those  for  fractures  of  the  long 
bones — of  the  short  bones — and  of  the  mixed  bones.  The  general  principles 
involved  are  the  same  in  all  classes.  Fractures  of  some  special  bones  require 
special  treatment. 

1  Much  of  what  follows  upon  this  subject  is  taken  from  a  paper  read  by  the  author  upon 
"The  Operative  Treatment  of  Fractures  in  General,''  before  the  surgeons  of  the  Chicago, 
Hamilton,  and  Dayton  Railway,  at  Dayton,  Ohio;  and  before  the  New  York  Post-Graduate 
Clinical  Society,  and  is  here  reproduced  or  modified  by  their  courtesy. 


RESECTION    FOR    FRACTURED    BONES.  215 

The  principles  involved: — the  placing  of  freshened  ends  of  bones  in  good 
position,  without  too  great  tension,  and  without  intervening  soft  parts — and 
the  maintaining  of  these  ends  strictly  in  position  by  competent  immobilizing 
splint. 

Following  is  a  brief  summary  of  the  technic  employed  in  the  majority  of 
cases; — exposure  of  ends  of  bones  as  nearly  subperiosteally  as  possible — 
resection  of  the  ends  as  nearly  transversely  as  the  nature  of  the  fracture  will 
permit — if  the  ends  of  the  bones  can  be  easily  approximated  and  easily  retained 
in  position,  place  them  in  apposition,  suture  the  periosteum,  approximate 
the  muscles  by  buried  sutures,  close  the  wound,  and  apply  an  immobilizing 
splint.  If  the  ends  are  not  likely  to  be  easily  kept  in  approximation  (especiallv 
as  the  result  of  an  oblique  section),  one  of  the  methods  of  holding  them  in 
apposition  (to  be  described  below)  may  be  resorted  to — in  addition  to  placing 
the  ends  in  contact  and  applying  a  retentive  form  of  apparatus. 

In  operating,  some  form  of  tourniquet  is  usually  applied.  The  site  of 
operation  is  to  be  shaved.  The  position  of  patient,  surgeon,  and  assistant 
will  be  determined  by  the  special  operation. 

The  instruments  used  are  those  employed  for  Osteotomy  (page  210). 

The  subject  of  the  Operative  Treatment  of  Fractures  may  be  considered 
under  several  headings: — (I)  Operative  Methods  of  Approximating  and 
Fixing  Ends  of  Fractured  Bones — (2)  Operative  Treatment  of  Simple  Frac- 
tures— (3)  Bone  Grafting,  or  Implantation — (4)  Operative  Treatment  of 
Delayed  Union,  Non-union  and  Mal-union — (5)  Operative  Treatment  of 
Compound,  Comminuted,  and  Complicated  Fractures — (6)  Operative  Treat- 
ment of  Fractures  Involving  Joints,  and  of  Fracture-dislocations — and  (7) 
Operative  Treatment  of  Separated  Epiphyses. 

The  results  to  be  aimed  at  in  fracture-treatment  are — union  without 
deformity — without  impairment  of  function  of  limb — and  with  as  limited 
loss  of  time  and  usefulness  as  possible. 

To  summarize  the  status  of  fracture-treatment,  it  may  be  said  that  the 
present  treatment  of  fractures  is  in  a  transitional  stage — and  is  now  in  the  act 
of  passing  from  the  routine,  hard-and-fast,  prolonged  splinting,  which  was 
in  common  use  until  a  very  short  time  ago — to  the  more  rational  methods 
of  the  present  time,  which  include  the  use  of  early  passive  movements  and 
massage  in  conjunction  with  removable  splints,  and  the  practice  of  open 
incision  in  appropriate  cases. 

Various  methods  are  in  use  for  bringing  the  ends  of  fractured  bones  into 
apposition  and  holding  them  in  place  until  bony  union  has  occurred.  The 
best  form  of  internal  fixation  for  the  special  case  cannot  be  known  in  advance 
of  the  actual  exposure  of  the  parts  involved.  The  technic  of  exposing  the 
ends  of  the  bones,  however,  does  not  materially  differ,  no  matter  what  form 
of  internal  fixation  be  employed — and  this  technic,  therefore,  will  be  first 
briefly  described — and  then  will  be  enumerated  the  most  generally  used 
methods  resorted  to  for  holding  the  broken  bones  together. 


OPERATION  FOR  RECENT  OR  UNUNITED  FRACTURE  BY  RESECTION 

OF  ENDS  OF  BONES,  WITH  RETENTION  OF  COAPTATED  ENDS  BY 

IMMOBILIZING  SPLINTS. 

Description. — The  ends  of  the  bones  are  exposed  and  excised,  and  the 
freshened  ends  are  then  brought  into  contact  and  held  in  apposition  by  a 
splint  or  a  plaster  cast. 


2l6 


OPERATIONS    UPON    THE    BONES. 


Take,  fur  an  example  of  the  technic,  the  operation  for  the  repair  of  a 
simple  recent  fracture  by  resection  of  the  ends  of  the  bones,  with  retention  of 
the  coaptated  ends  by  immobilizing  splints — where  no  form  of  mechanical 
fixation  is  used  other  than  that  secured  by  placing  the  ends  of  the  sawn  bones  in 
proper  relation  and  holding  them  in  such  relation  by  splints.  (And  what  is 
here  said  of  recent  fractures  applies  also  to  ununited  fractures.)  In  many  cases 
of  recent  fracture  the  nature  of  the  broken  ends  might  be  such  as  not  to  require 
their  resection  prior  to  the  application  of  the  special  form  of  internal  fixation. 

Operation. — Hav- 
ing exsanguinated  the 
limb  and  applied  a 
tourniquet,  an  inci- 
sion, sufficiently  free 
to  allow  of  protrusion 
of  the  ends  of  the 
bones,  is  made  in  the 
long  axis  of  the  limb, 
directly  over  the  ends 
of  the  bones — and 
placed  so  as  to  give 
free  access  by  the  most 
direct  and  safest  route 
to  the  involved  site. 
The  skin  and  fascia 
are  divided — the  mus- 
cles are  separated  in 
their  intermuscular 
planes  and  retracted 
— or,  if  separation  of 
the  muscles  in  their 
planes  be  impossible, 
they  are  divided  as  nearly  in  the  direction  of  their  fibers  as  possible.  Important 
vessels  and  nerves  are  carefully  avoided,  being  retracted  to  one  side.  The  wound 
is  made  fully  large  and  the  lateral  retraction  of  the  soft  parts  sufficient  to  make 
the  necessary  manipulations  possible  without  adding  to  the  traumatism. 
The  ends  of  the  bones  are  fully  exposed  and  entirely  freed  of  all  tissue  which 
may  intervene  between  the  fragments,  whether  normal  or  cicatricial.  As 
the  ends  of  the  bones  are  approached,  care  is  taken  to  avoid  injuring  the 
periosteum — which  should  be  split  longitudinally  and  freed  circumferentially 
from  the  ends  of  the  bones,  without  otherwise  severing  its  connection,  and 
should  be  raised  without  separation  of  overlying  muscle,  that  is,  as  a  musculo- 
periosteal  covering.  The  end  of  each  bone  is  dealt  with  in  turn,  and,  after 
being  thoroughly  freed,  is,  where  possible,  protruded  through  the  wound, 
the  limb  being  bent  at  an  angle  for  this  purpose  and  the  soft  parts  well  retracted, 
the  periosteum  being  carefully  peeled  back  during  this  step.  A  minimum 
slice  of  bone  is  now  removed  from  the  end  of  each  bone,  simply  enough  to 
insure  a  fresh,  raw  surface  upon  each.  If  the  bones  have  been  protruded, 
this  section  is  generally  best  made  with  a  butcher's  saw.  If  the  ends  have 
not  been  protruded  through  the  wound,  after  they  have  been  well  freed,  it  is 
best  to  slip  a  chain  or  Gigli  saw  between  the  bone  and  the  periosteum  and  thus 
make  the  section.  The  section  may  also  be  made,  though  generally  less 
satisfactorily,  with  a  chisel.  The  direction  of  the  section  will  depend  largely 
upon  the  nature  of  the  ends  of  the  bone; — if  a  rather  transverse  fracture,  the 


C  D 

-I. — Operations  for  Ununited  Frac- 
tures by  Simple  Section: — A,  B,  Simple  transverse  fracture, 
followed  by  transverse  section  of  bones;  C,  D,  Irregularly  trans- 
verse fracture,  followed  by  section  of  bone  parallel  with  fractures. 


SUTURING    FOR    FRACTURED    BONES. 


217 


section  is  made  transversely; — if  a  very  oblique  fracture,  the  section  is  made 
obliquely  (Figs.  170-173,  A,  B,  C,  D;  and  Figs.  174-177,  A,  B,  C,  D). 
Whether  the  section  be  made  transversely  or  obliquely,  the  section  is  so  planned 
as  to  leave  a  limb  in  correct  position,  as  to  its  axis  and  as  to  its  rotation,  and 
is  so  made  as  to  secure 
two  parallel  surfaces  for 
contact.  An  exception 
to  this  is  where  some 
special  form  of  section  is 
made,  as  when  the  bones 
are  so  sawed  as  to  have 
an  angularity  of  one  fit 
into  a  depression  of 
another,  producing  the 
mortising  effect — the 

great  principle  being  that 
the  ends  of  the  bones 
should  be  cut  so  as  to  fit 
each  other.  A  transverse 
section  of  the  bones  is 
always  preferable,  unless 
involving  too  great  a  sac- 
rifice of  length.  The 
ends  are  now  approx- 
imated in  the  position  in 
which  the  bones  will  re- 
main, and  are  held  in  this 
position  during  the  re- 
mainder of  the  operation  and  until  the  permanent  splint  be  applied.  The 
periosteum  is  sutured  with  gut.  The  muscles  are  brought  together  with  buried 
gut  sutures.  The  outer  wound  is  closed  in  the  usual  way.  The  limb  is  then 
placed  in  a  permanent  splint,  or  in  a  plaster  cast,  with  extreme  care,  so  steady- 
ing the  parts  during  the  dressing  that  the  ends  of  the  bones  remain  undisturbed. 
Where  the  case  is  one  of  mal-union,  either  the  ends  of  the  mal-united  bones 
are  excised,  or  the  badly  united  ends  are  sawn  or  chiseled  apart,  after  which, 
in  either  case,  the  ends  are  treated  as  in  cases  of  non-union. 

Comment. — (i)  The  operation  is,  practically,  that  of  osteotomy  by  the 
open  method.  (2)  In  a  recent  case,  the  after-treatment  is  that  of  a  compound 
fracture,  with  the  limb  put  up  in  a  position  to  relax  the  pull  on  the  fractured 
ends.  (3)  In  old  cases  where  bands  of  fascia,  or  tendons,  are  apt  to  draw 
the  ends  out  of  place,  these  should  be  divided.  (4)  Where  it  seems  likely 
that  the  ends  of  the  bones  will  tend  to  displacement,  especially  in  such  cases 
as  the  femur,  a  process  of  mortising  may  be  carried  out  in  fashioning  the 
ends  of  the  bones  for  approximation. 


-II. — Operations  for  Ununited 
Fractures  by  Simple  Section: — A,  B,  Wedge-shaped  and 
C,  D,  rectangular  fracture,  followed  by  section  of  bone  par- 
allel with  fracture. 


OPERATION  FOR  RECENT  OR  UNUNITED  FRACTURE  BY  SUTURING 
OF  ENDS   OF  BONES,  WITH   OR  WITHOUT  RESECTION. 

Description. — Instead  of  simple  approximation  of  the  broken  ends  and 
their  retention  by  splints  applied  to  the  outer  surfaces  of  the  limb,  some  form 
of  mechanical  device  may  be  also  used  to  hold  together  the  ends  of  the  bones 
themselves.     In  such  cases,  having  exposed  the  site  of  fracture  by,  approx- 


2l8  OPERATIONS    UPON    THE    BONES. 

imately,  such  steps  as  those  just  described,  the  broken  ends  of  the  bone  are 
now  to  be  brought  into  apposition  and  fixed  by  some  special  method  selected 
by  the  surgeon — of  which  the  following  are  the  chief  procedures  in  use — it 
being  understood  that  these  methods  apply  equally,  whether  the  case  be  a 
recent  fracture,  an  old  fracture  with  pseudarthrosis,  a  non-union,  a  mal-union, 
a  simple  fracture,  or  a  compound  fracture — and  whether  the  form  of 
fixation  be  employed  after  the  ends  of  the  bone  have  been  resected,  or 
without  resection.  In  the  method  about  to  be  described,  in  addition  to 
the  retention  of  the  coaptated  ends  of  the  bones  by  splints,  the  ends 
are  previously  drilled  and  held  in  contact  by  some  form  of  suturing.  In 
the  case  of  new  fractures,  where  the  ends  are  left  so  shaped  as  likely  to  remain 
in  position  when  sutured,  resection  of  the  ends  of  the  bones  need  not  be  done 
— otherwise  the  ends  should  be  resected.  In  all  cases  of  old  fracture  the 
ends  of  the  bones  are  always  resected,  so  as  to  present  freshened  surfaces.     As 


Fig.   178. — Method  of  Drilling  Bone  for  Wiring: — A,  Bone-holding  forceps;  B,  hand-drill. 


the  chief  dependence  is  in  the  ultimate  bony  union  between  the  fractured 
or  resected  ends,  and  as  the  chief  function  of  the  retaining  substance  is  tem- 
porarily to  hold  the  ends  in  position  until  union  is  sufficiently  advanced  to  fix 
the  ends  of  the  bones  firmly  and  permanently,  it  is  unquestionably  best  to  use 
the  material  which,  while  fulfilling  that  temporary  office,  will  then  disappear 
of  its  own  accord  and  give  no  future  trouble — and,  therefore,  kangaroo  tendon, 
or  heavy,  30-40-day  chromic  gut,  is  the  ideal  material  for  this  purpose.  Of 
the  soft  materials,  silk  and  silkworm  gut  are  also  used.  Of  the  non-absorbable 
metallic  substances  used,  silver  wire  is  the  most  frequently  employed.  The 
wire  should  be  of  different  sizes  for  different  bones.  It  should  be  of  pure 
silver,  or  it  will  not  stand  as  much  strain  on  twisting.  It  should  be  cut  into 
lengths  and  straightened.  Each  piece  should  be  heated  to  a  dull  red  heat  in 
the  flame  just  before  using  (in  order  to  make  it  much  more  pliable  and  less  apt 
to  break) — then  cooled  and  dropped  into  sterile  solution  ready  for  use.  Some- 
times wire  is  used  with  the  intention  that  it  should  only  remain  in  temporarily 
and  be  removed  when  its  usefulness  is  at  an  end — -but  generally  it  is  hoped 


SUTURING    FOR    FRACTURED    BONES. 


219 


that  it  will  remain  in  permanently — the  ends  of  the  wire,  therefore,  are  treated 
according  to  the  views  entertained.  The  general  method  of  applying  the 
suture,  no  matter  what  the  material,  is  the  same. 

Operation. — The  steps  of  the  operation  are  the  same,  in  all  respects,  as 
for  resection  with  retention  by  splints — up  to  the  exposure  and  clearing  of 
the  ends  of  the  bones — after  which  the  technic  will  differ,  dependent  upon 
whether  the  bones  are  resected  or  not; — (a)  Suturing  of  the  bones  without 
resection: — The  ends  of  the  bones  are  grasped  and  steadied  by  some  special 
foim  of  bone-holding  forceps,  while  holes  for  the  passage  of  wire  are  drilled 
— sufficient  in  number  to  furnish  the  desired  strength  and  so  planned  in 
position  as  to  retain  the  normal  axis  of  the  bone  (Fig.  178).  The  holes  may 
be  drilled  and  the  suture  passed  in  several  ways.  Where  the  fracture  is 
practically  a  transverse  division  of  the  bone,  the  drill-holes  are  usually  made 
to  pass  through  one  wall  of  the  upper  and  the  corresponding  wall  of  the  lower 
fragment,  the  suture  thus  passing  through  but  a  small  portion  of  the  medulla 
of  the  bone  (Figs.   179-181,  A,  B,  C).     In  the  case  of  an  oblique  fracture, 


Figs.  179-181. — Operations  for  Un- 
united Fractures  by  Section  \nd  Sutur- 
ing : — I. — In  transverse  fractures; — A,  Single 
suture  through  both  walls  of  each  bone;  B, 
Double  suture  through  both  walls  of  each 
bone;  C,  Sutures  passed  through  single  wall 
of  each  end.  These  forms  may  be  used 
without  section  of  bone. 


C1      m 


Figs.  1S2-1S4. — Operations  for  Un- 
united Fractures  by  Section  and  Suturing: 
— II. — In  oblique  fractures; — A,  Double  sutures 
through  both  walls  of  each  end,  in  axis  of  bone 
(not  advisable);  B,  Same,  crossing  fracture  at 
right  angle  (advisable);  C,  Loop  of  suture 
carried  through  drill-hole,  and  free  ends  brought 
around  bone  and  through  loop  and  twisted. 
These  forms  may  be  used  without  section  of 
bone. 


the  holes  may  be  drilled  and  the  suture  passed  in  the  same  way — or  the 
fragments  may  be  held  in  position  and  the  holes  drilled  through  opposite 
walls  and  the  intervening  medullary  substance  (Figs.  182-184).  In  the 
case  of  wire,  the  ends,  in  either  of  the  methods  above  mentioned,  may  then 
be  twisted,  cut  short,  and  pressed  into  the  periosteum  and  bone — or  may 
be  twisted  long  and  brought  out  of  the  wound  (Figs.  185-187  and  188-190). 
In  both  methods  the  periosteum  is  pierced  by  the  suture,  though  elsewhere  it  is 
preserved  as  intact  as  possible  upon  the  bones.  In  previously  drilling  the 
holes  for  the  passage  of  the  suture,  the  most  useful  instrument  to  have  at  hand, 


220 


OPERATIONS    UPON    THE    BONES. 


next  to  one  of  the  many  forms  of  bone-drill,  is  a  pair  of  stout  bone-holding 
forceps  with  fenestrated  blades — by  which  the  bone  is  firmly  held  and  through 
the  fenestrated  openings  of  which  the  drill  is  applied,  thus  steadying  both  the 
bone  and  the  drill-point  (Fig.  178).  (b)  Wiring  of  the  bones  after  resection: — 
The  resection  of  the  ends  of  the  bones  is  accomplished  just  as  in  the  operation 
for  ununited  fracture  by  resection  of  the  ends  of  the  bones,  with  retention  of 
the  coaptated  ends  by  immobilizing  splints  (page  215).  The  ends  of  the  bones 
are  then  drawn  back  into  their  musculo-periosteal  sheaths — and  the  ends  are 
then  sutured  as  in  (a)  above.  Following  the  approximation  of  the  ends 
of  the  bones,  the  periosteum  is  sutured  with  gut — the  muscles  are  brought 
together  with  buried  gut  sutures — the  outside  wound  closed  as  usual — and 


Figs.  185-187. — Operations  for  Un- 
united Fractures  by  Section  and  Wir- 
ing:— III. — By  simple  loop-ligatures: — A, 
By  double  loops  around  bone  at  right  angle 
to  axis  of  bone;  B,  Double  loops  at  right 
angle  to  line  of  oblique  fracture;  C,  Double 
loops,  as  in  A,  reinforced  by  lateral  wire- 
loops.  These  forms  may  be  adopted  without 
section  of  bone. 


Figs.  188-190. — Operations  for  Ununited 
Fractures  by  Section  and  Wiring: — IV. — By 
frame-ligature;  A,  B,  C,  First,  second,  and  third 
stages  of  the  frame-ligature. 


an  immobilizing  splint  applied.  The  wire  is  not  expected  to  be  removed 
when  buried, — when  left  long,  it  is  subsequently  (after  firm  union)  untwisted 
and  drawn  out,  to  accomplish  which  it  is  sometimes  necessary  to  expose  the 
parts  by  incision  down  to  the  bone. 

Comment. — The  drill-holes  should  be  a  little  larger  than  the  silver  wire 
used.  The  wire  should  be  fairly  heavy.  The  holes  are  drilled  from  8  mm. 
to  1.3  cm.  (I  to  \  inch)  from  the  ends  of  the  bones,  penetrating  obliquely 
if  but  one  wall  of  the  upper  and  one  wall  of  the  lower  fragment  be  drilled — 
and  penetrating  at  a  right  angle  to  the  surface,  if  the  drilling  pass  transversely 
through  opposite  walls.  In  drilling  for  oblique  fracture,  the  suture  should 
pass  at  a  right  angle  to  the  line  of  fracture. 


METHODS    OF    FIXING    ENDS    OF    FRACTURED    BONES.  221 

OTHER   OPERATIVE  METHODS  OF  APPROXIMATING  AND  FIXING 
ENDS  OF  FRACTURED  BONES. 

In  the  various  forms  of  mechanically  uniting  ununited  bones,  about  to  be 
described,  the  preliminary  steps  of  exposing  and  preparing  the  ends  of  the 
bones  for  coaptation,  whether  resection  has  been  done  or  not,  are  the  same 
as  those  given  in  the  preceding  operations. 

Union  of  Fractured  Bone  by  Metallic  Nails  or  Ivory  Pegs. — While 
the  ends  of  the  bones  are  held  in  firm  contact  in  the  grip  of  strong,  fenestrated, 
bone-holding  forceps,  plated  nails  are  so  driven  as  to  bind  both  ends — or 
ivory  pegs  are  inserted  through  previously  drilled  holes.  The  nails  usually 
protrude  through  the  skin  and  are  subsequently  withdrawn  (in  about  two 
weeks) — whereas  ivory  pegs  are  generally  cut  flush  with  the  bone  and  are 
left,  in  the  hope  that  they  will  become  incorporated  with  the  osseous  tissue 
(or  they,  too,  may  be  left  long  and  be  withdrawn).  If  the  fracture  or  section 
be  transverse,  the  nails  or  pegs  are  put  in  obliquely,  passing  from  without 
through  the  proximal  wall  of  the  upper  fragment,   through  the  medullary 


Fig. 


191. — Uniting   Fractured    or    Re- 
sected   Bone    by    Nailing. 


Fig.    192. — Uniting    Fractured    or   Re- 
sected    Bone     by     Pegging. 


substance,  and  into  the  wall  of  the  lower  fragment,  from  within  outward. 
Two  or  more  nails  or  pegs  are  generally  inserted,  passing  in  different  direc- 
tions (Figs.  191  and  192).  If  the  section,  or  fracture,  be  oblique,  the  nails 
are  put  in  at  a  right  angle  to  the  surface  of  bone  and  pass  transversely  through. 
As  little  damage  as  possible  is  done  to  the  periosteum.  The  muscles  are 
brought  together  by  buried  gut  sutures — the  wound  closed — and  the  limb 
immobilized. 


2  22 


OPERATIONS   UPON   THE    BONES. 


Union  of  Fractured  Bone  by  Metallic  Screws. — The  technic  is  here 
very  similar  to  that  in  the  lust  proceeding,  except  that  plated  screws  replace 
the  nails.  The  holes  for  the  screws  which  bind  the  two  fragments  are  first 
drilled  of  a  slightly  smaller  size  than  the  diameter  of  the  screws — which  are 
driven  home  with  a  screw-driver  until  their  heads  are  flush  with  the  periosteum. 
It  is  necessary  to  have  a  large  variety  of  screws  on  hand,  especially  as  to 
length.  They  may  remain  permanently  in  situ — or  may  be  cut  down  upon 
and  unscrewed. 

Union  of  Fractured  Bone  by  Metallic  Plates  and  Screws. — Following 
the  technic  of  Steinbach,  silver  plates  of  various  sizes  and  shapes  are  used, 
secured  in  position  by  small  galvanized  steel  screws — those,  for  example,  for 
the  tibia,  their  most  useful  field  of  application,  are  6  mm.  (\  inch)  thick, 
g  cm.  (T>h  inches)  long,  and  8  cm.  (j|  inches)  wide,  and  with  screw-holes  1.2  cm. 
(|  inch)  apart.  Having  retracted  the  soft  parts  without  disturbing  the 
periosteum,  the  screw-holes  are  first  drilled  a  size  slightly  smaller  than  the 
screws,  some  into  the  upper  fragment,  some  into  the  lower,  and  the  drilling 
is  continued  until  loss  of  substance  shows  that  the  medullary  cavity  has  been 
entered,  when  the  screws  are  driven  firmly  into  place  by  means  of  a  screw- 
driver.    When  bony  union  is  solid,  the  plate  is  generally  cut  down  upon  and 


Figs.    193  and  194. — Uniting  Fractured  or  Resected  Bone  by  Screwing: — Screws  may 
be  used  alone — or  in  metallic  plates,  as  shown  in  diagram  to  left. 


the  screws  unscrewed,  and  all  removed.     The  plate  is  sometimes  left  per- 
manently in  situ  (Figs.   193  and  194). 

Union  of  Fractured  Bone  with  Metallic  or  Bone  Ferrules. — Rings  of 
thin  metal,  of  some  width,  or  of  bone,  are  slipped  over  the  ends  of  the  broken 
bone — especiallv  in  the  case  of  oblique  fractures.  The  metallic  ferrule  is 
difficult  to  remove,  should  it  become  necessary,  even  if  split  on  one  side.  The 
bone  ferrule  becomes  absorbed. 


METHODS    OF    FIXING    ENDS    OF    FRACTURED    BONES. 


223 


Union  of  Ununited  Fracture  by  Parkhill's  Clamp. — The  fragments 
of  bone  are  here  held  together  by  means  of  a  special  form  of  clamp  consisting 
of  four  long  steel  screw-pins  and  an  interlocking  mechanism.  The  ends  of 
the  bones  are  exposed  and  freed  in  the  ordinary  manner — and  resected,  if 
necessary.  Two  holes  are  drilled  in  the  long  axis  of  each  fragment,  in  direct 
line  with  each  other.  Four  long  steel  screw-pins  are  then  screwed  into  these 
holes  by  means  of  a  clock-key  attachment — after  which  the  "wings"  of  the 
instrument  are  adjusted.  While  the  ends  of  the  bones  are  held  in  accurate 
apposition  and  care  taken  that  the  proper  axis  of  the  bone  is  secured,  the 
two  fragments  are  clamped  together  in  the  special  manner  of  the  instrument. 
The  muscles  and  other  soft  parts  are  then  adjusted  about  the  screws  of  the 
clamp,  which  projects  without  the  wound.     The  dressing  is  then  applied — 


Fig.  195. — Operation  for  Fractured 
or  Resected  Bone  by  Parkhill's  Bone- 
clamp: — Surface  view  of  clamp  in  position. 


Fig.  196. — Operation  for  Fractured 
or  Resected  Bone  by  Parkhill's  Bone- 
clamp: — Side  view  of  clamp  in  position. 


and  the  pins  of  the  clamp  not  removed  for  from  four  to  six  weeks  (Figs.   195 
and  196). 

Ligation  of  Bone. — One  or  more  pieces  of  wire  are  passed  around  the 
fractured  portion  of  bone,  either  at  a  right  angle  to  the  axis  of  the  bone  or 
at  a  right  angle  to  the  line  of  fracture.     These  are  twisted,  cut  short,  and 


224 


OPERATIONS    UPON    THE    BONES. 


buried.  The  bone  may  be  notched  to  aid  in  holding  the  wire  in  place.  Longi- 
tudinal Loops  may  unite  the  circumferential  wire  bands  (Figs.   185-187 ). 

Combined  Ligature  and  Suture. — A  hole  is  drilled  through  the  frag- 
ments at  a  right  angle  to  their  line  of  fracture — a  loop  of  wire  is  passed  through, 
given  a  half-turn  in  the  center,  and  the  two  ends  passed  around  the  sides  of 
the  bone  and  through  the  loop  and  twisted  (Fig.   184,  C). 

Frame  Ligature  of  Bone.— Drill  two  holes  through  the  fragments, 
in  the  long  axis  of  the  bone — pass  the  free  ends  of  a  wire  loop  through  the 
holes — pass  the  loop  over  the  free  ends  and  draw  tight — then  bring  the  -free 
ends  around  to  the  holes  through  which  the  looped  end  originally  passed  and 
carry  them  under  the  wires  emerging  from  those  holes  and  twist  them  together 
in  the  long  axis  of  the  bone  (Figs.   188-190). 

Intramedullary  Pegging. — Pegs  of  ivory,  or  of  fresh  or  decalcified 
bone,  are  lightly  driven  into  the  medullary  canal  of  one  bone,  and  the  ends 
of  the  fractured  bone  so  displaced,  temporarily,  as  to  enable  the  medullary 
cavity  of  the  opposite  fragment  to  be  slipped  over  the  opposite  end  of  the 
peg  (Figs.   197  and  198).     Where  there  has  been  a  loss  of  substance  of  bone 


Figs.  197  and  198. — Operation  for 
Fractured  or  Resected  Bone  by  Intra- 
medullary Pegging: — A,  Peg  is  seen  in 
medullary  cavity  of  lower  bone,  and  about  to 
be  introduced  into  that  of  upper;  B,  Peri- 
osteum is  being  sutured  along  margins  of  bone. 


Fig.  199. — Operation  jor  Fractured 
or  Resected  Bone  by  Intramedullary 
Pegging  : — Where  part  of  one  bone  has  been 
excised  and  periosteum  is  being  sutured 
around  peg. 


and  the  periosteum  corresponding  to  the  absent  bone  is  preserved,  this  has 

been  sutured  over  the  bone  peg  with  success,  especially  in  the  young  (Fig.   199). 

Summary. — In  summing  up  the  subject  of  the  mechanical  fastening  of 

the  ends  of  broken  bones,  it  will  be  seen  that  the  uniting  substance  may  be 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES.  225 

buried  in  tissues  with  the  hope  that  it  will  remain  quiescent — or,  if  suitable 
for  absorption,  that  it  will  be  absorbed — while,  on  the  other  hand,  substances 
are  sometimes  put  in  temporarily,  with  the  purpose  of  removing  them  when 
they  have  accomplished  their  object  and  the  parts  have  become  solidly  united. 
The  best  method  can  only  be  determined  when  the  parts  are  exposed — and  the 
best  method  of  internal  fixation  is  that  method  which  immobilizes  most 
efficiently.  The  guide  for  the  selection  of  the  special  form  of  this  internal 
fixation  will  depend,  in  part,  upon  the  special  bone  involved  and  the  nature 
of  the  fracture — and,  in  part,  upon  the  views  and  habits  of  the  surgeon  as  to 
retentive  appliances.  The  judgment  of  the  writer  would  be  distinctly  in 
favor  of  kangaroo  tendon,  or  30-40-day  chromic  gut — as  being  an  absorbable 
substance,  and  as  being  a  method  of  wider  range  of  applicability  to  the  various 
fractures  of  the  body  than  any  other.  The  strength  of  either  of  these  sub- 
stances is  sufficient  to  retain  the  ends  of  fractured  bones  in  contact  the  necessary 
length  of  time,  if  properly  handled— at  the  end  of  which  time  absorption  usually 
renders  any  further  dealing  with  the  wound  unnecessary.  If  the  limb  be 
carefully  held  by  an  assistant  assigned  to  that  duty  alone,  so  that  the  tendon  or 
gut  is  not  put  upon  the  stretch  before  the  limb  is  secured  in  its  splint,  these 
substances  would  probably  never. stretch  to  an  extent  harmful  to  the  interests 
of  the  fracture,  as  claimed — and  which  has  been  an  objection  raised  by  some. 


OPERATIVE  TREATMENT  OF   SIMPLE  FRACTURES. 

Of  the  various  applications  of  operative  treatment  to  fractures,  the  question 
of  the  operative  treatment  of  simple  fractures  is  probably  the  most  interesting 
at  the  present  time,  for  not  only  is  the  field  for  the  application  of  operative 
interference  greater  in  simple  fractures  than  in  any  other  form  of  fracture, 
or  in  any  result  of  fracture,  but  the  practice  itself  is  comparatively  new,  and 
the  opinion  of  the  profession  at  large  has  not  yet  been  definitely  formulated 
as  to  the  full  scope  of  the  technic  and  the  variety  of  cases  to  which  it  should 
be  applied. 

As  matters  stand  at  present,  the  number  of  surgeons  who  are  operating 
in  cases  of  simple  fracture  seems  to  be  steadily  increasing. 

Compound  or  open  fractures  have  always  received  some  form  of  operative 
treatment,  if  only  to  the  extent  of  cleaning  the  site  and  putting  the  parts  into 
favorable  position  for  repair,  and  comminuted  and  complicated  fractures 
have  frequently  received  such  treatment,  so  that  the  application  of  a  somewhat 
more  radical  operative  treatment  than  heretofore  to  these  classes  of  cases  is 
not  so  distinctly  new — but  the  treatment  of  simple  or  closed  fractures  is  a 
new  field  brought  up  in  surgery  during  comparatively  recent  years. 

The  argument  that  the  operative  treatment  of  simple  fractures  converts 
every  simple  fracture  into  a  compound  fracture  does  not  carry  with  it  the  same 
gravity  as  formerly,  for  in  the  vast  majority  of  cases  such  a  procedure  carried 
out  with  thorough  asepsis  is  accompanied  by  comparatively  little  risk.  It  may 
be  said  that  the  way  to  the  operative  treatment  of  simple  fractures  was  paved 
by  the  operations  of  osteotomy,  by  the  subcutaneous  and  open  methods,  for 
all  such  operations  made  compound  fractures  of  the  cases,  and  results  in  such 
instances  nearly  invariably  come  to  a  satisfactory  conclusion  without  untoward 
complications. 

*The  special  objects  accomplished  by  the  open  operation  in  fractures,  in 
those  cases  where  it  is  indicated,  are  the  following: — ends  of  bones  may  be 
accurately  approximated  by  fingers  and  instruments  while  in  view  and  acces- 
l5  ' 


226  OPERATIONS    UPON    THE    BONES. 

sible  in  the  field; — these  ends  may  be  permanently  fixed  in  normal  position  by 
whatever  means  are  chosen; — some  fractures  which  cannot  be  reduced  at  all 
by  the  ordinary  methods  can  be  reduced  by  open  operation; — many  fractures 
which  are  reducible  by  the  ordinary  methods  only  with  difficulty  and  uncer- 
tainty can  be  reduced  with  ease  and  accuracy; — the  ends  of  many  fractured 
bones  not  capable  of  being  retained  in  position  by  postural  treatment  are 
easily  retained  by  internal  fixation; — ankylosis  is  often  avoided  in  fractures 
near  to  and  involving  joints; — partially  separated  and  detached  periosteum 
may  be  replaced,  and  sutured  if  necessary; — a  correct  diagnosis  is  possible; — 
all  tissues  intervening  between  the  ends  of  the  bones  can  be  removed  and 
placed  in  normal  positions; — clots  of  blood  may  be  gotten  rid  of; — injury  done 
to  the  neighboring  structures  may  be  repaired;  especially  torn  nerves  may  be 
sutured;  compressed  nerves  freed  of  their  pressure;  divided  vessels  ligated; 
lacerated  muscles  repaired;  and  spiculae  of  detached  bone  removed; — inflamed 
processes  are  often  reduced; — the  amount  of  callus  is  generally  lessened; — 
shortening  is  prevented; — deformity  is  less  frequent; — the  period  of  disability 
is  considered  by  some  surgeons  to  be  lessened  by  one-third; — and  a  gain  in 
the  range  of  function  is  often  secured.  The  open  method  of  treatment  is 
especially  applicable  to  many  compound  fractures,  comminuted  and  com- 
plicated fractures,  old  fractures  with  deformity,  cases  of  non-union,  and 
fracture-dislocations.  These  results,  it  must  be  admitted,  are  weighty  con- 
siderations, and  it  must  also  be  admitted  that  some  of  these  objects  cannot  be 
accomplished  at  all  by  the  ordinary  methods  of  treatment,  and  that  many  of 
those  which  are  accomplished  by  the  usual  methods  are  accomplished  more 
by  accident  than  by  intelligent  design,  for  the  ordinary  method  of  treating 
most  fractures  is,  both  figuratively  and  literally,  by  working  very  much  in 
the  dark,  as  to  both  sight  and  touch. 

Briefly,  the  object  of  operative  treatment  of  fractures  is,  in  the  language 
of  Van  Werden,  "to  bring  into  apposition,  and  hold  in  contact  by  direct 
temporary  mechanical  measures,  the  different  anatomical  constituents  of  the 
wound  until  the  process  of  repair  throughout  is  complete." 

Operative  treatment  is  fully  warranted,  therefore,  and  should  be  unhes- 
itatingly undertaken  where  the  complete  reduction  of  the  fracture  and  the 
retention  of  the  ends  of  the  bone  in  good  apposition  by  simpler  means  are 
impossible;  where  complications  otherwise  irremediable  exist;  and  is  further 
warranted  whenever  it  is  considered  that  a  distinct  gain  in  time  to  the  patient 
and  increase  in  function  of  the  part  can  be  expected  from  open  operation. 

The  compound  fracture  is  here  made  through  a  region  aseptically  ready 
for  it  and  but  slightly  apt  to  resent  it.  In  operating  upon  fractures  immediately 
after  the  accident,  the  soft  parts  offer  no  great  opposition  to  extension  and 
replacement,  but  after  a  few  days  have  elapsed,  physiological  shrinkage  may 
offer  so  much  opposition  to  extension  and  replacement  as  to  be  relieved  only 
by  flexing  the  contiguous  joints  or  by  division  of  tendons  and  fascia. 

Having  determined  upon  operation,  the  general  manner  of  exposing 
the  parts  is  similar  in  technic  to  that  already  described  under  Operative 
Methods  of  Approximating  and  Fixing  Ends  of  Fractured  Bones,  and  will 
not  be  given  in  further  detail  here. 

After  having  exposed  the  ends,  the  interlockable  nature  of  the  fragments 
may  be  such  as  to  make  any  other  form  of  fixation  other  than  simply  causing 
the  ends  to  interlock,  unnecessary.  Some  form  of  mechanical  fixation, 
however,  is  generally  done;  the  writer  would  prefer,  as  indicated  above,  kan- 
garoo tendon  or  chromic  gut  in  the  great  majority  of  cases. 

The  operative  treatment  of  simple  fractures  should  be  carried  out  imme- 


BONE-GRAFTING    OR    BONE-IMPLANTATION.  227 

diately  after  injury,  and  if  this  cannot  be  done,  some  surgeons  wait  until  a 
week  has  elapsed. 

Where  irregularly  fractured  ends  can  be  interlocked  in  their  normal  relation- 
ship before  being  sutured,  their  holding  together  is  more  firm  than  if  they  had 
been  sawed,  and  the  full  length  of  the  limb  is  maintained. 

It  has  only  been  since  the  introduction  of  the  open  method  of  treating 
simple  fractures  that  the  difficulties  in  their  reduction,  up  to  that  time  con- 
cealed by  unbroken  skin,  have  been  so  clearly  demonstrated.  Of  these  several 
difficulties  the  greatest  is  caused  by  the  shortening  of  all  the  soft  parts  in  the 
region  near  the  break,  which,  in  turn,  is  caused  by  inflammatory  action, 
hemorrhage  into  the  tissues,  and  by  contraction  of  the  tissues  themselves — 
for  after  the  fracture  there  is  no  resistance  to  the  contraction  of  the  soft  parts, 
as  compared  to  their  normal  stretched  condition.  The  bones  are  thus  pulled 
together,  and,  where  the  nature  of  the  fracture  makes  it  possible,  causes  an 
overriding  of  the  ends.  This  condition  of  contraction  is  prevented  when 
internal  fixation  of  the  fragments  has  been  satisfactorily  accomplished. 

BONE-GRAFTING   OR  BONE-IMPLANTATION. 

Bone-grafting  consists  of  the  transplantation  of  living  bone,  or  periosteum, 
from  the  same  or  different  individual,  or  from  an  animal,  into  the  defect  to  be 
repaired. 

There  is  another  group  of  substances  which  cannot  be  strictly  called 
bone-grafts,  but  which  are  rather  to  be  regarded — either  as  "scaffoldings," 
or  "trellis-works,"  along  which  bone-material  may  grow  in  the  process  of 
repair — or  as  irritants  which  serve  to  provoke  this  osteoplastic  process.  Such 
are:  dead  bone,  variously  prepared  and  rendered  aseptic — bone-plates — bone- 
ferrules — calcined  bone — decalcified  bone — and  even  fresh  bone  with  its 
periosteum  and  endosteum  scraped  off — and  bone-chips. 

It  has  not  been  absolutely  decided  whether  the  living  graft  ever  remains 
as  such  and  grows — or  whether  it  does  not  always  disappear  after  exciting 
new  bone-formation.  It  is  held  by  some  that  the  implanted  bone  lives — by 
others,  and  this  is  more  probable,  that  it  does  not  live  as  normal  bone.  Valan 
holds  that  the  center  of  the  graft  dies,  but  that  the  periphery  becomes  fused 
with  the  living  bone  and  lives.  In  still  other  cases  it  neither  grows  itself  nor 
excites  new  bone-formation — but,  in  such  cases,  and  where  the  operation  and 
its  subsequent  course  are  aseptic,  it  may  cause  the  formation  of  firm  fibrous 
tissue  which  is  almost  as  serviceable  as  bone. 

The  return  to  its  site  of  the  button  of  bone  temporarily  removed  by  tre- 
phining is  one  form  of  bone-implantation,  where  the  trephining  may  be 
regarded  as  a  deliberate  fracture  or  solution  of  bony  continuity  made  by  the 
surgeon  for  some  specific  object.  An  osteoplastic  amputation,  such,  for 
example,  as  those  about  the  lower  extremity,  is  an  illustration  of  bone-trans- 
plantation designedly  made  in  the  course  of  an  operation.  Of  the  artificially 
prepared  substitutes  for  bone,  calcined  bone,  either  in  the  form  of  coarse 
granular  powder  or  in  the  form  of  plates,  would  seem  to  be  an  approximate 
physiological  substitute  for  bone,  supplying,  as  it  does,  the  lime  salts.  It  is 
easily  prepared — easily  sterilized — readily  fills  the  cavities — and  is  so  porous 
that  it  is  gradually  replaced  by  bone  which  grows  over  it  and  through  its 
interstices  as  over  an  arbor.  The  calcined  bone-plates  are  made  from  the 
cancellated  bone  of  the  scapula  of  calves.  It  is  held  by  Valan  that  calcined 
bone  is  better  to  use  than  decalcified  bone — because  the  resulting  bone-tissue 
is  stronger. 


228  OPERATIONS    UPON    THE    BONES. 

The  chief  indication  for  hone-grafting,  or  bone-implantation,  is  to  fill 
in  the  interval  left  by  lost  bone  in  such  conditions  as  compound  or  comminuted 
fractures,  where  the  bone  is  very  much  fragmented  and  the  pieces  are  nearly 
or  entirely  detached,  or  seem  unlikely  to  live;  in  mal-union,  necessitating  opera- 
tion, with  loss  of  bone;  to  restore  the  continuity  of  long  bones  where  all  or  a 
considerable  portion  of  the  shaft  is  lost;  and  in  deformities,  to  replace  destroyed 
bone. 

There  are  several  varieties  of  bone-grafts:  (I)  Detached  portions  of 
human  bone  (from  the  same  or  another  individual),  living  at  the  time  of 
detachment  from  the  donor,  and  implantation  into  defect  of  recipient.  (2) 
Detached  portions  of  animal  bone,  living  at  the  time  of  detachment  from  donor 
and  implantation  into  defect  of  recipient.  (3)  Portions  of  human  bone 
adherent  by  periosteum,  soft  parts,  and  vascular  supply  to  an  adjacent  part 
of  the  donor's  body  (as  in  fractures  and  deformities  about  the  face).  (4) 
Portions  of  animal  bone  adherent  by  periosteum,  soft  parts,  and  vascular  supply 
tn  an  adjacent  part  of  the  donor's  body. 

There  are  now  a  sufficient  number  of  authentic  cases  of  extensive  successful 
bone-grafting  from  the  lower  animals  to  man  to  warrant  the  expectation  that 
the  technic  of  this  operation  will  be  rapidly  elaborated,  and  the  field  of  its 
usefulness  greatly  expanded. 

The  manner  of  exposing  the  site  to  be  grafted  is  the  same  as  that  described 
under  the  operations  for  exposing  the  ends  of  fractured  bones  for  the  purpose 
of  applying  internal  fixation;  or  a  preexisting  wound,  or  other  circumstances, 
may  determine  the  method  of  exposure.  Where  the  bony  defect  is  of  a 
limited  nature,  this  defect  may  often  be  repaired  from  the  adjacent  bone  of  the 
individual  himself — by  clipping  off  portions  of  the  bone  and  periosteum  and 
wedging  them  in  between  the  ends  of  the  bone  by  means  of  an  osteotome  or 
chisel.  If  small  pieces  of  bone  can  be  chipped  off  from  the  ends  of  the  broken 
bone  and  packed  into  a  tube  of  periosteum  connecting  these  ends,  there  is 
an  especially  favorable  outlook  for  bone-formation.  If  a  periosteal  tube  be 
absent,  the  soft  parts  may  be  brought  around  the  grafts  and  held  in  place  by 
catgut  sutures.  Some  surgeons  prefer  human  and  some  animal  grafts. 
The  latter  must,  of  course,  be  much  more  generally  available.  The  animal 
graft  may  be  implanted  as  a  solid  piece  of  the  required  length,  or  a  piece  of 
the  proper  length  may  be  split  longitudinally  into  several  small  pieces  and 
these  inserted  into  the  gap,  with  their  periosteum  adherent.  Where  a  graft 
fails  to  take  in  the  gap  between  the  ends  of  one  of  the  bones  in  a  double-bone 
limb,  a  portion  of  the  second  bone  should,  in  appropriate  cases,  be  excised  to 
correspond  with  the  opposite  gap,  thus  making  both  bones  of  the  same  length. 
This,  however,  should  only  be  done  as  a  last  resort. 

OPERATIONS  FOR  DELAYED   UNION,   NON-UNION,   AND   MAL-UNION 

OF  FRACTURES. 

Delayed  Union. — Fractures  which  have  resisted  the  ordinary  attempt  to 
bring  about  union  by  the  usual  form  of  procedure — as  carried  out  by  those 
who  are  in  the  habit  of  submitting  the  great  majority  of  fractures  to  splinting 
and.  its  accessories — are  usually,  and  generally  rightly,  subjected  to  a  second 
treatment  by  the  same  means,  with  especial  attention  to  constitutional  indica 
tions,  and  possibly  more  active  out-of-door  life.  Where,  on  the  other  hand,  de- 
layed unions  are  treated  by  those  who  more  frequently  adopt  the  open  operation 
in  even  simple  fractures,  they  will  probably  be  subjected  to  operative  treatment 
upon  their  first  failure  to  unite — in  which  cases  they  will  come,  as  far  as 


OPERATIONS    FOR    DELAYED    UNION    OF    FRACTURES.  229 

operative  technic  is  concerned,  within  the  following  category,  which  they 
resemble  in  all  but  their  duration. 

Non-union. — The  two  most  usual  methods  of  treating  non-union,  after 
having  exposed  the  parts,  are,  first,  to  resect  the  ends,  bring  the  bones  into 
apposition,  and  hold  them  in  this  position  by  plaster  or  other  splinting,  or, 
secondly,  after  having  resected  the  ends,  to  bring  and  hold  the  bones  together 
by  some  form  of  internal  fixation,  if  possible,  preferably  by  kangaroo-tendon 
or  chromic  gut,  or  by  silver  wire;  or,  where  the  resulting  gap  is  too  great  in 
the  involved  bone  of  a  double-bone  limb,  by  bone-grafting.  The  technic  of 
exposure  is  the  same  as  that  given  under  the  operative  method  of  approxi- 
mating and  fixing  the  ends  of  fractured  bones.  In  addition  to  the  technic 
there  given,  the  callus  and  all  inter-fragmentary  tissues  are  to  be  removed 
by  knife,  scissors,  and  bone  gouge.  Where  a  condition  of  pseudarthrosis 
exists,  the  structures  entering  into  the  formation  of  the  false  joint  are  all 
thoroughly  cleared  away.  The  ends  of  the  bone  are  then  sawed  off  squarely 
or  shaped  so  as  to  hold  more  firmly  when  brought  into  apposition,  orotherwi>e 
resected,  as  indicated  by  the  special  form  of  fracture,  or,  in  some  cases,  may  be 
simply  scraped  with  bone  gouge.  The  ends  are  then  brought  together  by 
the  form  of  internal  fixation  selected,  or  the  intervening  gap  filled  with  a  bone- 
graft,  as  just  indicated.  The  periosteum,  if  preserved,  is  sutured  with  catgut, 
the  muscles  separated  in  the  approach  are  brought  together  by  buried  gut 
sutures,  if  need  be,  the  wound  is  closed  without  drainage,  and  the  limb  put  up 
in  its  splint. 

Mal-union. — -Occurs  most  usually  in  the  upper  third  of  the  femur 
or  middle  of  the  humerus.  The  deformity  may  be  simply  a  shortening  of  the 
limb  from  overlapping  of  the  fragments,  the  limb  remaining  in  its  normal 
axis;  or  an  angularity  may  exist,  which  is  more  serious  when  near  a  joint. 
The  treatment  for  mal-union  should  invariably  be  by  open  osteotomy;  where 
a  simple  transverse,  linear  osteotomy,  or  cuneiform  osteotomy,  as  indicated, 
should  be  done;  or,  if  marked,  the  deformed  site  of  fracture  may  be  excised. 
Where  it  is  possible  to  do  so,  the  bone  section  should  be  made  as  subperios- 
teally  as  the  condition  of  the  original  torn  periosteum  permits,  that  is,  a 
longitudinal  incision  should  be  made  through  the  periosteum  over  the  bone, 
during  the  latter  steps  of  the  approach  to  the  bone;  beginning  well  over  the 
sound  periosteum  of  the  upper  bone,  and  extending  well  over  that  of  the  lower 
bone,  and  the  two  lips  of  periosteum  peeled  back  from  the  bone,  at  the  site 
where  the  section  is  to  be  made,  until  the  entire  circumference  of  the  bone  is 
exposed,  and  then  the  bone,  bared  of  periosteum,  is  to  be  divided  by  linear  or 
cuneiform  osteotomy.  In  this  way  the  periosteum  is  left  intact  to  materially 
aid  in  the  regenerative  process  of  callus  formation.  If  the  bone  of  a  single- 
bone  limb,  or  appropriate  bones  of  head  or  trunk,  have  been  thus  divided,  the 
ends  should  be  drilled  and  brought  together  with  kangaroo  tendon,  or  chromic 
gut,  which,  when  the  periosteum  has  been  first  temporarily  removed  from  the 
bone  at  the  site,  is  inserted  through  the  bone,  but  not  through  the  periosteum, 
so  that  the  periosteum  is  allowed  to  fall  back  in  place,  and  overlie  the  suture 
knots.  If,  on  the  other  hand,  the  bone  is  one  of  the  bones  in  a  double-bone 
limb,  if  a  tangible  piece  with  parallel  ends  be  removed,  the  ends  left  after 
the  incision  cannot,  of  course,  be  approximated  and  sutured  (owing  to  the 
fact  that  the  length  of  the  limb  or  part  is  maintained  by  the  other  bone),  and, 
in  these  cases,  the  site  has  either  to  be  put  up  with  the  ends  of  the  involved 
bone  apart,  or,  which  is  probably  better,  the  empty  casing  of  periosteum  can 
be  filled  with  either  a  single  bone-graft  or  bone-grafts,  and  its  lips  sutured 
over  such  graft  or  grafts.     Even  the  empty  casing  of  the  periosteum,  although 


230  OPERATIONS    UPON    THE    BONES. 

partly  collapsed  by  the  pressure  of  soft  parts,  would  probably  produce  bone 
which  would  fill  in  the  gap  between  the  ends.  Excision  of  a  corresponding 
length  of  the  opposite  bone  in  the  double-bone  limbs  is  sometimes  done,  but 
is  not  so  desirable.  In  any  of  these  cases  the  limb  is  subsequently  treated 
as  one  with  a  compound  fracture  made  under  favorable  circumstances. 
Under  no  circumstances  should  the  deformity  of  a  badly  united  fracture  be 
corrected  by  osteoclasis,  for  all  methods  of  bone-breaking  are  crude,  uncertain, 
dangerous  to  neighboring  parts,  and  are  distinctly  unsurgical — nor  is  the 
subcutaneous  division  by  saw,  or  osteotome,  of  the  bone  or  bones  involved 
in  the  mal-union  warrantable. 

OPERATIVE  TREATMENT  OF  COMPOUND,  COMMINUTED,  AND  COM- 
PLICATED FRACTURES. 

Compound  Fractures. — The  progressive  advance  in  the  treatment  of 
compound  fractures  is  one  of  the  most  marked  illustrations  of  the  evolution  of 
conservative  surgery.  At  one  period  a  very  large  percentage  of  compound 
fractures  came  to  amputation — and  in  many  hospitals  it  was  the  accepted  rule 
to  amputate  all  limbs  above  the  site  of  a  compound  fracture  involving  a  large 
joint.  Then  followed  a  period  when  conservatism  was  shown  by  saving  the 
limb  at  the  expense  of  shortening  it,  by  making  an  excision  at  the  site  of  com- 
pound fracture,  including  a  joint,  if  necessary.  At  the  present  time  still 
further  conservatism  is  accomplished  in  many  cases  by  neither  amputation  nor 
excision,  but  by  freely  exposing  the  parts  by  operation,  correcting  the  damage 
done  to  neighboring  soft  structures,  thoroughly  disinfecting  the  part  with 
antiseptic  irrigation,  followed  by  aseptic  douching,  treating  the  ends  of  the 
bone  as  indicated  by  the  conditions  found,  carrying  out  some  method  of  internal 
fixation  of  broken  ends,  and  putting  the  limb  in  an  open  or  fenestrated  splint. 
Owing  to  the  uncertainty  of  asepsis,  drainage  should  generally  be  instituted 
at  first.  It  should  be  maintained  as  long  as  the  necessity  for  it  exists,  but  can 
frequently  be  dispensed  with  in  two  or  three  days.  The  technic  applies  almost 
as  forcibly  to  compound  fractures  with  the  smallest  puncture,  as  to  those  with 
larger  external  wounds.  The  temptation  may  be  very  great  to  disinfect  exter- 
nally, and  to  try  to  disinfect  internally,  an  insignificant-looking  puncture  of  a 
compound  fracture  and  hermetically  seal  it  with  collodion,  but  subsequent 
septic  developments  will  often  cause  regret.  When  the  parts  are  exposed,  the 
extent  and  nature  of  the  damage  may  indicate  the  advisability  of  excision. 

Comminuted  Fractures. — Comminution  in  a  fracture  may  not  be  recog- 
nized by  ordinary  manipulation,  and  may  only  be  demonstrated  by  .v-raying. 
Even  when  present,  especially  where  simple  and  not  extensive,  it  may  not  par- 
ticularly complicate  the  fracture.  In  such  cases  ordinary,  non-operative  treat- 
ment of  the  fracture  may  be  carried  out.  But  where  the  comminution  is  more 
extensive  or  more  complicated,  or  even  where,  when  simple,  comminution 
prevents  the  exact  approximation  and  retention  of  the  bone-ends  in  position, 
the  involved  site  should  be  unhesitatingly  cut  down  upon  and  dealt  with  as  the 
needs  of  the  special  case  require.  The  fragments  can  often  be  tied  together 
or  sutured  to  one  end  of  the  main  bone  with  chromic  gut.  Large  fragments 
whose  periosteum  has  been  entirely  torn  off  are  not  so  likely  to  unite,  but  small 
chips  of  bone  will.  A  bond  of  union  by  periosteum  with  the  main  bone,  or 
with  a  larger  fragment,  is  very  useful  in  bringing  about  bony  connection. 
Pieces  of  bone  will  frequently  live  even  when  taken  out  of  the  wound,  disin- 
fected and  replaced,  and  often  even  if  they  have  been  reversed  in  position  and 
order.     Entirely  detached  bone  can,  therefore,  be  removed  temporarily,  disin- 


OPERATIVE    TREATMENT    OF    FRACTURE    DISLOCATIONS.  23 1 

fected  in  2\  per  cent,  carbolic  solution,  or  1-1000  bichloride;  rinsed  in  warm, 
sterile,  normal  salt  solution,  in  which  they  should  stay  until  needed,  and 
returned  to  their  normal  position,  where,  if  possible,  they  should  be  secured  to 
a  neighboring  bone  by  gut  suture.  If  much  periosteum  has  been  lost,  the  bone 
should  be  covered  with  soft  connective  tissue  and  muscles  (which  may  be  held 
about  the  bone  with  buried  gut  sutures).  In  cases  of  extensive  comminution, 
excision  of  the  bone-ends  may  be  called  for,  followed  by  internal  fixation  of  the 
ends  -r  by  bone-grafting. 

Complicated  Fractures. — One  of  the  strongest  arguments  in  favor  of  the 
more  general  treatment  of  fractures  by  operative  measures  followed  by  internal 
fixation  is  that  open  incision,  which  gives  free  access  to  the  fracture,  also  gives 
full  opportunity  to  rectify,  or  treat  as  indicated,  the  special  complication  of  the 
case,  which  complication  may  be  more  important  than  the  fracture  itself.  So 
that,  apart  from  the  general  operative  technic  of  exposing,  approximating,  and 
fixing  the  bone  fragments,  already  described,  the  special  treatment  of  the  case 
becomes  the  treatment  of  the  predominating  complications,  whatever  they  may 
be,  whether  involving  arteries,  veins,  nerves,  viscera,  or  other  soft  structures, 
and  their  line  of  treatment  will  be  determined  by  the  structure  involved  and 
the  nature  of  its  injury. 


OPERATIVE   TREATMENT    OF   FRACTURES    INVOLVING    JOINTS  AND 
OF  FRACTURE  DISLOCATIONS. 

Fractures  Involving  Joints. — The  difficulties  in  fractures  involving 
joints  treated  by  non-operative  methods  are,  first,  the  almost  impossibility  of 
getting  the  fragments  into  normal  position;  secondly,  the  keeping  of  them  in 
place;  and,  thirdly,  the  prevention  of  deformity  and  limited  movement.  While 
the  certainty  of  accomplishing  these  desirable  ends  does  not  by  any  means 
necessarily  follow  operative  treatment,  yet  the  chance  of  accomplishing  them 
by  open  incision  is  much  greater  than  without. 

When,  therefore,  examination  under  anesthesia  and  with  the  x-ray  (which 
should  always  be  used  in  these  cases,  and  are  very  serviceable  in  all  cases)  show 
that  the  broken  bones  will  not  stay  in  very  accurate  apposition  when  once 
reduced,  the  fractured  ends  should  be  cut  down  upon  and  united  by  internal 
fixation  (especially  here  by  some  absorbable  suture) ;  the  joint  cleared  of  effused 
blood  and  inflammatory  products;  the  wound  temporarily  drained,  and  the 
limb  put  up  in  a  splint.  It  must  be  remembered  that  union  has  to  be  unusually 
accurate  in  these  cases,  as  the  slightest  irregularity  upon  the  articular  surface 
of  a  bone  is  apt  to  lead  to  impaired  joint  movement.  By  this  course  of  treat- 
ment passive  movement  and  massage  are  also  made  possible  earlier,  with  the 
consequent  likelihood  of  the  prevention  of  both  extra-  and  intra-articular 
adhesions,  and,  therefore,  an  increased  range  of  functioning. 

Much  of  what  was  said  under  extra-articular  compound  fractures  also 
applies  to  intra-articular  compound  fractures.  Formerly,  many  compound 
fractures  involving  joints  cost  individuals  the  amputation  of  the  limb  above 
or  at  the  site  of  fracture.  Then,  as  a  great  advance  upon  this  destructive  sur- 
gery, immediate  excision  of  the  joint  was  generally  done,  in  order  to  get  a  mov- 
able joint  and  avoid  sepsis.  Now,  one  asepticizes  the  involved  regions,  and  is 
thoroughly  conservative,  and  though  he  may  have  to  excise  later,  generally  a 
shorter  excision  (less  loss  of  bone)  can  usually  be  accomplished  secondarily 
than  primarily. 

It  is  to  be  remembered  that  while  the  skin  wound  of  a  compound  fracture 


232  OPERATIONS    UPON    THE    BONES. 

may  extend  into  the  joint,  the  fracture  itself  may  not  do  so,  which  somewhat 
simplifies  matters. 

Dislocations  Complicating  Fractures. — When  a  fracture  is  not  imme- 
diately near  a  dislocated  joint,  and  where  operative  treatment  is  not  indicated, 
reduce  the  dislocation  first  (putting  up  the  broken  limb  in  temporary  splints, 
so  as  to  be  able  to  manipulate  it  somewhat  more  freely),  then  reduce  the  fracture 
and  so  splint  the  limb,  incasing  it  as  a  whole,  that  passive  movements  of  the 
joint  may  be  begun  early. 

When  the  fracture  is  near  the  joint,  the  distal  bone  was  formerly  put  up  in 
line  with  the  proximal  one,  and  when  the  fracture  was  well,  the  dislocation  was 
reduced,  but  now  the  more  rational  technic  is  to  expose  the  parts  by  operation, 
and  first  to  reduce  the  dislocation  and  suture  up  the  capsule,  and  then  approxi- 
mate the  ends  of  the  broken  bone  by  internal  fixation.  The  limb  is  then  put 
up  in  a  splint  and  massage  begun  early. 


OPERATIVE  TREATMENT  OF  SEPARATED  EPIPHYSES.. 

In  attempting  to  reduce  fractures  of  the  epiphyses,  wherever  it  is  found 
that  an  exact  alignment  of  the  epiphysis  with  the  shaft  can  not  be  obtained,  or 
where  obtained,  it  can  not  be  maintained,  some  form  of  operation  is  indicated. 

It  has  been  found  that  it  is  best,  in  operating  upon  separated  epiphyses,  to 
avoid  the  use  of  any  mechanical  means  which  penetrates  the  epiphyses  and 
remains  any  length  of  time  as  an  irritant  (as,  for  example,  a  nail),  for  while  an 
uninjured  though  detached  epiphysis  may  retain  its  integrity  for  some  weeks 
and  then  grow  to  the  main  bone  when  replaced,  yet  if,  on  the  other  hand,  con- 
stantly irritated  by  this  foreign  body,  it  may  either  suppurate  or  undergo  hyper- 
trophic overgrowth. 

The  treatment  of  epiphyseal  separation  differs  in  many  instances  materially 
from  the  treatment  of  a  fracture  in  the  same  locality,  and  especially  is  an  accu- 
rate knowledge  of  the  contiguous  anatomy  necessary  in  dealing  with  such  cases. 

If  operative  treatment  were  done  as  a  more  systematic  procedure  in  the 
treatment  of  such  injuries,  there  would  not  be  so  many  deformed  limbs  and 
joints. 

When  deformity  occurs  from  arrest  of  growth  in  one  of  the  parallel  bones  of 
the  double-bone  limbs,  conjugal  chondrectomy  (that  is,  excision  of  the  con- 
jugal cartilage  of  the  corresponding  normal  bone)  should  be  done,  if  the  age 
of  the  normal  bone  is  not  too  great,  namely,  beyond  its  period  of  active  growth. 

Epiphyseal  separation  occurs  in  a  vastly  larger  number  of  cases  among  males 
than  among  females,  and  the  separation  of  the  epiphyses  of  the  upper  extremity 
is  more  frequent  than  of  the  lower. 

Separation  of  epiphyses  occurs  in  the  following  order  of  frequency:  Upper 
epiphysis  of  humerus,  lower  of  radius,  lower  of  femur,  lower  of  tibia. 

^c-Raying  is  of  little  or  no  assistance  in  the  diagnosis  of  epiphyseal  separation, 
as  the  epiphyses  are  transparent  to  these  rays.  The  greatest  diagnostic  aid  is 
gotten  by  manipulation  under  anesthesia. 

Operation,  where  the  epiphysis  cannot  be  certainly  and  satisfactorily  manip- 
ulated into  place,  consists  of  exposure,  followed  by  suturing  the  epiphyses  to 
the  shaft  with  tendon  or  gut,  and,  where  the  epiphysis  is  entirely  or  partially 
intra-capsular,  of  closure  of  the  capsule. 


STIMSON'S    OPERATION    FOR    FRACTURED    PATELLA.  233 


Fig. 200.— Operation  for  Fractured  Patella  by  Stimson's  Method  of  Mediate  Suture  : 
— A,  Heavy  silk  suture  (of  mattress  variety)  passing  through  greater  thickness  of  quadriceps  extensor 
tendon,  above,  and  ligamentum  patellae,  below;  B,  Chromic  gut  suture  of  torn  capsule  and  fibro- 
periosteum. 

OPERATION   FOR    RECENT   OR   UNUNITED   FRACTURE   OF   PATELLA 

BY    SUTURING    OF    SOFT    PARTS. 

stimson's  METHOD. 

Description. — The  margins  of  bone,  after  being  cleared,  and,  if  necessary, 
freshened,  are  held  in  position  by  a  heavy  silk  suture-loop  passed  trans- 
versely through  the  quadriceps  extensor  tendon  above,  and  the  ligamentum 
patella.1  below. 

Position. — Patient  supine;  limb  fully  extended.  Surgeon  on  side  of 
operation.     Assistant  opposite. 

Landmarks. — Contour  of  patella. 

Incision. — Median,  in  long  axis  of  limb,  with  its  center  over  center  of 
patella  and  extending  considerably  above  and  below  the  patella  but  not 
passing  into  muscular  tissue. 

Operation. — The  incision  extends  through  skin,  fascia,  prepatellar  bursa, 
expansion  of  quadriceps  extensor  tendon,  and  periosteum  directly  to  the 
patella  bone.  The  soft  parts  are  well  retracted,  so  as  to  expose  the  entire 
extent  of  the  transverse  fracture  (which  is  possible  because  of  the  length 
of  the  incision)  (Fig.  200).  The  joint  is  irrigated  to  remove  the  clots.  If 
the  fracture  be  recent,  no  removal  of  fibrous  tissue  or  bone  is  necessary.  If 
old,  each  fragment  is  carefully  seized  with  bone-holding  forceps  and  steadied 


234  OPERATIONS    UPON   THE    BONES. 

in  such  a  position  as  to  render  it  accessible  to  the  saw,  and  a  thin  slice  of 
bone  is  then  removed.  A  heavy  silk  ligature,  threaded  upon  a  curved  needle, 
is  now  carried  transversely  through  the  ligamentum  patella?  near  its  apex, 
passing  through  about  two-thirds  of  its  width  and  thickness — then  trans- 
versely through  the  quadriceps  extensor  tendon,  near  the  upper  border  of 
the  patella,  also  passing  through  about  two-thirds  of  its  width  and  thickness. 
While  the  fragments  are  held  in  close  contact  this  ligature  is  tightly  tied. 
The  torn  capsule  on  either  side  of  the  patella  and  the  fibro-periosteum  are 
sutured  with  chromic  gut.  The  fibrous  tissues  overlying  the  patella,  and 
divided  in  the  median  incision,  may  then  be  sutured  with  buried  gut  suture. 
The  skin  wound  is  closed.  No  drainage  is  used.  The  limb  is  put  up  in 
full  extension. 

Comment. — In  some  old  cases  the  quadriceps  extensor  tendon  has  con- 
tracted to  such  an  extent  that  it  is  necessary  to  lengthen  the  common  quad- 
riceps extensor  (see  operation  for  muscle-lengthening,  page  246). 


OPERATION   FOR   RECENT   OR   UNUNITED  FRACTURE   OF   PATELLA 

BY    WIRING    OR   SUTURING    OF    BONE    AND    SOFT    PARTS. 

Description. — The  ends  of  the  bones,  after  being  cleared,  and,  if  neces- 
sary, freshened,  are  drilled  and  wired  together,  the  wire  being  buried  and 
left — or  they  may  be  sutured  with  an  absorbable  material.  The  joint  may 
be  exposed  by  a  median  vertical,  transverse,  or  by  Cheyne's  oval  incision — 
the  last  being  here  described. 

Position — Landmarks. — As  in  the  above  operation. 

Incision. — Oval,  outlining  a  flap  with  upward  convexity,  which  is  raised 
from  over  the  patella  and  temporarily  turned  downward.  The  incision 
begins  2.5  cm.  (1  inch)  to  one  side  of  the  patella,  on  a  level  a  little  below 
the  fracture — extends  vertically  upward  and  then  curves  across  the  front  of 
the  thigh  about  2.5  cm.  (1  inch)  above  the  upper  border  of  the  patella,  and 
descends  on  the  opposite  side  to  a  point  corresponding  with  its  commence- 
ment. This  flap-incision  gives  a  full  field  and  places  the  scar  above  the 
patella. 

Operation. — The  fractured  ends  of  the  bones  are  exposed,  the  joint 
irrigated,  and  the  fragments  slightly  everted  and  examined.  All  interposed 
periosteum,  fibrous  and  other  tissue  are  removed.  In  recent  cases  no  removal 
of  bone  is  ordinarily  indicated.  In  old  cases  a  thin  slice  of  bone  is  removed 
from  each  fragment.  Each  fragment  is  now  grasped  in  turn  by  means  of 
stout  bone-forceps,  injuring  the  bone  as  little  as  possible  while  firmly  steadying 
it  (Fig.  201).  One,  two,  or  three  wire  sutures,  as  seem  indicated,  are  now 
introduced  in  the  following  manner; — Two  holes  are  drilled  directly  opposite 
each  other  in  a  vertical  line,  in  the  upper  and  lower  fragments,  a  short  incision 
being  made  for  the  drill  through  the  fibrous  covering  of  the  patella,  within 
8  mm.  to  1.3  cm.  (^  to  \  inch)  of  the  fractured  edges — the  margins  of  the 
incision  through  the  fibrous  tissue  being  drawn  aside  and  the  drill  (hand  or 
motor)  directed  obliquely,  so  as  to  come  out  at  the  fractured  margin  after 
having  passed  through  about  two-thirds  of  the  thickness  of  the  bone.  All 
the  drill-holes  are  first  made,  and  are  made  from  without  inward.  Care  is 
taken  that  each  pair  of  holes  is  drilled  immediately  opposite  and  that  their 
points  of  emergence  on  the  fractured  surfaces  are  on  the  same  level.  The 
wires  are  now  passed,  are  grasped  with  strong  forceps,  and,  while  an  assistant 
firmly  approximates  the  margins  of  the  fragments,  these  wires  are  tightly 


OPERATION    FOR    FRACTURED    PATELLA    BY    WIRING. 


235 


twisted  for  three  or  four  turns,  cut  off  about  6  mm.  (J  inch)  long,  bent  upon 
the  bone,  and  slightly  buried  by  one  or  two  blows  of  the  mallet.  The  peri- 
osteum which  has  been  drawn  out  from  between  the  fragments  of  bones 
is  stitched  together  with  chromic  gut  to  the  opposite  lip  of  the  torn  periosteum. 


Fig.  201.— Operation  for  Fractured  Patella  by  Wiring:— a.  Lower  fragment  of  patella 
steadied  with  hone-holding  forceps  ;  B,  Drill  in  act  of  making  holes  for  passage  of  silver  wire,  one 
piece  of  which  is  seen  in  position ;  C,  Chromic  gut  suture  of  torn  capsule  and  fibro-periosteum. 


The  rent  in  the  capsule  generally  found  on  each  side  of  the  fractured  patella  is 
similarly  sutured  with  gut.  The  fibrous  covering  of  the  patella,  incised  in 
raising  the  oval  flap,  is  sutured  with  buried  gut.  The  wound  is  closed  through- 
out— no  drainage  being  used.     The  limb  is  put  up  in  full  extension. 

Comment. — Chromic  gut,  kangaroo  tendon,  and  silk  are  also  used  in 
the  same  manner  as  wire. 


236 


OPERATIONS    UPON    THE    BONES. 


OPERATION  FOR   RECENT   OR    UNUNITED   FRACTURE    OF   PATELLA 

BY    AN    ENCIRCLING    SUTURE    OF    THE    SOFT    PARTS. 

Description. — Having  exposed  the  fracture,  an  encircling  suture  of  kanga- 
roo-tendon, chromic  gut,  or  silver  wire  is  carried  through  the  soft  parts  border- 
ing upon  the  patella,  including  the  quadriceps  extensor  tendon,  the  ligamentum 
patellae,  and  the  capsule — which  is  then  tightened  and  tied  or  twisted,  while 
the  fragments  are  held  in  close  apposition. 

Position;— Landmarks.— As  in  the  preceding  operations. 


Fig.  202. — Encircling  Suture  used  in  Fracture  of  Patella: — The  suture  passes 
through  the  quadriceps  extensor  tendon  above,  through  the  ligamentum  patellas  below,  and 
through  the  capsule  and  lateral  ligaments  at  the  sides.  The  transverse  rent  in  the  capsule  is 
then  sutured  separately. 


Incision. — The  patella  may  be  exposed  by  either  of  the  incisions  just 
described — or  a  flap  with  downward  convexity  may  be  raised.  In  the  latter 
instance  a  flap  with  downward  convexity  is  outlined,  which  will  be  the  reverse 
of  the  one  in  the  preceding  operation.  It  begins  2.5  cm.  (1  inch)  to  one  side 
of  the  patella,  on  a  level  a  little  above  the  fracture — extends  vertically  down- 
ward and  then  curves  across  the  front  of  the  leg  about  2.5  cm.  (1  inch)  below 
the  lower  border  of  the  patella,  and  ascends  on  the  opposite  side  to  a  point  cor- 
responding with  its  commencement.  This  flap-incision  gives  a  full  field  and 
places  the  scar  below  the  patella. 


OPERATION  FOR  RECENT  FRACTURE  OF  OLECRANON. 


237 


Operation. — As  to  the  exposure  of  the  fractured  parts,  the  steps  of  the  oper- 
ation are  in  every  respect  similar  to  those  in  the  operation  described  at  page  233, 
the  manner  in  which  the  patella  is  surrounded  with  the  ligature  alone  differing. 
By  means  of  a  Reverdin  needle  heavy  kangaroo-tendon  is  carried  in  and  out 
through  the  soft  parts  bordering  upon  the  patella,  including  the  extensor  quadri- 
ceps tendon,  the  ligamentum  patellae,  and  the  lateral  aspects  of  the  capsular 
ligament,  in  the  manner  shown  in  Fig.  202.  Chromic  gut  or  silver  wire  may 
be  used.  In  the  case  of  using  the  last,  it  is  drawn  into  position  by  means  of  a 
silk  carrier.  After  the  suture  has  been  placed,  the  fragments  of  the  patella 
are  drawn  into  very  close  apposition  by  pointed  retractors  pulled  in  opposite 
directions — during  which  close  contact  of  the  margins  the  suture  is  drawn 
tight  and  tied,  or,  in  the  case  of  wire,  twisted.  The  rent  in  the  capsule  and 
lateral  ligaments  is  then  closed,  from  one  extreme  lateral  aspect  to  the  opposite 
and  across  the  front  of  the  patella,  as  in  all  operations  upon  the  patella.  The 
flap  is  now  brought  down  and  sutured  along  its  margin — without  drainage. 

Comment. — The  circular  suture  may  be  carried  continuously  through  the 
substance  of  the  quadriceps  extensor  tendon  and  the  ligamentum  patellae. 


Fig.  203.— Operation  for  Fractured  Olecranon  by  Wiring  : — A,  Drilling  holes  for  pas- 
sage of  silver  wire,  one  suture  being  seen  in  position,  and  one  being  drawn  through  ;  B,  Chromic  gut 
suturing  of  torn  capsule  and  nbro-periosteuni. 


238  OPERATIONS    UPON    THE    BONES. 

OPERATION  FOR  RECENT  OR  UNUNITED  FRACTURE  OF  OLECRANON 

BY    WIRING    OR    SUTURING    OF    BONE   AND    SOFT    PARTS. 

Description. — The  olecranon  is  quite  frequently  fractured  at  its  junction 
with  the  shaft  of  the  ulna — and  is  repaired  by  wiring  or  suturing  in  the  same 
general  manner  as  in  the  case  of  fracture  of  the  patella. 

Position. — Patient  supine;  forearm  drawn  across  chest,  by  an  assistant 
on  the  opposite  side,  presenting  to  the  surgeon  the  semiflexed  elbow,  while 
exposing  the  fragments;  and  fully  extended  by  the  side  while  suturing.  Surgeon 
stands  opposite  the  elbow. 

Landmarks. — Contour  of  olecranon;  shaft  of  ulna;  condyles  of  humerus. 

Incision. — The  site  of  fracture  may  be  exposed — (1)  By  an  oval  incision; — 
beginning  to  one  side  of  lateral  border  of  olecranon,  just  below  the  fracture 
— passes  upward  in  axis  of  limb  for  about  2.5  cm.  (1  inch)  above  the  olecra- 
non— thence  curves  across  arm  and  descends  to  a  corresponding  point  on  the 
opposite  side — thus  furnishing  a  free  exposure  of  the  fracture  and  providing 
a  scar  which  falls  out  of  the  way  of  pressure.     (2)  By  a  median  longitudinal 


Fig.  204. — Encircling  Suture  used  in  Fracture  of  Olecranon: — The  upper  limb 
of  the  suture  is  shown  passing  through  the  olecranon;  and  the  lower  limb  through  the  shaft  of 
the  ulna. 

incision; — beginning  and  ending  considerably  above  and  below  the  line  of 
fracture,  but  not  involving  the  muscles  above  or  below — and  having  its  center 
over  the  fracture.  The  length  of  this  incision  allows  of  sufficient  lateral 
retraction  to  well  expose  the  parts  (though  less  perfectly  than  the  incision 
just  described). 

Operation. — The  incision  passes  through  skin,  fascia,  bursa,  fibrous 
expansion  of  the  triceps  tendon,  and  periosteum  directly  onto  the  bone 
(Fig.  203).  The  manner  of  exposing  the  fractured  ends,  irrigating  the 
joint,  removing  a  slice  of  bone  from  each  fragment  in  old  cases,  drilling  the 
fragments,  passing  and  tightening  the  wire,  suturing  the  torn  periosteum  and 
fascia,  and  closure  of  wound  are  similar,  in  all  practical  essentials,  to  the 
corresponding  steps  in  the  operations  just  described  upon  the  patella  (page 
234).     The  limb  is  put  up  in  full  extension. 

Comment. — (1)   Chromic  gut,  kangaroo  tendon,  and  silk  may  be  used 


SEQUESTROTOMY. 


239 


instead  of  wire.  (2)  In  some  old  cases,  where  much  retraction  of  the  triceps 
has  occurred,  that  muscle  should  be  lengthened,  as  described  under  muscle- 
lengthening  (page  246).  (3)  Instead  of  passing  the  sutures  in  the  way  indi- 
cated above,  an  encircling  suture  may  be  carried  in  such  a  manner  as  to  pass 
through  the  shaft  of  the  ulna  below,  and  through  the  triceps  tendon  above  and 
be  tied  on  one  side,  as  shown  in  Fig.  204.  The  capsule  and  lateral  ligaments 
are  closed  by  sutures. 

SEQUESTROTOMY. 

Description. — An  operation  for  the  removal  or  excision  of  a  sequestrum 
(dead  bone)  en  masse.  The  operation  might  be  more  properly  termed 
sequestrectomy.  The  site  of  the  sequestrum  is  generally  determined  by  the 
presence  of  one  or  more  sinuses,  together  with  the  history  of  the  case. 

Position  and  Preparation. — Patient  is  so  placed  as  to  expose  the  in- 


Fig.  205.— Cross-section  of   Leg,  Showing  a  Sequestrum-cavity. 

volved  site  most  conveniently.  A  constrictor  is  usually  applied,  where 
possible,  to  control  hemorrhage. 

Landmarks. — Generally  the  existence  of  one  or  more  sinuses;  the  known 
anatomy  of  the  part. 

Incision. — Generally  placed  in  the  long  axis  of  the  limb,  or  in  such  a 
position  as  to  fall  in  with  the  intermuscular  cleavage  line  and  so  as  to  lead 
to  the  site  by  the  safest  route — with  its  center  over  the  sinus,  or  extending 
between  the  two  chief  sinuses  (Fig.  205). 

Operation. — The  incision  passes  down  to  and  through  the  periosteum. 
The  soft  parts,  including  periosteum,  are  then  retracted  laterally,  fully  exposing 
the  bone  in  the  neighborhood  of  the  sinus,  or  between  two  or  more  sinuses. 
It  may  be  at  once  possible  to  grasp  the  sequestrum  with  strong  forceps 
introduced  through  the  sinus-opening  and  draw  it  out — or  the  sinus-opening 
may  be  sufficiently  enlarged  for  this  purpose  by  rongeur  forceps.  If  neither 
of  these  can  be  clone,  the  sinus  may  be  enlarged  with  the  curved  chisel — 
or  the  bone  between  two  sinuses  may  be  chiseled  away — or  the  bone  may 
be  chiseled  away  in  the  long  axis  of  the  sequestrum,  even  where  but  one 
opening  exists — or  a  trephine-opening  (one  or  more)  may  be  made  instead 
of  using  the  chisel.  Following  the  removal  of  the  sequestrum,  the  cavity 
of  the  bone  should  be  well  scraped.  The  periosteum  and  muscles  are  then 
united  by  buried  gut  sutures,  and  the  skin  closed  with  sutures  of  silkworm - 
gut  or  silk — drainage  being  established  to  the  bottom  of  the  bone  cavity 
in  the  most  favorable  position.  If  the  limb  be  weakened  by  the  operation, 
it  should  be  put  up  in  a  splint. 


240  OPERATIONS    UPON    THE    BONES. 

Comment. — Bone-chips  may  be  used  in  the  cavity — or  the  entire  thick- 
ness of  the  soft  parts,  including  periosteum,  may  be  inverted  into  the  bottom 
of  the  bone  cavity  from  each  side  and  held  in  place  by  a  nail  or  peg  (Fig. 
206).     Or  the  cavity  may  be  packed  throughout  with  gauze. 


Fig.206— Sequestrotomy:— Neuber's  Operation.  The  antero-internal  aspect  of  the  tibia  is 
removed— sequestrum  cavity  scraped— the  integumentary  tissues  nailed  to  its  floor— and  relaxation 
sutures  placed. 

OSTEOPLASTY. 

Description. — Transplantation  of  bone — in  the  form  of  bone-chips  or 
decalcified  bone-fragments — which  are  placed  in  the  desired  site  and  among 
which  organization  of  the  blood-clot  takes  place.  The  transplantation  of 
a  larger  section  of  bone,  entirely  detached,  has  not  yet  been  commonly  done — 
though  the  success  of  reinserting  the  trephine-buttons  suggests  the  practi- 
cability of  such  a  course.  This  principle  will  be  further  mentioned  under 
osteoplastic  amputations. 

Operation. — The  site  of  operation  having  been  rendered  bloodless  by 
a  proximal  constrictor,  and  having  provided  the  bone-chips  in  advance 
(which  come  specially  prepared  by  decalcification),  the  locality  is  exposed. 
If  the  chips  are  to  be  used  within  a  bone  cavity,  such  as  a  scraped  medullary 
cavity,  it  is  seen  that  this  is  thoroughly  aseptic  before  their  introduction. 
If  they  are  to  be  used  within  a  periosteal  cavity  (as  after  the  partial  resection 
of  a  bone),  this  periosteal  cavity  should  be  kept  as  nearly  like  the  special 
form  of  the  original  bone  as  possible.  In  the  case  of  the  bone  cavity,  the 
bone-chips  are  dropped  into  the  cavity  and  the  soft  parts  sutured  as  just 
described  in  the  above  operation.  In  the  case  of  a  periosteal  cavity,  sutures 
of  gut  are  made  to  approximate  the  periosteal  margins  over  the  included  bone- 
chips — and  the  muscles  over  the  periosteum — and  finally  the  skin,  in  the  usual 
manner.  The  tourniquet  is  then  removed  and  the  blood  allowed  to  flow 
into  the  part  and  fill  the  interstices  between  the  bone-chips.  The  part  is 
usually  put  up  in  an  immobilizing  splint. 

Comment. — If  the  neighboring  parts  do  not  cover  the  site  in  which  the 
bone-chips  have  been  deposited,  they  may  be  covered  by  sterilized  rubber 
tissue.  Other  applications  of  osteoplasty  are  mentioned  under  Bone-grafting 
(page  227). 

EXCISION. 

Excision  of  the  bones  is  described  under  the  general  head  of  Excisions 
and  Osteoplastic  Resection  of  Bones  and  Joints  (pages  463  to  531). 


CHAPTER  VI. 

OPERATIONS  UPON  THE  JOINTS. 

EXPLORATORY  PUNCTURE  OF   JOINTS. 

Description. — The  exploration  of  the  fluid  contents  of  a  joint  by  means 
of  the  needle  of  a  suction-syringe — for  the  purpose  of  ascertaining  the  nature 
of  those  contents — or  for  the  evacuation  of  the  fluid  found. 

Indications. — Collection  of  pus,  or  other  fluid,  within  a  joint. 

Preparation — Position. — As  for  arthrotomy. 

Special  Instruments. — Exploratory  or  aspirating  syringe. 

Operation. — The  same  preliminaries  having  been  observed  as  in  ar- 
throtomy, the  needle  of  the  exploratory  syringe  is  thrust,  by  the  safest  and 
shortest  route,  into  the  joint — the  cylinder  withdrawn  and  the  contents 
aspirated.  Following  the  withdrawal  of  the  needle,  the  punctured  wound 
is  hermetically  closed  with  sterilized  collodion. 

ARTHROTOMY. 

Description. — A  simple  incision  into  a  joint. 

Indications. — Exploration;  removal  of  foreign  body;  evacuation  of  pus, 
or  other  fluid;  irrigation;  drainage. 

Preparation. — As  for  a  major  operation  of  the  same  joint. 

Position. — Determined  by  the  special  operation — and  such  as  to  render 
the  site  of  incision  prominent  and  convenient. 

Special  Instruments. — Scalpel;  dissecting  forceps;  artery-clamp  forceps; 
retractors;  tourniquet  (sometimes). 

Operation. — The  patient  having  been  placed  in  a  position  to  render 
the  joint  most  accessible — and  the  overlying  tissues  in  the  best  position  with 
reference  to  the  joint — an  incision,  of  the  simplest  form  and  shortest  extent 
compatible  with  the  object  in  view,  is  made  over  that  aspect  of  the  joint 
which  will  lead  into  the  interior  of  the  joint-structures  by  the  route  which  is 
shortest  and  safest,  both  in  regard  to  the  joint-structures  and  the  tissues 
intervening  between  skin  and  joint.  Having  opened  up  the  joint,  the  sub- 
sequent steps  will  depend  upon  the  special  object  of  the  operation; — (a) 
Where  exploration  is  the  object;  its  interior  is  examined  by  some  form  of 
probe  or  sound,  or,  preferably,  by  the  gloved  finger-tip; — (b)  Where  the 
removal  of  a  foreign  body  is  sought;  suitable  forceps  are  introduced,  with 
which  it  is  grasped  and  withdrawn; — (c)  Where  drainage  is  indicated;  a 
tube,  or  other  drain,  is  inserted  through  the  incision,  with  or  without  a  counter- 
opening.  In  the  first  two  cases,  the  wound  is  entirely  closed.  In  all  cases 
the  joint  is  immobilized. 

ARTHROPLASTY. 

Description. — The  formation  of  a  movable  joint,  by  the  interposition 
between  the  loosened  ends  of  the  bones  of  some  of  the  neighboring  soft  tissues 
or  of  some  foreign  material. 

Indications. — Ankylosis  of  the  joints. 
16  241 


242  OPERATIONS    UPON   THE    JOINTS. 

Preparation; — Position; — Incision. — Determined  by  the  special  oper- 
ation. 

Operation. — The  site  of  the  former  normal  joint  is  exposed  in  the  usual 
manner.  At  the  original  joint-line  the  ankylosed  bones  are  divided  by  means 
of  a  chisel  or  saw.  All  bone  interfering  with  joint-movement  is  cut  away. 
Synovial  membrane  and  capsule  are  excised  and  any  other  structures  apt  to 
prevent  movement  of  the  new  joint.  Muscular  and  tendinous  attachments 
are  preserved.  Shortened  muscles  are  lengthened.  All  cicatricial  tissue 
is  removed.  The  preparation  for  the  interposition  of  the  neighboring  soft 
parts  must  be  thorough.  A  musculo-aponeurotic  flap,  covered  by  fat,  and 
large  enough  to  cover  the  ends  of  the  divided  bones,  is  raised  from  the  neighbor- 
hood of  the  special  joint  and  turned  in  between  the  sawn  ends  of  the  bones, 
and  is  sutured  to  the  margin  of  the  capsule  which  has  been  left  in  situ.  Where 
the  aponeurosis  is  insufficient,  a  muscle-flap,  with  as  much  adherent  fat  as 
possible,  is  used.  The  part  is  immobolized  for  a  week  or  more — after  which 
passive  motion  is  begun  (with  anesthesia  if  necessary),  followed  my  massage — 
irrespective  of  the  suffering  caused,  as  the  production  of  a  joint  will  depend 
upon  the  transformation  of  the  interposed  tissue  to  a  bursa. 

Comment. — Animal  membrane,  such  as  a  piece  of  bladder,  has  been  used. 
Foreign  substances  have  also  been  employed,  such  as  silver,  tin,  rubber,  cellu- 
loid, silver  foil,  and  the  like,  in  the  form  of  plates — but  the  interposition  of 
the  neighboring  soft  parts,  especially  fat  (which,  under  pressure,  readily 
develops  connective  tissue  and  forms  a  bursa),  produces  the  best  results. 


ARTHRODESIS. 

Description. — The  production  of  an  artificial  ankylosis  in  a  joint  by  the 
removal  of  a  part  or  all  of  the  articular  cartilage. 

Indications. — Sometimes  resorted  to  in  order  to  produce  a  rigid  joint  in 
certain  muscular  paralyses  and  flail-like  joints. 

Preparation; — Position; — Incision. — Dependent  upon  the  individual 
joint. 

Operation. — The  special  joint  is  exposed  by  a  convenient  incision.  The 
articular  cartilage  entering  into  the  formation  of  the  joint  is  removed  by  means 
of  a  knife  or  chisel,  in  a  thin  layer,  from  the  surfaces  of  the  bones  forming  the 
joint.  The  denuded  bones  are  then  placed  in  apposition,  and  either  held 
there  by  subsequent  plaster  dressing  or  splints,  or  by  means  of  nailing  or  sutur- 
ing the  parts  together.  The  site  is  thus  immobilized  until  ankylosis  has 
occurred. 

Comment. — In  some  situations,  the  ankle-joint,  for  instance,  the  operation 
may  be  reinforced  by  the  transplantation  of  tendons. 


ERASION  OR  ARTHRECTOMY. 

Description. — Etymologically,  erasion  signifies  the  scraping  or  curetting 
of  a  joint — and  arthrectomy,  the  cutting  out  of  a  joint.  Practically,  both 
expressions  are  used  synonymously — and  are  taken  to  signify  the  exposure 
of  a  joint  with  the  removal  of  the  diseased  tissue  alone.  While  arthrectomv 
signifies,  literally,  the  cutting  out  of  a  joint,  it  is- not  here  used  as  the  word  ex- 
cision commonly  signifies.  In  excision,  the  articular  ends  of  the  bones  are 
invariably  removed — in  erasion  or  arthrectomy,  while  a  certain   amount  of 


ERASION    OR    ARTHRECTOMV.  243 

bone  may  be  incidentally  removed  (and  always  as  much  as  is  diseased  is 
removed)  in  the  gouging,  only  the  articular  cartilages  and  synovial  membrane 
are  supposed  to  be  scraped  or  curetted.  When  bone  is  removed  at  all,  the 
least  possible  is  removed,  and  that  is  generally  done  with  a  gouge — and  the 
whole  operation  conducted  with  as  little  injury  as  possible  to  the  neighboring 
structures.  In  extreme  cases  all  the  articular  cartilage  is  gouged  away,  all 
the  synovial  membrane  is  dissected  out,  and  some  of  the  bone  is  removed. 
An  erasion  or  arthrectomy  is,  therefore,  commonly  understood  as  the  applica- 
tion of  scraping  to  the  interior  of  a  joint — the  laying  open  of  a  joint  and  the 
removal  of  as  many  and  as  much  of  the  tissues  forming  the  joint  as  are  dis- 
eased— synovial  membrane,  capsular  ligaments,  cartilage,  and  bone — the 
removal  generally  being  accomplished  by  some  form  of  gouge  for  cartilage 
and  bone,  and  scissors  and  knife  for  soft  parts.  An  arthrectomy,  finally, 
may  be  regarded  as  a  procedure  the  same  in  general  purpose,  though  less 


Fig.  207.— Erasion  of  the  Knee-joint: — A,  Removal  oi  cartilage  of  condyle  of  lemur  wilh 
raspatory  ;  B,  Removal  of  cartilage  of  tibia  with  curette.  The  joint  is  exposed  by  a  transversely 
curved  incision  and  the  patella  turned  backward. 

severe  in  degree,  as  an  excision — and  is  distinctly  a  conservative  measure  espe- 
cially applicable  to  early  cases.  An  arthrectomy  is  a  part  of  every  excision. 
Arthrectomy  has  its  greatest  application  in  joints  of  simple  structure  and  easy 
approach — the  knee  being  its  most  frequent  site  of  application.  A  movable 
joint  is  always  to  be  sought  after  erasion,  even  in  the  case  of  the  knee 
(although  in  the  latter  case  some  surgeons  prefer  to  secure  ankylosis  in 
preference  to  a  probable  weak  joint).  Arthrectomy  is  always  preferable  tc 
excision  in  children,  owing  to  its  non-interference  with  the  growth  of  bone. 

Indications. —  Disease  of  the  articular  structures,  especially  tubercular. 

Preparation — Position. — As  for  excisions  (page  397). 

Special  Instruments. — Besides  those  used  for  excisions,  the  following 
are  specially  required; — Gouges,  curettes;  spoons — of  many  sizes  and  shapes, 
dull  and  sharp.     Flushing-gouges. 

Operation. — No  form  of  constrictor  is  ordinarily  used — though  may  be 
used,  as  in  excisions.  The  incision  is  generally  the  same  as  that  for  the 
excision  of  the  corresponding  joint.  Having  exposed  the  interior  of  the  joint, 
the  following  structures  are  closely  examined,  and,  if  necessary,  removed 
— the  guide  being  that  all  diseased  tissue  should  be  removed; — (a)  Synovial 


244  OPERATIONS    UPON   THE    JOINTS. 

membrane;  where  but  slightly  involved,  is  curetted, — where  extensively,  it  is 
grasped  with  toothed  forceps  and  dissected  out,  in  as  continuous  a  layer  as 
possible,  with  scissors  or  scalpel.  Every  recess  is  sought  and,  if  diseased, 
thoroughly  curetted  or  removed,  (b)  Bursa*  communicating  with  joint;  are 
subjected  to  the  same  treatment  as  the  synovial  membrane — opened  up 
and  followed  to  their  furthest  extent,  (c)  Ligamentous  tissue;  to  be  scraped 
and  cut  away,  (d)  Articular  cartilage;  all  involved  or  suspicious  areas  are 
gouged  out  with  a  sharp  spoon,  (e)  Articular  ends  of  bones;  if  actually 
diseased,  or  suspicious,  to  be  removed  with  gouge,  (f)  Extra-synovial  and 
extra-articular  tissues;  to  be  dissected  out  and  removed,  if  involved.  Finally, 
where  much  debris  results,  it  is  well  to  use  a  flushing-gouge  and  clean  out 
the  area  of  operation.  Drainage  is  usually  not  necessary — but  may  be 
temporarily  used  where  thought  best.  The  capsular  ligament,  if  not  dis- 
sected away  in  removing  disease,  is  closed  by  buried  gut  sutures.  Muscles 
separated  in  reaching  the  joint  are  similarly  brought  together  with  buried 
gut  sutures.  The  limb  is  put  up  upon  an  immobilizing  splint.  The  after- 
treatment  is  practically  the  same  as  after  excisions — and  a  more  satisfactorily 
functioning  joint  is  to  be  expected.     (Fig.  207.) 


OPERATION  FOR   DISLOCATED    SEMILUNAR   CARTILAGES. 

Description. — A  dislocated  semilunar  cartilage  of  the  knee  may  be  exposed 
and  sutured  back  into  position — or  may  be  removed  in  part  or  in  its  entirety. 

Indications. — Those  cases  in  which  postural  and  mechanical  treatment 
have  failed. 

Preparation; — Position; — Landmarks. — As  in  the  operation  of  excision 
of  the  knee-joint  (page  521). 

Incision. — A  vertical  incision  may  be  made  to  either  side  of  the  patella, 
dependent  upon  the  particular  semilunar  involved.  Or  the  entire  joint  may 
be  exposed  by  means  of  a  transverse  curved  incision,  as  for  excision  (page  522). 

Operation. — A  sufficiently  free  exposure  of  the  joint  is  made  to  enable 
manipulation  of  the  involved  structure.  If  the  cartilage  be  only  slightly  sepa- 
rated from  its  peripheral  attachment,  or  be  torn  to  a  limited  extent  radially, 
it  may  be  sutured  into  its  normal  position  with  catgut  sutures  and  the  joint 
closed.  If  this  technic  does  not  promise  to  suffice,  a  portion  of  the  cartilage 
may  be  excised.  If  a  greater  degree  of  separation  or  damage  be  found,  the 
entire  cartilage  may  be  excised.  The  joint  is  closed  without  drainage,  unless 
hemorrhage  into  the  joint  indicate  the  need  for  temporary  drainage.  The 
joint  is  immobolized  for  six  to  eight  weeks — the  muscles  being  kept  up  by 
massage  in  the  mean  time.  The  functional  result  of  the  joint  is  usually  satis- 
factory. 

EXCISION. 

Excision  of  the  joints  is  described  under  the  general  head  of  Excisions  and 
Osteoplastic  Resections  of  Bones  and  Joints  (pages  463  to  531). 


CHAPTER  VII. 

OPERATIONS  UPON  THE  MUSCLES. 


MYOTOMY. 

Description. — Division  of  muscle — generally  done  as  a  preliminary  to 
muscle-lengthening,  or  in  the  exposure  of  underlying  parts,  or  in  deformities. 

Operation. — The  muscle  is  fully  exposed  by  an  appropriate  incision — 
or  is  exposed  in  the  course  of  some 
operation.  Having  been  isolated 
from  neighboring  structures,  the 
muscle  is  cleanly  divided  with  a 
scalpel,  cutting  transversely,  or 
very  slightly  obliquely,  to  the  di- 
rection of  its  fibers.  A  grooved 
director  may  first  be  passed  beneath 
the  muscle,  but  is  rarely  necessary. 
Myotomy  should  be  done  by  the 
open  method.  Muscles  are  some- 
times divided  subcutaneously  (as 
the  sternomastoid,  for  torticollis), 
but  this  is  even  less  advisable 
(owing  to  their  greater  size  and 
less  accurately  defined  contour) 
than  the  subcutaneous  division  of 
tendons. 

MYORRHAPHY. 

Description. — -Suturing  of 
muscle  which  has  been  either  pur- 
posely and  cleanly  divided  (as  in 
an  operation) — or  accidentally  and 
unevenly  divided  or  ruptured  (as 
from  injun-  or  from  excessive 
action). 

Operation. — (a)  Where  mus- 
cle has  been  deliberately  cut  in  the 
course  of  an  operation,  to  expose 
underlying  parts  (as  in  dividing 
the  sternomastoid  in  removing  the 
cervical  glands); — The  muscle  is 
here  cleanly  and   evenly    divided, 

preferably  in  a  transverse  or  very  slightly  oblique  direction.  At  the 
time  of  suturing,  the  parts  are  put  into  a  position  to  relax  the  muscle  as 
much  as  possible.  While  the  two  opposing  ends  of  the  muscle  are  carefully 
held  in  easy  contact,  as  many  muscle-sutures  are  inserted  and  tied  as  the 

245 


Fig.208.— Myorrhaphy  : — The  divided  biceps 
is  here  shown  sutured  in  several  ways  ;  A,  Mat- 
tress suture;  B,  Lateral  knotted  suture;  C, 
Peripheral  suture  ;  D,  Lateral  through-and- 
through  suture;  E,  Antero-posterior  through-and- 
through  suture.  The  last  two  are  here  shown  as 
relaxation — or  reinforcing — sutures. 


246  OPERATIONS    UPON    THE    MUSCLES. 

size  and  form  of  the  muscle  require.  Chromic  gut  or  kangaroo  tendon  is 
used  for  suturing — and  the  sutures  are  all  buried.  One  of  several  forms  of 
stitch  may  be  applied.  As  the  muscle-sutures  are  practically  the  same  as 
tendon-sutures,  and  applied  in  the  same  manner,  they  will  only  be  briefly 
mentioned  here  and  their  fuller  description  given  under  tendons,  (i)  Inter- 
rupted mattress  sutures  (Fig.  208,  A).  This  is  probably  the  best  form  of 
muscle-suturing.  (The  manner  of  its  insertion  is  given  at  page  252.)  (2) 
Interrupted  sutures  passing  transversely  through  the  upper  and  lower  ends 
uf  the  cut  muscle  (page  252).  (3)  Lateral  knotted  sutures  (Fig.  208,  B) 
(page  253).  (4)  Simple,  peripheral  longitudinal  coaptation  sutures  (Fig.  208, 
C)  (page  252).  (5)  Relaxation  sutures  for  reinforcement; — In  any  of  the 
above  forms  of  primary  or  coaptation  sutures,  one  or  more  relaxation  sutures 
of  heavy  catgut  may  be  applied,  passing  transversely  through  the  entire  thick- 
ness of  the  muscle  considerably  above  and  below  the  primary  sutures,  and  tied 
tightly  enough  to  take  the  chief  tension — and  thus  free  the  primary  sutures 
from  strain  (Fig.  208,  D,  E).  (6)  Binnie's  form  of  suture  is  particularly 
good — it  is  a  continuous  suture,  passing  well  into  the  substance  of  the  muscle 
and  reinforced  at  intervals  by  transverse  passage  of  the  needle,  (b)  Where 
the  muscle  has  been  accidentally  and  unevenly  ruptured; — The  ruptured 
muscle  is  exposed  by  the  safest,  most  direct,  and  least  damaging  route — remem- 
bering that  the  ends  of  the  muscles  may  have  retracted  far  away  from  their 
normal  position.  If  the  ends  of  the  muscle  have  been  left  very  irregular,  they 
are  carefully  trimmed,  and  are  then  sutured  in  one  of  the  above  manners.  If 
they  be  torn  almost  transversely,  they  are  approximated  and  sutured 
without  trimming.  If  much  muscle  tissue  have  been  lost,  or  be  sacrificed  in 
trimming,  some  process  of  lengthening  may  have  to  be  resorted  to  before  the 
ends  can  be  made  to  meet  without  too  great  tension  (see  muscle-lengthening, 
below).  In  order  that  the  skin-incision,  used  in  reaching  the  part,  may  not 
lie  over  the  muscle  wound,  bringing  two  cicatrices  directly  opposite,  a  curved 
incision  may  be  used — or  an  oval  flap  of  overlying  parts  may  be  raised.  In 
completing  the  operation,  the  part  should  be  so  immobilized  in  the  dressing 
as  to  relax  the  muscle  as  completely  as  possible. 

MUSCLE-LENGTHENING. 

Description. — In  old  cases  in  which  muscle  tissue  has  contracted  con- 
siderably (as  in  long-standing  cases  of  fractured  patella  or  olecranon) — or 
in  cases  in  which  much  muscle  tissue  has  been  lost  in  injury,  or  has  been 
sacrificed  in  trimming  muscles  for  suturing — it  is  impossible  to  approximate 
the  separated  ends  without  too  great  tension,  unless  the  muscle  be  lengthened. 
Muscle-lengthening,  therefore,  is  resorted  to  in  two  sets  of  cases, — those  in 
which  muscle  must  be  lengthened  to  enable  parts  below,  other  than  the 
muscle,  to  be  approximated  without  too  great  tension  (as  in  the  case  of  the 
triceps  or  the  common  quadriceps  extensor,  in  fractures  of  olecranon  and 
patella), — and  those  in  which  lengthening  is  necessary  after  an  old  transverse 
rupture  of  a  muscle  in  which  the  ends  are  separated  too  far  to  allow  of  ap- 
proximation without  too  great  tension  (as  in  transverse  rupture  of  the  biceps 
muscle).     In  either  category  of  cases  the  operation  is  the  same. 

Operation. — The  patient  having  been  placed  so  as  to  relax  the  part 
completely,  the  site  of  lengthening  is  exposed  by  a  longitudinal  incision  of 
about  7.5  to  10  cm.  (3  to  4  inches)  in  length,  placed  over  the  involved  muscle. 
The  incision  should  be  sufficiently  long  to  afford  free  access  and  manipulation 
and  planned  to  reach  the  parts  by  the  safest,  most  direct,  and  least  damaging 
route.     Retract  the  overlying  soft  parts  and  isolate  the  muscle.     Divide  the 


MUSCLE-LENGTHENING. 


247 


muscle  in  a  zig-zag  line  running  transversely,  and  about  7.5  to  10  cm. 
(3  to  4  inches)  above  the  ruptured  part.  This  is  a  series  of  bluntly  rounded 
serrations  or  V's — the  incision  passing  upward  about  5  cm.  (2  inches)  and 
downward  the  same  distance,  until  the  width  and  entire  thickness  of  the 
muscle  is  traversed  (Fig.  209,  A).  The  muscle  on  either  side  of  the  zig-zag 
incision  is  now  drawn  apart  until  the  apices  of  the  V's  touch.  If  the  teeth 
or  serrations  are  5  cm.  (2  inches)  in  length,  when  the  suturing  is  done, 
nearly  5  cm.  (2  inches)  in  length 
will  be  gained.  The  adjacent  late- 
ral margins  of  the  t.vo  muscle-ends 
are  now  sutured  by  the  knotted 
sutures  described  above  (Fig.  210, 
E,  E)  (page  253).  A  V  from  above 
is  now  sutured,  by  the  same  knotted 
suture,  or  other  form  of  suture,   to 


Fig.  20Q.— Muscle-lengthening:— I.—  Fig.     210.— Muscle-lengthening:— II. 

A,  By  means  of  a  series  of  U-shaped  incisions;        — Manner    of    suturing    the    muscle-sections 

B,  by  a  single  long  V-shaped  incision.  A  case  shown  in  the  last  illustration:  A,  Needle  carrv- 
of  ruptured  patella  is  here  represented.  (The  ing  one  part  of  a  lateral  knotted  suture  through 
manner  of  uniting  these  sections  is  shown  in  one  of  the  tongues  of  the  split  muscle;  B, 
the  following  diagram.)  Opposite  part  placed;  C,  Each  half  tied  and 

the  free  ends  being  knotted;  D,  A  completed 
lateral  knotted  suture;  E,  E,  Lateral  knotted 
sutures  approximating  the  bases  of  the  tongues 
and  also  serving  as  relaxation-sutures;  F, 
Suture  of  the  tongue-and-groove  suture. 

the  A  below,  so  that  their  blunted  tips  are  held  in  contact  by  the  sutures 
passed  through  above  and  below  their  tips  (unless  some  such  form  of 
suture  be  used,  as  shown  in  Fig.  208,  A,  B,  C,  D).  Theoretically,  the  apex 
of  a  V  above  will  correspond  with  the  base  of  a  V  below,  but,  practically, 
the  apices  are  so  disposed  in  the  suturing  as  to  bring  them  in  contact.  Suffi- 
cient length  having  been  gained,  the  lower  operation,  for  which  the  lengthening 
was  primarily  done,  is   now  performed   (an   ununited   fracture  of  patella  or 


24S  OPERATIONS    UPON    THE    MUSCLES. 

olecranon,  or  ruptured  biceps) — and  unless  this  site  has  been  exposed  in 
the  original  incision,  a  separate  incision  is  made  for  that  purpose.  Both 
wounds  are  then  closed  and  the  limb  placed  in  a  splint  that  will  cause  full 
relaxation  of  the  parts  during  healing.  Lengthening  may  also  be  accom- 
plished by  a  long  V-shaped  incision,  as  in  Fig.  209,  B,  which  is  then  sutured 
as  shown  in  Fig.  210,  F.  Some  of  the  methods  of  tendon-lengthening 
described  on  pages  254  to  259  are  also  applicable  to  muscles. 


CHAPTER  VIII. 

OPERATIONS  UPON  THE  TENDONS  AND 
TENDON-SHEATHS. 

TENOTOMY. 

Description. — Division  of  tendons. 

Varieties. — Open  Tenotomy,  where  the  tendon  is  freely  exposed  before 


Fig- 2 1 1.— Open  Tenotomy  : — Of  the  tendo  Achillis. 


being  cut.     Subcutaneous  Tenotomy,  where  the  division  is  made  beneath 
the  skin,  by  the  sense  of  touch.     Complete  Tenotomy,  where  the  entire  thick- 

249 


250      OPERATIONS  UPON  THE  TENDONS  AND  TENDON-SHEATHS. 

ness  of  the  tendon  is  divided.  Partial  Tenotomy,  where  a  part  only  of  the 
thickness  of  the  tendon  is  divided,  the  remaining  fibers  being  stretched. 

Indications. — Shortening  of  tendons.     To  prevent  action  of  muscles. 

Special  Instruments. — For  open  tenotomy; — scalpel;  artery-clamps;  dis- 
secting forceps;  retractors.  For  subcutaneous  tenotomy; — tenotomes,  straight, 
curved,  sharp  and  blunt. 

Open  Tenotomy. — The  tendon  is  here  divided  in  an  open  wound.  The 
incision  for  its  exposure  is  generally  made  parallel  with  and  directly  over 
the  tendon.  The  overlying  soft  parts  are  retracted — the  tendon  is  exposed 
and  isolated — and  its  sheath,  if  any,  is  opened.  The  tendon  is  then  grasped 
with  forceps  and  divided  with  a  scalpel.     The  ends  retract  in  both  directions. 


Fig. 2 1 2. —Subcutaneous  Tenotomy  : — Of  the  tendo  Achillis. 

The  wound  is  entirely  closed  and  the  limb  dressed  upon  a  splint,  or  the  part 
immobilized  (Fig.  211). 

Subcutaneous  Tenotomy. — The  tendon  is  here  divided  subcutaneously, 
through  the  smallest  possible  wound.  Having  put  the  tendon  upon  the 
stretch,  to  render  prominent,  an  incision  is  made  parallel  with  and  just  to 
one  side  of  the  tendon  to  be  cut,  and  so  placed  as  to  do  the  least  damage 
to  other  structures  in  the  neighborhood.  The  incision  is  first  made  with  a 
sharp  tenotome,  through  skin  and  fascia  down  to  the  tendon — upon  this  as 
a  guide  the  blunt  tenotome  is  passed  sidewise  (the  sharp  one  being  withdrawn). 
The  tenotome  is  then  insinuated  beneath  the  tendon,  which  it  closely  hugs 
throughout.  Sometimes  temporary  relaxation  of  the  tendon  will  aid  the 
passage  of  the  knife  beneath  it.  The  cutting-edge  of  the  tenotome  is  then 
turned   outward — the   tendon   put   upon   the   stretch — the   forefinger   of  the 


TENORRHAPHY. 


251 


left  hand  being  placed  over  the  site  of  section  as  a  guard  and  guide — and  the 
tendon  cut  by  a  short  sawing  movement,  the  last  fibers  being  cut  carefully 
as  the  tendon  is  felt  to  yield.  The  knife  is  finally  withdrawn  upon  its  side. 
The  wound  is  sutured  and  the  limb  dressed  upon  a  splint  '(Fig.  212). 

Comment. — (1)  In  simple  sections  where  the  tendons  are  easily  accessible 
and  the  neighboring  parts  are  not  important,  subcutaneous  tenotomy  may 
be  done.  Where  the  opposite  conditions  exist,  open  tenotomy  should  always 
be  practised.  (2)  In  doing  subcutaneous  tenotomy,  the  tenotome  is  some- 
times inserted  between  skin  and  tendon  and  the  section  made  inward  upon 
the  tendon — which  is  more  dangerous  than  cutting  from  beneath  the  tendon 
outward. 

TENORRHAPHY. 

Description. — Suturing  of  tendon.  In  recent  cases  the  ends  of  the 
tendons  can  ordinarily  be  approximated  without  great  difficulty.  In  old  cases 
if  the  ends  cannot  be  approximated  and  sutured  after  freshening  them  by 


Figs.2 13-2 16.— Tenorrhaphy  : — A,  Single  suture  through  entire  thickness  of  tendon;  E,  Two 
sutures  entirely  through  tendon,  in  opposite  directions;  C,  Peripheral  sutures;  D,  Woelfler's  quilt 
sutures. 


trimming,  some  method  of  lengthening  must  be  used — and  if  their  union 
cannot  be  accomplished  by  lengthening,  transplantation  to  adjacent  tendons 
may  be  resorted  to. 

Varieties. — Primary,  when  the  tenorrhaphy  is  done  near  the  time  of 
injury.     Secondary,  when  done  after  healing. 

Operation. — In  recent  cases  an  already  existing  wound  may  be  present 
(except  in  such  cases  as  subcutaneous  rupture  of  a  tendon) — and  where  a  wound 
is  present,  this  is  simply  enlarged  and  the  tendon  more  fully  exposed  and  the 
ends  isolated.  Where  no  wound  exists  at  the  time  of  the  tenorrhaphy,  the 
main  tendon  and  its  ends  are  exposed  by  an  incision  which  reaches  the  site 
by  the  safest  and  simplest  route.  In  primary  tenorrhaphy  the  ends  may 
require  no  trimming,  especially  in  clean  cuts, — or  but  slight  trimming.  In 
secondary  tenorrhaphy,  a  transverse  or  oblique  section  of  the  tendon  ends 
is  always  necessary,  prior  to  suturing.     In  either  case,  the  opposite  ends  of 


25: 


OPERATIONS  UPON  THE  TENDONS  AND  TENDON-SHEATHS. 


the  tendons  are  brought  well  into  the  wound  and  approximated.  Chromic 
catgut  and  kangaroo  tendon  are  the  best  materials  for  uniting  the  ends. 
Several  methods  of  suturing  are  used — the  chief  of  which  will  be  here  de- 
scribed: (a)  Interrupted  sutures  passing  transversely  through  upper  and 
lower  ends  of  divided  tendon  (Figs.  213  and  214,  letters  A,  B) ; — A  straight 
needle  enters  the  proximal  surface  of  the  upper  portion  and  passes  transversely 
through  its  thickness,  about  8  mm.  or  1.3  cm.  (from  ^  to  ^  inch)  from  the 
cut  margin — emerges  at  same  level  upon  distal  surface — crosses  the  gap- 
enters  the  distal  surface  of  the  lower  portion,  from  8  mm.  to  1.3  cm.  ($  to  \ 
inch)  from  the  cut  end — passes  transversely  through — emerges  at  same  level 
on  proximal  surface.  The  two  ends  of  the  suture  are  drawn  upon  until  the 
tendon  ends  are  approximated,  and  are  then  tied.  When  the  tendon-ends 
have  been  cut  obliquely,  the  sutures  are  so  passed  as  to  cross  the  line  of 
division  at  a  right  angle  (Fig.  222,  B).  (b)  Interrupted  mattress  sutures; — ■ 
A  curved  needle  enters  the  proximal  surface  of  the  lower  portion,  about  8 
mm.  (3  inch)  from  its  end — passes  axially  through  two-thirds  of  the  thickness 


Figs.  217-220. 


-Tenorrhaphy: — A,   Mattress  sutures;    B,   Same,   tied;   C,   Lateral;   knotted 
sutures  (a  less  usual  form  of  tenorrhaphy);  D,  Same,  tied. 


of  the  tendon — emerges  on  the  cut  margin — crosses  the  gap  to  the  upper 
portion — enters  the  cut  margin  about  two-thirds  its  thickness  from  the  prox- 
imal surface — emerges  about  8  mm.  (J  inch)  above  the  end — passes  over 
the  outer  surface  of  the  upper  portion  of  the  tendon  for  from  8  mm.  to  1.3 
cm.  (3  to  ^  inch) — again  enters  the  upper  portion  on  a  level  with  the  point 
at  which  it  has  just  emerged  from  the  upper  portion — passes  through  about 
two-thirds  its  thickness — emerges  on  the  cut  margin — crosses  the  gap  to  the 
lower  portion — enters  its  cut  margin  about  two-thirds  its  thickness  from 
the  proximal  surface — and  emerges  on  the  proximal  surface  on  a  level  with 
the  original  entrance — when  the  two  ends  of  the  tendon  are  drawn  upon 
until  the  cut  surfaces  come  well  into  contact  and  are  then  tied  (Figs.  217  and 
218,  A  and  B;  and  Fig.  216,  D).  (c)  Peripheral  longitudinal  coaptation 
sutures; — A  curved  needle  enters  the  lateral  surface  of  the  upper  portion, 
about  8  mm.  or  1.3  cm.  Q  to  \  inch)  from  the  cut  edge — passes  longitudinally 
through  the  tendon  and  emerges  on  the  cut  margin  about  6  to  8  mm.  {\  to  \ 


TENORRHAPHY 


253 


inch)  from  the  lateral  surface — crosses  the  gap — enters  the  cut  margin  of  the 
lower  portion,  from  6  to  8  mm.  (j  to  ^  inch)  from  the  lateral  surface — passes 
longitudinally  through  the  muscle  and  emerges  on  the  lateral  surface,  about 
8  mm.  to  1.3  cm.  (^  to  ^  inch)  from  the  cut  margin.  The  upper  and  lower 
ends  of  the  sutures  are  now  tied,  approximating  the  tendons.  These  sutures 
are  repeated  at  intervals  of  about  8  mm.  to  1.3  cm.  (J  to  \  inch)  around  the 
entire  circumference  of  the  tendon  (Fig.  215,  C).  (d)  Lateral  knotted  sutures; 
— A  curved  needle  enters  the  lateral  surface  of  the  upper  portion  about  8 
mm.  to  1.3  cm.  (£  to  \  inch)  from  the  cut  margin — passes  transversely  through 
the  tendon  tissue  for  about  8  mm.  to  1.3  cm.  (£  to  \  inch)  in  width,  and  8  mm. 
(|  inch)  in  depth — and  emerges  on  the  level  of  entrance.  The  two  ends 
of  the  suture  are  now  tied,  care  being  taken  to  but  slightly,  if  at  all,  pucker 
the  tendon — and  one  end  of  the  suture  is  then  cut  short  The  same  kind  of 
suture  is  applied  immediately  below,  in  the  lower  portion  of  the  tendon,  and 
one  end  of  the  suture  similarly  cut  short.  The  two  long  ends  of  the  sutures 
are  then  tied  together,  thus  approximating  the  two  ends  of  the  tendon.     As 


Figs.  221-223. — Tenorrhaphy: — A,  Reinforcing  or  relaxation  suture,  applicable  to  any 
form  of  suturing  (shown  with  first  turn  of  knot);  B,  Suturing  of  obliquely  divided  ends;  C, 
Reinforcing  through-and-through  suture  by  lateral  suture  through  loops  of  first  suture  (a  less 
usual  form  of  suturing). 

many  of  these  pairs  of  sutures  are  introduced  as  necessary  (Figs.  210  and 
220,  C  and  D).  The  extreme  margins  of  the  tendon-ends  may  be  further 
sutured,  between  these  sutures,  by  method  "c."  (e)  Relaxation  sutures; — 
In  any  of  the  above  forms  of  primary  or  coaptation  sutures,  one  or  more 
relaxation  sutures  of  heavy  catgut  may  be  applied,  passing  transversely 
through  the  entire  thickness  of  the  tendon  considerably  above  and  below  the 
primary  sutures — and  tied  tightly  enough  to  take  the  chief  tension,  and  thus 
free  the  primary  sutures  from  strain  (Fig.  221,  A),  (f)  Combination  of  the 
interrupted  mattress  (method  "b"),  or  lateral  knotted  sutures  (method  "d"), 
with  relaxation  sutures  (method  "e").  Of  these  various  methods,  either 
method  "a"  or  "b"  is  probably  most  generally  applicable — the  former 
especially  in  smaller  tendons  and  the  latter  in  larger.  Having  united  the 
tendon-ends,  the  wound  is  closed  and  the  limb  put  up  upon  an  immobilizing 
splint. 


254       OPERATIONS  UPON  THE  TENDONS  AND  TENDON-SHEATHS. 

Comment. — (i)  While  a  constrictor  is  not  generally  necessary,  its  use  is 
ordinarily  advisable.  (2)  Some  surgeons  prefer  to  expose  the  parts  by  a 
curved  incision,  beginning  and  ending  over  the  tendon,  above  and  below 
the  rupture,  but  not  over  the  rupture — so  that  there  may  be  no  possibility 
of  adhesion  between  the  tendon  cicatrix  and  the  skin  cicatrix.  (3)  The 
ends  of  the  tendons  often  form  adhesions  to  their  sheaths,  and  must  be  freed 
before  they  can  be  brought  together.  (4)  All  tendon-sheaths  opened  to  expose 
tendons  must  be  repaired  with  catgut.  (5)  The  upper  end  of  the  divided 
tendon  retracts  further,  and  is  harder  to  find,  than  the  lower.  The  upper 
end  retracts  more  because  of  the  more  active  shortening  of  the  proximal  end 
of  the  muscle.  It  may  be  found,  in  hard  cases,  by  "milking"  the  tendon- 
sheath  downward — or  by  incising  over  the  tendon  higher  up  and  tracing 
downward — or  by  incising  the  sheath  in  the  lower  part  of  the  wound  and 
tracing  upward.  The  upper  end  of  the  tendon  may  sometimes  be  brought 
into  view  by  extending  the  fingers  or  toes,  the  fibro-serous  vincula  pulling 
down  the  adjacent  tendons.  The  lower  end  is  generally  not  hard  to  be 
found — when  hard,  incise  over  the  sheath  lower  down  and  trace  upward — 
or  pass  a  probe  into  its  sheath  from  below  and  protrude  it  upward.  (6) 
If  the  two  ends  cannot  be  found,  one  end  must  be  transplanted  into  a  neigh- 
boring tendon  of  the  same  group  or  function  (see  transplantation  and  grafting 
of  tendons,  pages  261  to  265).  (7)  The  limb  is  put  up  so  as  to  relax  the 
tendon  and  muscle  fully,  and  held  so  in  a  splint  during  union.  After  union 
has  occurred,  passive  and  active  movements  are  begun  early  and  persisted 
in — in  order  to  prevent  adhesion  of  tendon  to  sheath,  and  to  get  full  range 
of  movement.  (8)  It  will  be  seen  by  comparing  the  illustrations  of  Neuror- 
rhaphy (pages  160  to  162)  that  many  of  the  methods  used  in  uniting  nerves 
are  applicable  to  the  union  of  tendons,  and  vice  versa. 


TENDON-LENGTHENING. 

Description. — Tendon-lengthening,  sometimes  called  tendoplasty,  is  ap- 
plied to  the  lengthening  of  shortened  tendons,  or  to  the  union  of  severed 
tendons,  by  processes  of  plastic  elongation. 

Varieties. — Tendon-lengthening  may  be  required  in  two  classes  of  cases; 
— (1)  Where  the  tendon  is  intact  but  shortened; — (2)  Where  the  tendon  has 
been  severed  and  the  divided  ends  have  retracted.  As  to  the  time  of  per- 
forming the  operation,  tendon-lengthening  may  be  either  primary  (done  near 
the  time  of  injury),  or  secondary  (when  done  after  retraction  and  healing). 

Operation. — Much  that  has  been  said  under  Tenorrhaphy,  as  to  the 
exposure  of  the  tendon,  is  equally  applicable  here — (see  Operation,  page  251, 
and  Comment,  page  254).  Having  exposed  the  shortened  tendon,  or  the 
retracted  tendon-ends,  in  the  wound,  one  of  several  methods  of  lengthening 
may  be  applied — the  chief  of  which  will  be  here  described: — (a)  Operations 
for  lengthening  shortened  intact  tendons: — (1)  By  long  oblique  division 
of  tendon,  with  gliding  of  beveled  ends; — The  obliquity  of  the  division  will 
determine  the  amount  of  lengthening — the  ends  being  slid  past  each  other  far 
enough  to  still  leave  sufficient  substance  for  union — and  then  the  ends  are 
sutured  by  several  transverse  sutures  of  chromic  gut  or  kangaroo  tendon. 
An  oblique  incision  of  5  cm.  (2  inches)  will  furnish  a  lengthening  of  from 
2.5  to  4  cm.  (1  to  ij  inches)  (Fig.  225,  B).  (2)  By  central  longitudinal 
splitting  of  tendon  with  transverse  division  of  the  split  ends  and  their 
approximation,    surface    to    surface; — Having   split   the    shortened     tendon 


TENDON-LENGTHENING. 


2  55 


Figs.  224— 227.— Tendon-lengthening  : — A,  Splitting  tendon  transversely  and  longitudinally  and 
suturing  ends  laterally  ;  B,  Splitting  and  suturing  tendon  obliquely  ;  C,  Splitting  tendon  obliquely  and 
longitudinally  and  suturing  split  portions  end-to-end  ;  D,  Splitting  one  end  obliquely  and  longitudi- 
nally and  suturing  the  split  end  laterally  to  opposite  unsplit  end. 


Figs.  228-231. — Less  Usual  Forms  of  Tendon-lengthening: — A,  Splitting  one  end 
longitudinally  and  transversely,  reinforcing  where  bent,  and  suturing  split  end  into  opposite 
unsplit  end;  B,  Splitting  both  ends  longitudinally  and  transversely,  reinforcing  where  bent,  and 
suturing  split  portions  end  to  end;  C,  Same,  with  suturing  of  split  portions  laterally;  D,  Same 
as  last,  with  different  sutures  (lateral  knotted  and  ordinary). 


256       OPERATIONS    UPON    THE    TENDONS    AND    TENDON-SHEATHS. 


Fig.  232. — Bayer's  Method  of  Tendon-lengthening: — A,  The  lines  of  through-and-through 

division  of  one-half  the  width  of  the  tendon  are  shown. 
Fig.   233. — B,  The  appearance  of  the  tendon  after  traction  and  the  gliding  of  the  longitudinal 

fibers  past  each  other. 

down  its  center,  as  far  as  necessary  to  furnish  the  needed  length,  the  ends  of  the 
split  portion  are  divided  transversely,  or  slightly  obliquely,  in  opposite  direc- 


Fig.  234. — A  less  Common  Form  of  Tendon-lengthening: — A,  The  preliminary  rectangular 

incisions. 
Fig.  235. — B,  The  subsequent  appearance  of  the  tendon  after  traction  upon  its  ends. 


tions.     They  are  then  glided  past  each  other  and  fastened  laterally  near  their 
ends  by  two  or  more  sutures  passing  through  their  combined  thickness  (Fig. 


TENDON-LEXGTHENIXG. 


257 


224,  A).  (3)  By  central  longitudinal  splitting  of  tendon  with  transverse 
division  of  the  split  ends  and  their  approximation,  end  to  end; — Somewhat 
similar  to  the  method  just  described,  except  that  the  extreme  ends  of  the  split 
portions  are  sutured  end-to-end,  rather  than  surface-to-surface  (Fig.  226,  C). 

(4)  Bv  zig-zag  incisions; — Incisions,  transverse  to  the  length  of  the  tendon, 
are  made  on  opposite  sides  of  the  tendon,  passing  half-way  across,  and  not 
placed  directly  opposite  each  other.  As  many  as  are  deemed  necessary  are 
thus  placed,  and  the  tendon  lengthened  by  traction  (Figs.  241  and  242,  A,  B). 

(5)  A  tendon  may  be  lengthened  by  Bayer's  method  of  partial  division,  followed 
by  gliding  the  uncut  fibers; — one-half  of  the  width  of  the  tendon  is  divided 
from  its  lateral  (right)  margin  transversely  to  its  center — and  the  opposite 
half  of  the  width  is  similarly  divided  from  its  lateral  (left)  margin  transversely 
to  its  center,  but  at  a  distance  of  2.5  cm.  (1  inch)  or  more  from  the  first  trans- 


Figs.  236-239. — Less  Common"  Forms  of  Tendon-lengthening  : — A,  Double  splitting 
of  both  ends,  reinforcing  where  bent,  and  suturing  split  portions  end-to-end;  B,  Bridging  with 
gut,  or  reinforcing  or  relaxing  with  lateral  knotted  sutures;  C,  Bridging  with  twisted  gut;  D, 
Interpolation  with  another  piece  of  tendon. 

verse  division.  By  putting  the  tendon  under  tension,  the  margins  of  the  trans- 
versely cut  portions  separate,  and  the  fibers  of  the  portions  between  the  cuts 
may  be  made  to  glide  past  each  other  as  far  as  desired.  The  parts  which  are 
about  to  glide  entirely  out  of  contact  may  be  reinforced  by  a  double  suture. 
(Figs.  232  and  233.)  (6)  A  tendon  may  be  lengthened  by  being  incised  as 
shown  in  Fig.  234,  A — followed  by  traction  and  the  production  of  the  effect 
shown  in  Fig.  235,  B.  (b)  Operations  for  lengthening  shortened  severed 
tendons: — (I)  By  partially  splitting  one  end,  twisting  the  split  half,  and 
suturing  it  to  itself  and  to  the  end  of  the  opposite  end.  Calculating  the  required 
amount  of  tendon  needed,  the  upper  end  of  the  tendon  is  partially  split,  twisted 
upon  itself,  and  sutured  to  itself — and  its  free  end  sutured  to  the  opposite  lower 
end  of  the  unsplit  tendon  (Fig.  227,  D;  and  Fig.  228,  A).  (2)  By  partially 
.splitting  both  ends,  twisting  the  split  portions  and  suturing  them  to  themselves 
17 


258       OPERATIONS    UPON    THE    TENDONS    AND    TENDON-SHEATHS. 

and  to  the  end  of  the  opposite  end.  This  is  the  application  to  both  ends  of 
the  principle  applied  in  "1"  to  one  end  (Fig.  229,  B).  (3)  By  partially  split- 
ting both  ends,  twisting  the  split  portions  and  suturing  them  to  themselves 
and  laterally  to  the  opposite  end  (Fig.  230,  C).  (4)  By  distance  suturing, 
or  bridging,  with  catgut; — The  ends  are  approximated  by  lateral  knotted 
sutures,  as  far  as  possible,  then  a  continuous  catgut  suture  is  run  back  and 
forth  between  the  ends  and  between  the  lateral  knotted  sutures,  partially  filling 
in  the  gap  by  catgut  strands,  upon  which  lymph  and  blood  are  poured,  and, 
together  with  the  catgut,  organized  (Figs.  237  and  238,  B  and  C;  and  Fig. 
243,  C).  (5)  Tendon  lengthening  by  means  of  interposed  silk  sutures  (Lange's 
method); — If  the  end  of  a  severed  tendon  is  not  long  enough  to  reach  to  the 
opposite  end  of  the  tendon,  or  to  the  site  cf  its  periosteal  insertion,  it  may  be 
attached  to  this  opposite  end,  or  periosteum,  by  means  of  one  or  more  stout  silk 
sutures  introduced  in  the  fashion  of  a  mattress  suture.  Experience  has  shown 
that  tendon  will  form  along  this  intervening  silk  and  thus  continue  the  con- 
tinuity of  the  tendon.  Especially  careful  technic  has  to  be  employed,  as  septic 
infection  is  likely  to  invalidate  the  result.  Four  strands  are  used  in  ordinary 
tendons — and  eight  to  twelve  in  tendons  the  size  of  the  quadriceps  extensor. 
The  silk,  which  is  stout,  is  boiled  in  1-1000  bichloride  of  mercury  solution. 
With  a  long,  straight  needle,  the  silk  is  introduced  in  the  manner  illustrated 
in  Fig.  240.     When  the  knot  is  tied  tightly,  the  pull  comes  squarely  from  the 


Fig.  240. — Lange's  Method  of  Tendon-lengthexing  by  Means  of.  Interposed 
Silk  Sutures: — The  method  of  introducing  the  suture  is  here  shown  in  the  case  of  a  small 
tendon.  Several  sutures  are  used  in  larger  tendons,  evenly  distributed  throughout  the  substance 
of  the  tendon. 

points  of  emergence  of  the  silk  from  one  end  of  the  tendon,  to  the  points  of 
entrance  into  the  opposite  end,  directly  in  the  long  axis  of  the  tendon.  A  drain 
for  forty-eight  hours  is  used,  to  carry  off  the  fluids  of  the  wound.  Following  the 
union  of  the  tendon-ends,  the  tendon-sheath,  if  it  have  been  incised  or  other- 
wise injured,  is  repaired  with  catgut  sutures,  as  far  as  possible.  In  exposing 
the  tendon,  the  sheath  should  not  have  been  needlessly  freed,  for  the  vessels 
of  the  tendon  reach  it  through  the  sheath.  The  overlying  muscles  are  brought 
together  with  buried  catgut  sutures.  The  skin-wound  is  then  closed — and  the 
limb  immobilized  upon  a  splint,  which  will  insure  relaxation  of  the  part.  Pas- 
sive and  active  motion  should  be  begun  as  soon  as  sound  healing  has  occurred. 

Comment. — Many  of  the  methods  of  nerve-lengthening  are  equally 
applicable  to  tendon-lengthening  (pages  163  to  165).  Not  only  may 
tendon-lengthening  be  accomplished  by  processes  of  plastic  elongation  in  the 
sense  of  bringing  into  position  undetached  portions  of  tendon — but  elongation 
may  be  also  accomplished  by  the  interposition  of  tendon  substance,  in  those 
cases  where  the  gap  is  too  long  to  be  bridged  by  other  means,  as  in  the  similar 
operation  for  nerve-lengthening.  The  two  most  ordinary  ways  are  the 
following; — (a)  A  piece  of  tendon  of  the  required  length  and  as  nearly  the 
desired  size  as  possible,  taken  from  a  human  being  just  operated  upon,  or 


TEXDOX-LEXGTHEMXG. 


259 


from  a  lower  animal,  is  inserted  into  the  interval  between  the  severed  ends, 
which  have  been  freshened,  and  is  sutured  to  both  ends  of  the  main  tendon 
by  longitudinal  peripheral  sutures,  or  other  method  (Fig.  239,  D).  (b)  Half 
the  thickness,  and  as  much  of  the  length  as  required,  of  part  of  the  same  or 
of  one  of  the  neighboring  tendons  of  the  patient  is  taken,  and  sutured,  as 


Figs.  241-243. — Tendon-lengthening: — A,  Poncet's  accordion  method  (in  case  of  tendo 
Achillis) — incisions  partly  across  tendon;  B,  Same,  showing  amount  of  lengthening  by  traction 
upon  tendon;  C,  Bridging  with  gut,  reinforced  with  decalcified  bone-cylinder. 

above,  into  the  gap.  The  wound  is  treated  as  after  other  forms  of  tendon- 
lengthening.  The  interpolated  tendon  probably  disappears,  as  such,  after 
serving  as  a  framework. 


TENDON-SHORTENING. 

Description. — The  shortening  of  a  tendon  for  the  purpose  of  increasing 
the  action  of  a  muscle  which  has  become  impaired  by  the  elongation  of  its 
tendon, — or  for  the  purpose  of  improving  a  deformity  (as  the  shortening  of 
the  tendo  Achillis  for  talipes  calcaneus). 

Operation. — Having  exposed  the  involved  tendon,  its  shortening  may  be 
accomplished  in  one  of  several  ways; — (r)  By  excision  of  a  piece  of  the  tendon, 
with  the  union  of  the  resulting  ends  by  one  of  the  methods  of  tenorrhaphy. 
(2)  By  oblique- division  of  the  tendon,  followed  by  gliding  of  the  ends  in  such 
a  way  as  to  lessen  the  length  of  the  tendon,  and  the  suturing  of  the  ends  as 
in  Fig.  244,  A.  (3)  By  division  and  shortening  of  the  tendon,  followed  by 
the  beveling  of  one  end  into  a  wedge,  and  the  splitting  of  the  other  end — and 
the  suturing  of  the  wedge  into  the  split  portion,  thus  using  up  the  excess  of 
length  (Fig.  246,  C).  (4)  By  the  figure  of  Z  method  (Fig.  245,  B); — make 
a  vertical  incision  down  the  center  of  the  tendon  from  F  to  K,  and  transverse 


20O       OPERATIONS    UPON    THE    TENDONS    AND    TENDON-SHEATHS. 

ones  along  E  F  and  K  L.     Having  drawn  the  cut  portions  apart,  shorten  each 
piece  by  removing  the  ends  at  G  H  and  I  J.     E  F  and  G  H  are  then  sutured 


Figs.  244-247. — Tendon-shortening: — A,  Portion  of  tendon  excised  obliquely  and  sev- 
ered portions  sutured  end-to-end,  in  direct  contact  or  overlapping  (reverse  of  Fig.  225,  B);  B, 
Z-shaped  incision  is  made,  followed  by  excision  of  E  F  G  H  and  I  J  K  L,  after  which  E  F  is 
sutured  to  K  L:  C,  Following  excision,  ends  of  tendon  are  sutured  in  form  of  mortise;  D,  Ex- 
cision of  portion  of  tendon  by  transverse  incision,  followed  bv  mattress-suturing  of  opposite 
ends  (portion  between  circular  transverse  incisions  is  here  excised). 

together,  and  I  J  and  K  L — as  well  as  the  vertical  line  of  division.     The  wound, 
following  the  operations  for  tendon-shortening,  is  closed  and  treated  as  after 


Fig.  248. — Hoffa's   Method   of   Tendon-shortening: — A,    The   manner   of   inserting    the 

through-and-through  suture. 
Fig.   249. — B,  The  appearance  of  the  tendon  after  the  tightening  and  knotting  of  the  suture. 


TENDON-GRAFTING. 


261 


tendon-lengthening.  Another  form  of  tendon-shortening  is  shown  in  Fig.  247, 
D,  where  a  portion  of  tendon  is  removed.  (5)  A  tendon  may  be  shortened 
by  passing  through  its  substance,  lengthwise,  two  stout  silk  sutures  after  the 
fashion  of  the  cords  in  Venetian  blinds  (Fig.  248,  A) — traction  upon  which, 
and  knotting  will  produce  the  shortening  shown  in  Fig.  249,  B,  Hofta's  method. 

TENDON-GRAFTING. 

Description. — Tendon-grafting,  tendon-transplantation,  or  tendon-im- 
plantation, as  the  operation  is  variously  termed,  is  the  attachment  of  the 
distal  end  of  a  divided  tendon  into  a  neighboring  sound  tendon  of  the  same 
general  group  or  function.  The  attachment  is  sometimes  made  laterally, 
without  the  division  of  the  involved  tendon.  A  limb  may  be  tunnelled  and  a 
tendon  of  one  group  drawn  entirely  through  the  limb  and  sutured  to  a  tendon 
of  another  group  on  the  opposite  aspect. 

Indications. — (1)  Those  cases  in  which  so  much  of  the  tendon  has  been 
destroved  that  its  reconstruction  is  impossible — and   the  damaged  tendon 


Fig. 250.— Tendon-grafting  :— Of  sound  extensor  of  great  toe  into  impaired  anterior  tibial ;  A, 
Tendon  of  tibialis  amicus;  B.  Proximal  end  of  extensor  proprius  hallucis, which  has  been  severed 
from  lower  end,  C,  and  engrafted  upon  anterior  tibial  tendon;  D,  Innermost  tendon  of  extensor 
brevis  digitorum. 


is  therefore  grafted  to  a  neighboring  tendon  (for  instance,  should  one  of  the 
four  tendons  of  the  flexor  sublimis  or  profundus  digitorum  be  too  extensively 
damaged  for  union  of  the  proximal  and  distal  ends,  its  distal  end  may  be 


262       OPERATIONS    UPON   THE    TENDONS    AND    TENDON-SHEATHS. 

attached  to  one  of  the  neighboring  sound  tendons  of  the  same  muscle).  (2) 
Those  cases  in  which  a  group  of  muscles,  or  a  single  muscle,  has  been  para- 
lyzed— and  one  or  more  of  the  tendons  of  the  paralyzed  group  is  therefore 
grafted  to  a  tendon  of  an  unparalyzed  group  (for  instance,  if  the  tibialis 
anticus  were  paralyzed  and  the  extensor  propius  hallucis  intact,  the  tendon 
of  the  latter  may  be  grafted  upon  the  tibialis  anticus)  (Fig.  250).  Where  the 
tendon  of  the  muscle  from  which  the  power  is  to  be  derived  is  of  comparatively 


Figs.  251-254. — Tendon-grafting  : — I. — Where  the  tendon  of  the  muscle  supplying  the 
power  is  of  comparatively  little  importance  (shown  on  the  right,  in  light),  the  entire  sound 
tendon  is  grafted  upon  the  impaired  tendon   (shown  on  the  left,  in  dark).     (Modified  from 

Vulpius.) 


Figs.  255-259 — Tendon-grafting: — II — Where  the  tendon  of  the  muscle  supplying  the 
power  is  of  greater  importance  (shown  on  the  right,  in  light),  only  a  portion  of  the  sound 
tendon  is  grafted  upon  the  impaired  tendon  (shown  on  the  left,  in  dark).  (Modified  from  Vulpius.) 

little  importance  functionally,  and  the  paralyzed  muscle  is  of  more  importance, 
the  entire  sound  tendon  may  be  diverted  into  the  paralyzed  muscle  (Figs. 
251-254).  But  where  the  tendon  of  the  muscle  which  is  to  supply  the  power 
is  more  important  than  the  paralyzed  tendon,  then  but  a  portion  of  the  sound 
tendon  should  be  diverted  into  the  paralyzed  one  (Figs.  255-259). 


OPERATION    FOR    UNITING    TENDON    TO    PERIOSTEUM. 


263 


Operation. — Having  exposed  the  field  of  operation  by  an  incision  harming 
the  adjacent  structures  as  little  as  possible,  and  having  isolated  the  involved 
and  the  sound  tendons,  the  technic  of  grafting  may  be  accomplished  in  one 
of  several  ways — the  chief  of  which  will  be  here  mentioned; — (a)  Tendon- 
grafting  by  lateral  attachment : — In  the  case  of  a  divided  tendon,  the 
distal  end  is  freshened  by  an  oblique  paring  (Fig.  260,  A).  In  the  case  of  a 
paralyzed  (undivided)  tendon,  it  is  divided  obliquely  (also  A,  Fig.  260). 
That  portion  of  the  sound  tendon  to  which  the  involved  tendon  is  to  be  at- 
tached is  freshened  upon  its  lateral  aspect — to  which  the  obliquely  divided 
distal  end  of  the  injured,  or  paralyzed,  tendon  is  now  sutured  with  gut  by 
peripheral  coaptation  sutures,  or  other  form  of  suturing.  Sometimes  the 
paralyzed  tendon  is  not  divided,  but  its  lateral  aspect  freshened,  just  as  in 
the  case  of  the  sound  tendon — these  aspects  being  then  brought  together 
and  sutured  (Fig.  261, 
B).  Especially  would 
this  be  indicated  where  it 
is  possible  for  the  struc- 
ture of  the  paralyzed 
muscle  eventually  to  re- 
gain its  functioning,  (b) 
Tendon  -  grafting  by 
implantation  :  —  The 
sound  tendon  is  split  en- 
tirely through  its  center, 
over  an  area  sufficiently 
long  to  accommodate  the 
tendon  to  be  grafted. 
Freshen  the  distal  end 
of  the  involved  tendon 
(injured  or  paralyzed) 
by  paring  both  sides  in 
a  beveling  or  wedge- 
shaped  fashion.  The 
wedge-shaped  piece  of 
tendon  is    then  inserted 


between  the  lips  of  the 
split  tendon  and  held  in 
place    by  two    or   more 


Figs.260-262.— Tendon-grafting  :— A,  Grafting  end  of  di- 
vided tendon  into  lateral  aspect  of  undivided  tendon  ;  B,  Grafting 
undivided  tendons  laterally;  C,  Implantation  of  beveled  end  of 
tendon  between  the  split  portions  of  sound  tendon. 


gut  sutures  passed  trans- 
versely through   both   tendons  (Fig.  262,  C).     The  wound  is  finally  closed 
in  the  usual  way — and  the  limb  put  up  upon  a  splint  in  such  a  position  as  to 
secure  relaxation  of  the  parts. 


OPERATION  FOR   UNITING  TENDON  TO  PERIOSTEUM. 

lange's  method. 

Description. — It  sometimes  happens  that  the  end  of  a  divided  tendon  can 
not  be  made  to  reach  its  normal  site — it  is  then  to  be  sutured  either  to  a  neigh- 
boring tendon  or  into  adjacent  periosteum  or  bone,  as  near  to  its  original 
insertion  as  possible.  In  the  case  of  uniting  it  to  the  periosteum,  the  technic 
is  as  follows: — a  flap  of  periosteum,  from  1  to  2  cm.  ({  to  f  inch)  in  length 
is  detached  with  periosteal  elevator,  in  convenient  relationship  to  the  tendon. 


264       OPERATIONS    UPON    THE    TENDONS    AND    TENDON-SHEATHS. 

The  end  of  the  tendon  is  then  cut  obliquely  in  such  a  way  as  to  present  a  favor- 
able surface,  and  this  freshened  surface  is  sutured  with  fine  chromic  gut  to  the 


Fig.  263. — Lange's  Method  of  Uniting  Tendon  to  Periosteal  Flap. 

outer  surface  of  the  periosteal  flap.  The  neighboring  soft  parts  are  brought 
normally  about  the  site  of  operation,  buried  sutures  being  used  where  indicated 
— and  the  wound  closed.     (See  Fig.  263.) 


Fig.  264. — Wolff's  Method  of  Implanting  Tendon  into  Bone. 

OPERATION   FOR   UNITING  TENDON   TO  BONE. 
wolff's  method. 

Description. — Instead  of  uniting  the  end  of  the  tendon  to  periosteum  as' 
in  the  operation  just  given,  the  tendon  may  be  implanted  within  the  bone  and 


REPAIR    OF    RUPTURED    OR    DIVIDED    TENDON-SHEATHS. 


*5 


surrounded  by  the  periosteum.  The  periosteum  is  incised  over  the  site  where 
the  end  of  the  tendon  is  to  be  implanted.  After  having  retracted  the  two  lips 
of  the  incised  periosteum,  a  groove  is  chiselled  in  the  exposed  bone.  The 
bevelled  end  of  the  tendon  is  buried  in  this  groove — and  the  margins  of  the 
periosteum  are  sutured  to  the  implanted  tendon  and  to  each  other.  The 
wound  is  closed  without  drainage,  unless  otherwise  indicated.     (Fig.  264.) 

TRANSPLANTATION  OF  TENDON  WITH  ITS  OSSEOUS  INSERTION. 
Description. — It  occasionally  happens,  after  fracture  of  the  patella 
(especially  when  repair  is  not  undertaken  until  after  contracture  has  taken 
place)  and  after  rupture  of  the  tendon  of  the  quadriceps  extensor  or  the  tendo 
Achillis,  that  it  is  impossible  to  approximate  the  fragments  of  bone,  or  ends  of 
the  tendons,  without  the  transplantation  proximally  of  the  osseous  prominences 
into  which  the  tendons  are  inserted.  Let  it  be  supposed  that  the  quadriceps 
extensor  tendon  has  been  ruptured  a  short  distance  above  the  patella; — 
When  the  site  of  rupture  is  exposed,  it  is  found  impossible  to  bring  the  ends  of 
the  tendon  together.  The  vertical  incision  for  its  exposure  is  continued  down- 
ward. The  patella,  ligamentum  patella?,  and  tibial  tubercle  are  exposed.  The 
tibial  tubercle  is  now  chiselled  from  the  tibia — and  any  adhesions  which  bind 
the  parts  down  are  freed.  The  ruptured  extensor  tendon  is  now  sutured — 
during  which  the  separated  tibial  tubercle  has  glided  upward  upon  the  tibia 
into  a  new  position.  In  this  higher  position  upon  the  anterior  aspect  of  the 
tibia,  sufficiently  far  below  the  upper  margin  of  the  tibia  not  to  interfere  with 
the  joint-movement,  a  steel  nail  is  driven  through  the  tibial  tubercle — a  nail 
sufficiently  long  to  be  left  protruding  through  the  skin  to  be  removed  after  union 
is  complete.     The  soft  parts  are  then  closed  about  the  nail — as  well  as  over 


Fig.  265. — Transplantation  of  Tendon  with  its  Osseous  Insertion. 

the  site  of  the  ruptured  tendon.     This  same  technic  may  be  applied  to  the 
tendon  of  the  triceps.     (Fig.  265.) 


REPAIR  OF  RUPTURED  OR  DIVIDED  TENDON-SHEATHS. 

Description. — A  tendon-sheath  may  be  accidentally  ruptured  by  violent 
action  or  injury,  as  in  the  case  of  the  long  head  of  the  biceps,  or  may  be  pur- 
posely divided  in  an  operation  temporarily  to  expose  the  tendon  within,  or 


266      OPERATIONS    UPON    THE    TENDONS    AND    TENDON-SHEATHS. 

the  underlying  parts  beyond  (as  the  division  of  the  sheath  of  the  tendo  Achillis 
for  tenorrhaphy,  or  the  division  of  the  common  sheath  of  the  peroneus  longus 
and  brevis  tendons  temporarily  to  retract  the  contained  tendons  in  the  excision 
of  the  ankle-joint). 

Operation.  When  the  object  is  to  expose  the  tendon  and  sheath  alone, 
a  slightly  curved  incision  is  made,  coming  over  the  sheath  above  and  below 
but  somewhat  to  one  side  at  the  site  of  rupture  (so  that  the  cicatrices  of  skin 
and  sheath  will  not  fall  directly  over  each  other).  Or  a  straight  incision 
may  be  made  directly  over  the  tendon-sheath.  When  the  sheath  is  divided 
in  the  course  of  some  other  operation,  the  position  of  the  incision  will  have 
been  determined  by  the  special  operation.     The  part  is  then  put  into  that 


Fit 


266. — Excision  of  Tkndon-sheath  : — Sheath  is  seized  with   forceps   and    divided  circularly 
around  the  tendon  at  both  ends  of  the  involved  area. 


position  which  will  relax  the  tendon  to  the  greatest  extent — the  tendon  and 
sheath  are  then  clearly  located,  and  the  former  placed  within  the  latter, 
while  the  edges  of  the  sheath  are  held  aside.  The  sheath  is  then  carefully 
dropped  together  over  the  tendon  and  the  sheath-margins  sutured  with  a 
fine  continuous  gut  suture.  The  wound  is  now  closed  and  the  limb  put  up 
so  as  completely  to  relax  the  tendon.  In  about  ten  days  the  limb  is  taken  out 
of  the  splint  at  intervals  and  passively  moved,  to  prevent  adhesion  of  tendon 
to  sheath — while  the  surgeon's  left  thumb  placed  over  the  tendon  during 
manipulation  holds  it  in  place  within  the  sheath  and  relieves  part  of  the 
strain  upon  the  recently  sutured  sheath. 

Comment. — In  cases  of  paralysis,  the  peroneus  longus  has  been  grafted 


EXCISION    OF    TEXDOX-SHEATHS.  267 

into  the  tendo  Achillis,  into  the  tibialis  posticus,  and  even  into  the  tibialis 
anticus; — the  tibialis  anticus  into  the  extensor  proprius  haUucis; — the  sartorius 
into  the  rectus  femoris,  and  the  like.  Tendons  are  sometimes  approximated 
by  tunneling  under  other  structures. 

EXCISION  OF  TENDON-SHEATHS. 

Description. — The  removal  of  more  or  less  of  the  sheath  of  a  tendon. 
Generally  resorted  to  in  cases  of  obstinate  tenosvnovitis. 

Operation. — The  special  tendon-sheath  involved  is  exposed  by  an  incision 
directly  over  it, — or  by  an  incision  beginning  and  ending  over  the  sheath  but 
passing  to  one  side  of  the  sheath  throughout  the  rest  of  its  course,  thus  en- 
abling a  skin-flap  to  be  turned  to  one  side,  so  that  when  replaced  its  scar 
will  not  fall  directly  over  the  tendon.  Having  retracted  the  soft  parts,  the 
tendon-sheath  is  entirely  isolated,  with  care,  from  the  neighboring  structures — 
especially  from  those  forming  its  bed.  The  sheath  of  the  tendon  is  now 
divided  circularly  around  the  tendon,  above  and  below  the  diseased  portion 
— but  without  cutting  the  tendon  itself.  Having  completed  the  two  circular 
incisions  at  either  end,  the  sheath  is  split  in  the  long  axis  of  the  tendon— 
and  thus  laid  completely  open — and  may  be  removed  in  one  piece  (Fig.  266). 
Any  diseased  portions  of  the  contained  tendon  found,  should  be  scraped. 
The  skin-flap  is  then  united — and  the  limb  put  up  so  as  to  immobilize  the 
tendon. 


CHAPTER  IX. 


OPERATIONS  UPON  THE  LIGAMENTS. 

SYNDESMOTOMY. 

Description. — Division  of  ligaments.  Generally  performed  for  the  con- 
traction of  ligaments  occurring  as  the  cause,  in  whole  or  in  part,  of  some 
of  the  deformities. 

Operations. — The  ligament,  or  ligaments,  at  fault  may  be  divided  by 
the  subcutaneous  or  open  method — the  latter  being  preferable.  In  the  open 
method  the  involved  ligaments  are  exposed  by  the  simplest  and  safest  route 
— and  divided  in  the  same  general  manner  as  the  division  of  tendons  by  the 
open  method — and  the  wound  similarly  treated. 


SUTURING  OF  LIGAMENTS. 

The  suturing  of  ligaments  is  performed  upon  the  same  general  principles 
as  is  tendon-suturing  (see  page  251). 


LENGTHENING  OF  LIGAMENTS. 

Description. — Lengthening  of  ligaments  which  have  become  shortened 
through  disease  or  injury — especially  in  cases  of  deformity. 

Operation. — Many  of  the  same  methods  involved  in  tendon-lengthening 
are  applicable  to  the  lengthening  of  ligaments.  Where  a  ligament  is  attached 
to  a  bony  prominence,  this  has  been  chiseled  off  and  displaced  to  a  neigh- 
boring site  and  there  nailed  (as  in  the  case  of  the  ligamentum  patella?,  where 
the  tubercle  of  the  tibia  has  been  displaced  to  the  upper  portion  of  the  tibia 
— but  with  uncertain  success).     (See  Tendon-lengthening,  page  254.) 


SHORTENING  OF  LIGAMENTS. 

Description. — Shortening  of  ligaments  which  may  have  become  lengthened 
through  disease  or  injury. 

Operation. — Many  of  the  tendon-shortening  methods  may  also  be  ap 
plied  to  elongated  ligaments.     As  in  the  above  operation,  where  a  ligament 
is  attached  to  a  prominence  of  bone,  this  may  be  chiseled  from  its  normal 
site  and  nailed  to  an  adjacent  site  (as  in  the  case  of  the  ligamentum  patellae, 
where  the  tibial  tubercle  has  been  displaced  lower  down  the  tibia). 

Note. — Most  of  the  work  done  upon  Ligaments  will  be  found  described 
in  special  writings  upon  orthopedic  surgery.  (Also  see  Tendon-shortening, 
page  259.) 

268 


CHAPTER  X. 

OPERATIONS  UPON  THE  FASCIA. 

FASCIOTOMY   OR   APONEUROTOMY. 

Description. — Fasciotomy  or  aponeurotomy  signifies  the  division  of 
bands  or  planes  of  contracted  fascia.  The  term  is  used  with  especial  reference 
to  operations  upon  contracted  palmar  and  plantar  fascia,  in  the  deformities 
of  those  parts — and  in  connection  with  the  contracted  fascia  lata,  and  the 
contracted  fascia  following  burns,  and  the  like. 

Operation. — The  division  is  usually  accomplished  by  the  subcutaneous 
or  open  method.  The  general  principles  of  the  operations  will  be  here  de- 
scribed— the  steps  of  the  special  operation  will  be  determined  by  the  anatomy 
and  contraction  of  the  part  involved,  (a)  Fasciotomy  by  the  Subcutaneous 
Method  : — Where  the  contracted  fascia  is  in  the  form  of  narrow  bands,  a 
sharp-pointed  tenotome  with  a  narrow  cutting-edge  (of  about  6  mm.,  or  J 
inch)  is  best.  Where  the  fascia  is  contracted  in  the  form  of  planes,  a  sharp- 
pointed  tenotome  with  a  longer  cutting-edge  is  to  be  preferred.  The  short- 
bladed  fasciatome,  however,  is  the  safer  form  of  tenotome,  as  far  as  damaging 
the  neighboring  structures  is  concerned.  The  instrument  is  inserted  flatwise 
beneath  the  fascia — the  cutting-edge  is  then  turned  toward  the  contracted 
fascia,  which  is  rendered  further  prominent  by  extending  the  part,  and  the 
special  band  of  fascia  is  divided  against  which  the  knife-edge  presses — then 
another  band  is  sought — new  bands  appearing  to  spring  into  existence  as 
others  are  cut — the  tenotome  being  carefully  pushed  in  different  directions 
until  all  the  bands  are  cut.  Just  before  each  band  is  cut,  the  tip  of  the  surgeon's 
left  forefinger  should  be  placed  over  the  tense  band  of  fascia  and  make  counter- 
pressure,  and  thereby  serve  as  a  guide  of  the  progress  of  the  knife  toward  the 
skin.  Sometimes  all  the  bands  can  be  divided  through  one  introduction 
of  the  tenotome — in  other  cases  the  tenotome  is  introduced  at  several  sites. 
The  tenotome  is  sometimes  introduced  between  the  skin  and  the  fascia  and 
divides  the  latter  by  cutting  downward,  which  is  somewhat  more  risky. 
When  all  or  nearly  all  of  the  ligaments  have  been  divided  which  the  tenotome 
can  detect  and  reach,  the  part  is  fully  extended,  breaking  down  the  remaining 
ones  if  any.  The  tenotome  wound  or  wounds  are  then  closed  by  a  suture 
or  two  and  the  limb  immobilized  in  a  splint,  which  is  worn  for  a  long  period. 
(b)  Fasciotomy  by  the  Open  Method  : — A  number  of  limited  incisions 
may  be  made  from  without  inward,  through  the  skin  and  fascial  bands, — 
or  the  involved  fascial  bands  may  be  exposed  through  a  skin-flap  which  is 
raised  and  retracted  to  one  side,  or  through  a  long  straight  incision  whose 
margins  are  retracted  laterally.  Following  the  thorough  exposure  of  the 
parts,  in  the  last  method,  the  contracted  fascia  is  dissected  out  wherever 
present.  In  either  one  of  the  open  methods,  the  part  is  fully  extended  after 
the  operation,  the  skin-wound  closed  and  the  part  immobilized. 

Note. — Much  of  the  work  done  upon  the  Fascia  will  be  found  described 
in  special  writings  upon  orthopedic  surgery. 

269 


CHAPTER  XI. 

OPERATIONS  UPON  THE  BURSAE. 

PUNCTURE  OF  BURSAE. 

Description. — Generally  resorted  to  for  exploring  the  nature  of  the 
bursal  contents,  or  for  injecting  fluid  for  destroying  its  secreting  surface,  or 
simply  for  the  evacuation  of  its  contents. 

Operation. — The  needle  of  the  syringe  is  introduced,  with  the  usual 
precautions,  into  the  interior  of  the  enlarged  bursa — piercing  the  skin  as 
directly  over  the.  cyst  as  possible  and  passing  by  the  safest  route  through,  or 
preferably  between,  the  overlying  tissues.  The  site  of  the  introduction  will 
depend  upon  the  special  bursa. 

INCISION  OF  BURSAE. 

Description. — Usually  resorted  to  for  the  evacuation  of  pus,  or  other 
fluid;  or  to  expose  the  interior  for  curettage. 

Operation. — An  incision  is  made  down  to  the  bursal  sac — selecting  a 
site  where  the  least  important  structures  will  be  encountered  and  the  sac 
most  readily  reached.  The  intervening  parts  having  been  retracted  to  one 
or  both  sides  and  the  bursa  steadied  by  the  surgeon's  left  forefinger  and 
thumb,  its  wall  is  incised  with  a  scalpel — after  which  the  special  object  of 
the  operation  is  accomplished.  The  steps  of  the  operation  will  depend  upon 
the  special  bursa.  In  some  cases  the  incision  will  pass  from  the  skin  directly 
into  the  bursal  cavity,  without  any  intervening  dissection. 

EXCISION  OF  BURSAE. 

Description. — Generallv  done  for  the  removal  of  chronically  inflamed 
or  diseased  bursa? — the  majority  of  the  latter  cases  being  tubercular. 

Operation. — The  exposure  of  the  enlarged  bursa  is  accomplished  as 
described  under  the  operation  for  incision.  The  surrounding  parts  having 
been  then  drawn  well  aside,  the  entire  bursal  sac  is  dissected  from  its  bed, 
partly  by  blunt  and  partly  by  sharp  dissection — carefully  guarding  the  neigh- 
boring structures,  and  especially  those  joints  with  which  the  bursa  may 
communicate.  Whenever  possible,  the  communication  with  a  joint  should 
be  closed  by  suturing  together  the  edges  of  the  neck  of  the  excised  bursa. 
The  wound  is  then  closed,  or  drained,  as  indicated. 


270 


CHAPTER  XII. 

AMPUTATIONS, 

GENERAL  CONSIDERATIONS. 

Definition. — Amputation — the  removal  of  a  limb  through  its  continuity. 
Disarticulation — the  removal  of  a  limb  at  a  joint. 

Indications. — Any  injury,  disease,  or  malformation  rendering  retention 
of  the  limb  incompatible  with  life  or  comfort; — avulsion  of  limb;  compound 
fracture;  compound  dislocation;  fracture  with  great  comminution  of  bone; 
laceration  of  important  vessels;  extensive  contusion;  extensive  laceration;  gun- 
shot injuries;  aneurism;  effects  of  heat  and  cold;  gangrene;  extensive  bone 
disease;  tumors;  elephantiasis;  tetanus;  snake-bite;  deformities.  Amputa- 
tions are  far  less  frequent  in  modern  conservative  surgery  than  formerly — 
limbs  now  being  often  saved  by  excision,  and  other  operations,  which  were 
at  one  time  sacrificed. 

Preparation  of  Patient. — The  constitutional  preparation  of  the  patient 
— and  the  previous  and  immediate  local  antiseptic  preparation  of  the  part — ■ 
are  the  same  as  for  any  major  operation.  The  part  should  be  shaved,  where 
its  condition  admits  of  this  preparation — and  should  come  to  the  table  with 
the  preliminary  dressing  in  position. 

Position  of  Patient,  Surgeon,  and  Assistant. — (i)  Patient  rests  upon 
back,  lying  near  side  of  table,  and  nearer  the  upper  end  for  amputations  of 
the  upper  extremity,  that  the  limb  may  be  held  out  from  the  table  at  a  right 
angle; — and  nearer  the  lower  end  for  amputations  of  the  lower  extremity, 
that  the  limb  may  be  held  both  out  from  the  table,  and  also  over  the  end  of 
the  table.  (2)  Surgeon  so  places  himself  as  to  enable  him  to  grasp  with 
his  left  hand  the  patient's  limb  between  the  saw-line  and  the  trunk — which 
will  place  him  upon  the  outer  side  of  the  right  limbs,  and  on  the  inner  side 
of  the  left  limbs  (between  the  table  and  the  left  limbs)  (Fig.  267).  This  is 
the  general  rule,  of  almost  universal  application  (and  will  not  be  repeated 
with  each  operation) — where  exceptions  occur  they  will  be  mentioned  with 
the  special  amputations.  In  amputations  of  the  upper  part  of  the  left  arm 
and  upper  part  of  the  left  thigh,  especially  the  latter,  it  may  be  more  con- 
venient to  stand  to  the  outer  side  of  the  limb,  in  which  case  the  left  hand 
grasps  the  limb  below  the  saw-line.  This  avoids  wedging  one's  self  between 
the  table  and  the  upper  part  of  the  limb,  which,  in  the  case  of  the  lower  limb 
particularly,  cannot  be  stretched  out  at  a  right  angle  from  the  table.  (3)  As- 
sistant : — grasps  the  part  of  the  limb,  wrapped  in  an  aseptic  towel,  that  is 
to  be  removed,  standing  facing  the  surgeon,  so  that  he  can  better  steady  the 
limb  against  the  movements  of  the  saw  than  if  he  stood  at  the  end  of  the 
limb — his  arms  being  thus  parallel  rather  than  at  a  right  angle  to  the  working 
of  the  saw. 

Instruments. — Esmarch's  rubber  bandage  and  tourniquet;  amputating 
knives,  long  and  short;  scalpels,  various;  cartilage  knives;  Catlin  knives; 
saws,  ordinary  amputating,  bow,  and  butcher;  small  thin  saw,  for  spicule 
of  bones;  periosteal  elevators;  metallic  retractors  (for  flaps);  linen  retractors 

271 


272 


AMPUTATIl  >\S. 


(for  flaps);  broad  metallic  or  ivory  spatula?  and  retractors  to  hold  soft  parts 
out  of  way;  dissecting  and  toothed  forceps;  artery-clamp  forceps,  numerous; 
rongeur  forceps;  scissors,  straight  and  curved,  sharp  and  blunt;  tenacula; 
probes;  grooved  directors;  ligatures  and  sutures,  silk,  catgut,  plain,  chro- 
mic,   silk-worm    gut,    tendon;   needles,    straight   and    curved;   needle-holder; 


Fig.  267. — Illustrating  Position  of  Surgeon  in  Amputating: — Standing  to  outer  side 
of  right  and  to  inner  side  of  left  limbs — manipulating  knife  with  right  hand,  and  steadying  limb 
(also  retracting  soft  parts)  with  left  hand  placed  between  saw-line  and  trunk. — Hands  of  assistant 
are  shown  in  various  positions,  grasping  and  supporting  part  to  come  away.  This  may  be  taken 
as  a  bird's-eye  view  of  patient  in  dorsal  decubitus. 

drainage-tubes;  irrigator  and  irrigation  fluid;  normal  salt  solution  and  instru- 
ments for  intravenous  infusion;  dressings  for  stump;  splint.  Special  instru- 
ments will  be  mentioned  under  special  amputations. 

Anesthesia  in  Amputations. — While  general  anesthesia  (preferably  nitrous 
oxid  and  ether)  is  ordinarily  used  in  amputations,  spinal  analgesia  and  neural 
infiltration  may  be  used  where  especially  indicated  (where,  for  instance, 
general  anesthesia  is  contraindicated) . 

Control  of  Hemorrhage  in  Amputations. — Hemorrhage  may  be  con- 
trolled in  one  of  two  general  ways — by  some  form  of  tourniquet  or  constrictor 
or  by  digital  compression.     (A)  Control   of   hemorrhage   by   tourniquet 


GENERAL    CONSIDERATIONS. 


273 


or  constrictor: — Several  forms  of  tourniquet  control  are  in  use; — (1) 
Esmarch's  Broad  Rubber  Bandage,  and  Tourniquet  of  Rubber  Tubing  or 
Narrow  Band; — These  constrictors  may  be  used  in  two  ways; — (a)  Use  of 
Bandage  and  Tourniquet  (Esmarch  Method) ; — The  bandage  is  applied 
from  the  fingers  or  toes  upward,  for  example,  nearly  to  the  shoulder  or  hip 
— the  tourniquet  is  then  applied  above  the  bandage — and  the  bandage  re- 
moved. This  saving  to  the  patient  of  the  blood  in  the  limb  is  more  particu- 
larlv  indicated  when  the  limb  is  healthy  and  the  patient  anemic — otherwise  a 
patient  who  loses  a  limb  can  also  generally  afford  to  lose  its  proportional  amount 


Fij;- 268.— Illustrating  Methods  of  Hemorrhage  Control:— Wyeth's  method  by  rubber 
tourniquet  and  needles,  at  right  shoulder-joint.— Same  at  left  hip-joint.— Ordinary  rubber  tourniquet 
and  pad  at  left  shoulder-joint,  reinforced  (kept  from  slipping)  by  strips  of  roller-bandage. — Same, at 
right  hip-joint.— Use  of  Esmarch  rubber  tourniquet  above  left  elbow.— Exsanguination  of  limb  by 
Esmarch  rubber  bandage,  followed  by  application  of  rubber  tubing  1  or  Esmarch  rubber  tourniquet) 
above  left  knee. — Compression  of  right  femoral  by  Petit  type  of  tourniquet.— Preliminary  ligation 
of  left  femoral. — Digital  compression  of  main  arteries  at  right  wrist. 


of  blood.  (Fig.  268,  left  leg.)  (b)  Use  of  Esmarch's  Tourniquet  Alone;— The 
limb  is  held  elevated  for  about  three  minutes  (this  empties  the  veins  mechani- 
cally and  causes  the  arteries  to  contract  reflexly,  thus  lessening  the  blood  to  the 
limb;  but  if  the  elevation  be  too  long,  the  arteries  recover,  dilate,  and  let  in 

18 


274  AMPUTATIONS. 

more  blood) — and,  during  the  time  of  this  elevation,  a  healthy  limb  may  be 
massaged  downward  to  aid  exsanguination — the  tourniquet  alone  is  then 
applied  as  high  up  the  limb  as  indicated  for  the  special  operation,  no  form  of 
bandage  having  been  previously  applied  (Fig.  268,  left  arm).  In  operating  any- 
where below  the  elbow  or  knee,  the  constriction  should  be  applied  just  above  the 
elbow  or  knee, — and  in  amputating  anywhere  above  the  elbow  or  knee,  the  con- 
striction should  be  applied  as  near  the  trunk  as  possible.  This  is  the  general 
method  of  hemorrhage  control  in  the  majority  of  cases.  The  objections 
which  have  been  urged  against  the  Esmarch  bandage  and  tourniquet,  or 
tourniquet  alone,  are — the  increased  bleeding  following  the  operation,  from 
temporary  vasomotor  paralysis;  the  possible  lowered  vitality  of  the  com- 
pressed parts;  occasional  temporary  paralysis  of  nerve-trunks  from  pressure; 
and  the  possibility  of  forcing  pathological  products  into  the  body.  The 
great  advantage  over  these  disadvantages,  however,  is  that  it  controls  all 
bleeding — and  its  use,  therefore,  is  advisable  in  spite  of  the  disadvantages. 
(2)  Tourniquet  of  the  Petit  Type; — The  entire  limb  is  compressed,  with 
special  pressure  over  the  main  artery  (Fig.  268,  right  thigh).  (3)  Tourniquet 
of  the  Signorini  Type; — No  circular  constriction  is  used — a  pad  on  one  arm 
of  the  tourniquet  compresses  the  artery  against  a  counter-pad  on  the  other 
arm  of  the  tourniquet  opposite  or  beneath  the  limb  or  body.  (B)  Digital 
compression  of  the  main  artery : — Compression  is  generally  made  through 
the  skin — but  may  be  made  directly  upon  the  main  vessel  through  an  incision 
made  immediately  over  it.  (Fig.  268,  right  hand.)  The  office  of  hemorrhage- 
control  by  digital  compression  is  sometimes  delegated  to  a  single  individual 
in  a  hospital.  Note : — Special  methods  of  controlling  the  circulation  will  be 
mentioned  in  connection  with  special  amputations,  especially  those  about 
the  shoulder-  and  hip-joints  (Fig.  268,  shoulders  and  hips).  Also  see  dis- 
articulations at  shoulder  and  knee  (pages  374  and  433). 

THE  GENERAL  TECHNIC  IN  AMPUTATING. 
LOCATION  OF  LINE  OF  BONE-SECTION,  OR  DISARTICULATION. 

The  determination  of  the  saw-line  in  an  amputation,  or  the  disarticula- 
tion-line  in  a  disarticulation,  is  the  first  step — generally  marking  the  upper 
limit  of  the  operation — and  is  the  necessary  guide  to  the  subsequent  steps. 

Level  at  Which  the  Bone,  or  Bones,  are  to  be  Sawed. — Is  to  be  deter- 
mined by  the  individual  case — and  its  position  should  be  such  that  enough 
healthy  tissue  will  be  provided  for,  between  the  saw-line  and  the  upper  limit 
of  the  diseased  or  injured  tissues  to  be  removed,  to  furnish  ample  covering 
of  soft  parts  to  protect  the  stump  without  undue  tension. 

Level  of  Joint-line  at  which  Disarticulation  is  to  be  Done. — The 
position  of  the  articulation-line  is,  of  course,  fixed — it  is  only  necessary  to 
recognize  it  anatomically — and  to  determine  whether  sufficient  sound  tissue 
intervenes  between  joint-line  and  upper  limit  of  the  parts  to  be  removed  to 
afford  covering  satisfactory  in  quantity  and  quality  to  protect  the  stump. 
Otherwise  the  disarticulation  will  have  to  be  converted  into  an  amputation 
at  a  higher  level. 

Relation  of  Saw-line  to  Length  of  Flap,  and  Vice  Versa. — While 
the  position  of  the  saw-line  determines  the  amount  of  tissue  (and,  conse- 
quently, length  of  flap  or  flaps  or  of  circular  covering)  which  will  be  required 
to  cover  the  sawed  bone — so  also  does  the  choice  of  the  method  of  amputation 
to  be  used  largely  determine  the  amount  of  bone  to  be  sacrificed  (and,  con- 
sequently, the  length  of  the  resulting  limb) — for  (a),  In  circular  amputations 


LOCATK  >N    <  >F    LIMITS    OF    SKIN    INCISIONS. 


275 


and  amputations  by  equal  flaps,  the  minimum  amount  of  bone  is  sacrificed; 
and  (b),  In  amputations  by  a  single  flap,  the  maximum  amount  of  bone  is 
sacrificed. 

LOCATION  OF  LIMITS  OF  SKIN  INCISIONS. 

A  total  covering  of  soft  parts  equivalent  to  ih  diameters  of  the  limb  at 
the  saw-line  is  the  general  rule  of  allowance.  It  is  necessary,  therefore,  to 
determine  the  lower  limit  of  the  skin  incision,  as  this  forms  the  lower  limit 
of  the  total  covering.  This  limit  may  be  determined  accurately  or  approx- 
imately. 

In  Circular  Amputations. — (a)  Accurately; — Find  the  circumference  of 
the  limb  at  the  saw-line  by  means  of  a  metallic  tape-line  (say,  15  cm.,  or  6 
inches) — one-third  of  the  circumference  will  give  the  diameter  (say,  5  cm., 
or  2  inches).  Therefore,  to  furnish  ih  diameters  (say,  7.5  cm.,  or  3  inches) 
the  lower  limit  of  the  skin  incision  would  have  to  be  3.8  cm.,  or  1^  inches, 
below  the  saw-line,  (b)  Approximately; — Place  the  thumb  at  the  saw-line 
on  the  anterior  aspect  of  the  limb  (the  nail  facing  the  junction  of  the  limb 
with  the  trunk)  and  the  tip  of  the  index-finger  immediately  opposite  on  the 
posterior  aspect  of  the  limb  (without  compressing  the  soft  parts).  Xow, 
keeping  the  thumb  where  first  placed,  and  keeping  the  distance  between 
the  tip  of  the  thumb  and  tip  of  the  index  unchanged,  rotate  the  hand  around 
(making  these  two  fingers  act  as  the  two  arms  of  callipers)  until  the  tip  of 


Fig.  269.— Relation  of  Skin  Incision  to  Saw-line: — Methods  of  amputation  by  equal 
flaps,  circular  covering,  and  unequal  flaps  are  shown  each  to  furnish  a  covering  of  \l,'2  diameters  of 
limb  at  saw-line. 

the  index  rests  upon  the  anterior  aspect  of  the  limb  in  a  vertical  line  below 
the  tip  of  the  thumb.  The  distance  between  the  thumb-tip  and  the  finger-tip 
will  be  the  diameter  of  the  limb  at  the  saw-line — and  three-fourths  of  this 
measurement  will  insure  a  covering  of  the  requisite  \\  diameters  of  the  limb. 
In  calculating  the  covering  in  the  circular  method  of  amputating,  it  is  to  be 
remembered  that  as  the  circular  covering  will  be  sutured  in  a  straight  line. 
either  from  before  backward  or  from  side  to  side,  practically  the  covering 
may  be  regarded  as  being  furnished  by  two  aspects  of  the  limb,  either  the 
front  and  back  or  the  two  sides — that  is,  as  though  furnished  by  two  equal 
flaps  (Fig.  269). 

In  Equal  Flap  Amputations. — Same  as  for  the  circular  method,  whether 
calculated  accurately  or  approximately  (Fig.  269). 

In  Unequal  Flap  Amputations. — (say  the  anterior  twice  as  long  as 
the  posterior  flap) ; — (a)  Accurately; — Finding  the  circumference  and  diameter 
in  the  above  manner  (the  measurements  being  as  there  given) — the  lower 
limit  of  the  anterior  flap  would  be  5  cm.  (2  inches)  below  the  saw-line,  and 
the  lower  limit  of  the  posterior,  2.5  cm  (1  inch)  below,  (b)  Approximately; — 
Having  gotten  the  measurement   of  the  full   diameter   marked   out  on  the 


276 


AMPUTATIONS. 


anterior  aspect,  as  explained  above,  this  will  represent  the  length  of  the 
anterior  flap — and  one-half  of  this  measurement  will  give  the  length  of  the 
posterior  flap  (Fig.  269). 

INCISION  OF  SKIN  AND  FASCIA. 

In  general  terms,  it  is  considered  that  the  aspects  of  the  limb  furnish  an 
average  covering  of  1^  diameters  of  the  limb  at  the  saw-line — whether  this 
covering  consist  of  skin  alone,  or  of  skin  and  muscle  combined — and  whether 
furnished  by  one  or  more  aspects  of  the  limb.  In  the  circular  method  of 
amputating,  the  covering  is  furnished  equally  from  all  aspects  of  the  limb. 
In  the  method  by  equal  flaps,  it  is  furnished  equally  by  two  aspects  of  the 
limb.  And  in  the  method  by  unequal  flaps,  the  inequality  of  length  may 
be  parceled  out  in  any  way  indicated,  just  so  the  total  covering  is  equivalent 
to  ih  diameters  at  the  saw-line.  If  the  covering  be  from  one  aspect  alone, 
as  in  the  single  flap  or  in  the  elliptical  methods,  the  total  diameter  and  a  half 
comes  from  that  one  aspect.  Where  the  amputation  is  done  through  a  site 
of  maximum  contractility  of  skin  and  muscles  (as  through  the  lower  half  of 


Fig. 


:7c— Incising   Skin  and   Fascia   in   Circular  Amputation: — I,  Position  of  long  knife  in 
incising  upper,  further  and  part  of  lower  aspects  of  limb. 


the  arm,  or  the  lower  half  of  the  thigh),  a  somewhat  greater  allowance  may 
become  necessary  (even  to  the  extent  of  two  diameters).  Where  the  ampu- 
tation is  done  through  a  site  of  minimum  contractility  of  skin  and  muscles 
(as  through  the  dense  tissues  of  the  palm  of  hand  and  sole  of  foot),  a  somewhat 
less  allowance  than  the  average  may  be  provided. 

Manner  of  Incising  Skin  and  Fascia  in  Circular  Amputations. — 
Whether  a  stump  is  going  to  be  covered  by  skin  alone,  or  by  skin  and  muscle, 
the  skin  is  invariably  cut  first  and  cut  separately.  Standing  to  the  outer 
side  of  the  right  and  inner  side  of  the  left  limbs,  grasp  the  part  above  the  level 
of  the  skin  incision  with  the  left  hand  and  retract  the  skin  upward,  either 
entirely  alone  or  aided  by  an  assistant  (the  assistant's  aid  being  more  necessary 
in  large  limbs) — the  retraction  being  evenly  maintained  throughout.  This 
is  done  to  provide  as  ample  a  skin  covering  for  the  muscles  as  possible,  for, 
as  the  average  contractility  of  the  skin  involved  in  an  amputation  is  greater 


INCISION    OF    SKIN    AND    FASCIA. 


277 


than  the  average  contractility  of  the  muscles  involved,  if  the  skin  and  muscles 
were  divided  on  the  same  level  it  would  subsequently  be  found  difficult,  or 
impossible  to  make  the  skin  meet  over  the  cut  muscles.  Therefore  this 
circular  division  of  skin,  which  has  been  well  drawn  up  under  the  knife-cut 
prior  to  incising,  means  an  actual  division  of  the  skin  a  little  lower  than  the 
position  of  the  knife  on  the  limb  indicates — but  insures  having  a  somewhat 
fuller  measure  of  skin  than  if  it  were  cut  without  retraction.  Having  thus 
retracted  the  skin,  take  a  long  knife  with  a  blade  one-and-a-half  times  the 
diameter  of  the  limb  to  be  removed — and,  holding  it  in  a  full  hand,  like  a 
pruning-knife,  pass  the  arm  under  the  patient's  limb  and  bring  the  cutting- 
edge  into  contact  with  the  upper  surface  of  the  limb,  the  back  of  the  knife 
being  horizontal  and  pointing  upward,  the  heel  of  the  knife  being  over  the 
center  of  the  limb,  and  the  point  projecting  beyond  the  limb  toward  the 
surgeon.  Beginning  the  incision  with  the  heel  of  the  knife,  steadily  and 
evenly  draw  the  knife  from  heel  to  point,  passing  with  one  sweep  of  the  knife 


Fig.  271— Incising  Skin  and    Fascia   in  Circular  Amputation  : — II — Position  of  I01 
incising  nearer  and  remainder  of  lower  aspect  of  limb. 


through  three-fourths  of  the  circumference  (Fig.  270).  The  knife  is  then  with- 
drawn and  reinserted  with  its  heel  at  the  place  of  beginning  of  the  incision 
on  the  supero-external  surface  (in  operating  on  the  right  limbs),  and,  with 
one  sweep,  passes  through  the  remaining  fourth  of  the  circumference 
(Fig.  271).  The  attempt  to  make  the  complete  circuit  with  one  sweep  is 
not  to  be  recommended,  as  the  ends  of  the  resulting  wound  are  not  apt  to 
be  in  line,  and  the  wound,  generally,  imperfectly  made.  This  circular  skin 
incision  is  sometimes  made  with  a  small  knife.  The  assistant  can  aid  the 
surgeon  by  rotating  the  limb  to  meet  the  knife.  The  blade  is  held  perpen- 
dicular to  the  skin  throughout.  The  incision  passes  through  skin  and  fas- 
cia, but  not  into  muscles.  Owing  to  the  unequal  retraction  which  some- 
times takes  place  upon  the  different  aspects  of  a  limb,  it  may  be  necessary 


278 


AMPUTATIONS. 


to  plan  one  portion  of  the  circular  incision  upon  a  lower  level  than  the  rest 
of  the  incision — this  greater  allowance  of  skin  at  this  site  will,  however,  be 
drawn  up  on  a  level  with  the  rest  of  the  circular  incision,  owing  to  the 
greater  retraction  there.  So  that  what  may  appear  as  an  oblique  incision, 
will  become  circular  and  upon  the  same  level  after  the  division. 

Manner  of  Incising  Skin  and  Fascia  in  Flap  Amputations. — As  in 


Fig.  272.— Incising  Skin  and  Fascia  in  Flap  Amputation: — I — In  cutting  rounded  flaps. 


Fig.  273.— Incising  Skin  and  Fascia  in  Flap  Amputation  :— II — In  cutting  rectangular  flaps. 

the  circular  method,  whether  the  covering  is  to  be  of  skin  alone,  or  of  skin 
and  muscles,  the  skin  is  invariably  cut  first  and  separately — and  whether 
the  flap  be  cut  from  without  inward,  or  from  within  outward  (by  transfixion). 
The  preliminary  steps,  as  to  position,  retraction  of  skin,  and  general  prin- 


FREEING  SKIN  AND  FASCIA.  279 

ciples  involved,  are  the  same  as  in  making  the  skin  incision  in  the  circular 
amputation.  When  all  is  ready,  the  surgeon  takes  an  ordinary  scalpel  of 
medium  size,  and,  holding  it  as  a  violin-bow,  enters  its  point  into  the  skin 
vertically,  at  the  upper  limit  of  the  base  of  the  flap.  The  knife  passes  through 
skin  and  connective  tissue,  and  as  it  travels  vertically  down  one  limb  of  the 
flap  the  cutting-edge  is  lowered  until  it  forms  less  than  a  right  angle  with 
the  surface  being  cut — when  nearly  the  lower  limit  of  the  flap  is  reached, 
the  knife  rounds  the  corner  of  the  flap — thence  passes  transversely  across 
that  aspect  of  the  limb  from  which  the  flap  is  being  taken — then  similarly 
rounds  the  opposite  corner — and  thence  travels  vertically  upward  to  a  point  cor- 
responding with  the  point  of  beginning  (Fig.  272).  Care  should  be  exercised 
that  each  flap  should  measure  one-half  the  circumference  of  the  limb  at  its  base, 
and  one-half  of  the  circumference  at  that  part  of  its  free  end  just  above  the 
rounded  corners — and  that  these  corners  should  be  very  bluntly,  and  not 
sharply,  rounded  (that  they  should  be  squarely  rounded,  as  it  were),  for  if 
they  be  too  much  tapered  at  their  free  ends,  the}'  will  cover  the  stumps  with 
difficulty  and  unsatisfactorily.  Instead  of  cutting  the  entire  flap  with  one 
sweep  of  the  knife,  each  vertical  limb  and  one  corner  of  the  flap  should  be 
made  with  one  downward  cut  of  the  knife.  While  all  flaps  should  be  prac- 
tically square,  with  merely  the  corners  rounded,  an  exception  is  made  in  the 
method  of  unequal  rectangular  flaps  of  skin  and  fascia  (Teale's  method) — 
the  corners  of  the  flaps  being  here  right-angled,  instead  of  rounded  (Fig. 
273).  This  is  also  the  case  in  the  conversion  of  a  circular  method  of 
amputation  into  a  flap  method  by  two  vertical  incisions  placed  laterally — 
and  even  here  the  corners  mav  be  rounded. 


FREEING  SKIN  AND  FASCIA. 

Having  incised  skin  and  fascia,  for  either  a  circular  or  a  flap  amputation, 
the  manner  and  extent  of  further  freeing  skin  and  fascia  will  depend  upon 
whether  the  method  is  to  be  one  of  simply  skin  and  fascial  covering,  or  of 
skin,  fascial,  and  muscular  covering  for  the  stump. 

Freeing  Skin  and  Fascia  in  Simple  Skin  and  Fascial  Covering  for 
Stump. — The  skin  and  fascia,  after  having  been  divided,  are  partlv  retracted 
and  partly  dissected  back  to  the  line  of  future  division  of  muscles.  The  edges 
of  skin  and  fascia  (avoiding  the  separation  of  the  one  from  the  other,  as  the 
vessels  reach  the  skin  through  the  fascia)  are  grasped  by  the  fingers  of  the 
left  hand,  lifted  from  the  muscles,  and  drawn  upward — and,  while  held  in 
this  position,  and  while  under  slight  tension,  the  fascia  is  touched  here  and 
there  at  points  where  it  especially  binds  along  the  line  of  its  junction  with 
the  muscles  and  deep  fascial  planes,  by  a  scalpel  held  at  a  right  angle  to  the 
surface  of  the  muscles  and  with  its  cutting-edge  toward  the  part  to  be  removed 
— and  thus  scoring  of  the  skin  and  consequent  damage  to  its  blood-supply  are 
avoided.  The  skin  and  fascia  are,  by  this  means,  raised  in  one  layer  from 
the  muscles — and  the  skin  should  be  raised  with  all  the  underlying  fascia 
possible — and  the  combined  skin  and  fascia  should  be  raised  evenly  up  tc 
the  future  line  of  muscle  division  (Fig.  274). 

Freeing  Skin  and  Fascia  in  Skin,  Fascial,  and  Muscular  Covering 
for  Stump. — Special  care  is  here  taken  not  to  separate  skin  and  fascia  from 
underlying  muscles,  any  further  than  simply  in  the  immediate  line  of  original 
skin  incision,  and  simply  for  the  purpose  of  allowing  of  full  retraction.  The 
skin  and  fascia  are  here  not  picked  up  and  separated  from  the  muscles — ■ 


28o 


AMPUTATIONS. 


the  only  knife-touches  necessary  being  a  few  where  the  fascia  has  not  been 
thoroughly  divided  and  where  it  is  necessary  further  to  divide  a  fascial  attach- 
ment here  and  there  in  order  that  the  skin  and  fascia  may  retract  as  far  as 


Fig.  274.— Freeing  Skin  and  Fascia  from  Underlying  Muscles. 

they  naturally  will  unaided  by  manual  retraction — and  this  is  done  by  touching 
the  points  of  binding  at  the  bottom  of  the  original  incision,  by  the  point  of  a 
knife  held  vertically. 


Fig.  275. — Retraction  of  Skin  and  Fascia. 


RETRACTION  OF  SKIN  AND  FASCIA. 

Where  Stump-coverings  are  to  be  of  Skin  and  Fascia  Alone. — Having 
freed  skin  and  fascia  from  the  underlying  parts,  as  above  described,  partly 
by  retraction  and  partly  by  dissection,  until  the  line  is  reached  at  which  the 
muscles  are  to  be  divided,  the  skin  and  fascia  are  further  retracted  above 


DIVISION  OF  MUSI  l.KS  IN  CIRCULAR  METHODS  OF  AMPUTATION.     281 

this  line  and  are  held  out  of  the  way  by  the  hands  of  an  assistant,  or  by  re- 
tractors (Fig.  275). 

Where  the  Stump-coverings  are  to  be  of  Skin,  Fascia,  and  Muscles. 
— Retraction  of  skin  and  fascia  from  the  underlying  muscles,  other  than  that 
which  occurs  unaided,  is  not  practised.  It  is  sought,  on  the  other  hand,  to 
keep  in  contact,  as  one  layer,  skin,  fascia,  and  muscles. 


DIVISION  OF  MUSCLES  IN  CIRCULAR  METHODS  OF  AMPUTATION. 

In  the  Ordinary,  or  Infundibuliform,  Variety  of  Circular  Amputa- 
tion.— (For  description,  see  page  303.) — (a)  Division  of  More  Superficial 
Muscles; — The  position  of  surgeon,  manner  of  holding  limb,  kind  of  knife 
and  manner  of  manipulating  it,  are  all  the  same  as  in  making  the  skin  incision. 


Fig.  276.— Division  of  Muscles  in  Infundibular  Variety  of  Circular  Amputation: — I — Di- 
viding more  superficial  muscles  on  level  with  retracted  skin  and  fascia. 

The  skin  and  fascia  having  been  circularly  incised  and  allowed  to  retract, 
the  surgeon  grasps  the  limb  above  the  naturally  retracted  skin,  and  further 
retracts  skin  and  fascia,  putting,  at  the  same  time,  the  muscles  upon  the 
stretch  by  this  upward  retraction  of  the  overlying  parts,  aided  by  an  assistant 
in  the  case  of  larger  limbs.  The  more  superficial  muscles  are  now  divided 
circularly  on  an  exact  level  with  the  retracted  skin,  by  one  sweep  of  a  long 
knife  passing,  first,  through  three-fourths  of  a  circle,  followed  by  a  second  sweep 
through  the  remaining  fourth  (Fig.  276).  It  is  not  always  possible  to  divide 
only  and  wholly  what  are  generally  understood  as  the  superficial  layers  of 
muscles — it  is  only  meant  that  one  divides,  in  this  first  circular  division,  about 
one-half  of  the  muscular  covering  of  the  limb,  the  knife  sometimes  dividing 
a  group  of  muscles  completely  and  sometimes  only  partially.  To  allow  for 
unequal  retraction,  the  muscles  may  sometimes  have  to  be  divided  lower 
on  one  aspect  of  the  limb  than  on  another,     (b)  Retraction  of  More  Super- 


>S2 


AMPUTATIONS. 


ficial  Muscles; — This  layer  of  muscle  tissue  is  now  retracted  as  the  skin  was 
above  it.  It  is  not  expected  that  the  first  muscle  layer  includes  all  and  only 
the  superficial  muscles,  and  the  deep  layer  all  and  only  the  deep  muscles — 


Fig- 2/7- 


-Division  of  Muscles   in   Infundibular   Variety    of   Circular  Amputation :— II— 
Dividing  deeper  muscles  on  level  with  retracted  superficial  muscles. 


the  former  includes  simply  the  more  superficially  placed,  and  the  latter  the  more 
deeply  placed  muscles.  There  is  no  general  use  made  of  the  scalpel  in  freeing 
the  superficial  muscle  layer,  as  in  the  case  of  separating  the  fascia  and  skin 
from  the  muscles,  but,  where  indicated,  a  touch  of  the  knife  may  be  used  to 


Fig.  278—  Division  of   Muscles  in  Cuff  Variety  of  Circular  Amputation— on  a  level  with 
the  turned-back  cuff  and  fascia. 

enable  the  more  superficial  muscles  to  be  evenly  retracted,  (c)  Division  of 
Deeper  Muscles; — Having  retracted  the  divided  muscles  more  superficially 
placed,  the  more  deeply  situated  muscles  are  now  circularly  divided  on  a 


DIVISION  OF  MUSCLES  IN  CIRCULAR  METHODS  OF  AMPUTATION.    283 
level  with  the  retracted  superficial  muscles,  and  in  a  manner  similar  to  the  divi 


Fig. 279.— Division  of  Muscles  in  Modified  Circular  Amputation— showing  flaps  of  skin 
and  fascia  turned  back,  the  more  superficial  muscles  divided,  and  the  knife  in  the  act  of  dividing  the 
deeper  muscles  in  the  infundibular  fashion. 

sion  of  the  first  layer  (Fig.  277) .  It  is  to  be  planned  that  this  circular  division 
of  the  deep  muscles  will  come  down 
upon  the  bone  sufficiently  far  below  the 
saw-line  to  provide  for  a  periosteal  flap, 
(d)  Retraction  of  Deeper  Muscles;— 
This  is  done  preparatory  to  forming 
the  periosteal  covering.  Note — it  will 
thus  be  seen  that,  having  divided  skin 
and  fascia  lowest  of  all,  the  superficial 
muscles  have  been  divided  upon  a  higher 
level,  and  the  deep  muscles  upon  a  still 
higher  level — forming,  thereby,  when  the 
bone  is  sawed,  a  hollow  cone,  whose  apex 
will  be  formed  by  the  sawed  bone,  whose 
base  will  be  the  margin  of  skin  and 
fascia,  and  whose  sides  will  be  com- 
posed of  the  cut  muscles  (Fig.  302). 

In  the  Circular  Amputation  "a 
la  Manchette,"  or  Cuff  Variety  of 
Circular  Amputation. — (For  descrip- 
tion, see  page  305.) — In  this  method, 
all  the  muscles  are  divided  circularly 
down  to  the  bone  at  one  level,  which 
is  that  of  the  reflected  cuff  of  skin — cal- 
culating to  come  down  upon  the  bone 
sufficiently  far  below  the  saw-line  to 
form  a  musculo-periosteal  covering  (Fig.  w  n 

„  r  o  \      o       pjg-28o.  —  Division   of   Muscles  in   Oval 

27"y-  Method  of  Amputation. 


284  AMPUTATIONS. 

In  the  Modified  Circular  Amputation. — (For  description,  see  page 
306.) — After  the  flaps  of  skin  and  fascia  have  been  retracted,  the  more  super- 
ficial muscles  are  divided  on  a  level  with  the  retracted  flaps — this  layer  of 
muscle  tissue  is  retracted — and  the  deeper  layer  is  divided  upon  a  level  with 
the  retracted  superficial  layer — calculating  to  come  down  upon  the  bone  far 
enough  below  the  saw-line  to  allow  for  a  musculo-periosteal  covering  (Fig.  279). 
The  division  of  muscles  being,  in  other  words,  just  as  in  the  ordinary  circular 
amputation.  This  is  the  better  way  of  dividing  the  muscles  in  the  modified 
circular  operation.  Where,  in  the  modified  circular  amputation,  the  muscles 
are  all  divided  at  one  level  (that  of  the  retracted  flaps),  the  muscles  are  di- 
vided as  in  the  circular  amputation  a  la  manchette. 

In  the  Oval  Method  of  Amputating. — (For  description,  see  page  307.) 
-After  having  made  the  oval  incision  through  skin  and  fascia,  the  muscles 
are  divided  directly  to  the  bone — the  knife  entering  the  muscle  tissue  upon 
the  line  of  the  retracted  skin  and  fascia.  Along  the  queue,  or  vertical  portion 
of  the  oval,  which  begins  at,  or  just  above,  the  saw-line,  or  disarticulation- 
line,  the  two  lines  of  incision  will  coincide — parting  below  to  follow  the 
outlines  of  the  oval — and  meeting  at  the  mid-point  behind  (Fig.  280). 

In  the  Racket  Method  of  Amputating. — (For  description,  see  page 
308). — The  principle  here  is  the  same  as  in  the  oval  method. 

DIVISION  OF  MUSCLES  IN  FLAP  METHODS  OF  AMPUTATION. 

In  Amputating  by  Single  Flap  of  Skin  and  Muscle. — (For  description, 
see  page  309.) — The  skin-and-fascia  flap  having  been  outlined  and  incised, 
the  muscles  are  cut,  preferably  from  without  inward  (or  may  be  cut  from 
within  outward,  by  transfixion),  beveling  inward,  on  a  line  with  the  retracted 
skin-and-fascia  flap — the  incision  coming  down  upon  the  bone  sufficiently 
far  below  the  saw-line  to  provide  for  a  musculo-periosteal  covering  (Fig.  281). 

In  Amputating  by  a  Single  Skin-flap. — (For  description,  see  page 
311). — Having  retracted  skin-and-fascia  flap,  the  muscles  are  divided  cir- 
cularly at  the  saw-line,  or  disarticulation-line. 

In  Amputating  by  Equal  Flaps  of  Skin  and  Muscle. — (For  description, 
see  page  311.)  —Same  as  by  single  flap  of  skin  and  muscle  (Fig.  282). 

In  Amputating  by  Equal  Flaps  of  Skin. — (For  description,  see  page 
311.) — Same  as  by  single  skin  flap. 

In  Amputating  by  Unequal  Flaps  of  Skin  and  Muscle. — (For  de- 
scription, see  page  313.) — Same  as  by  single  flap  of  skin  and  muscle. 

In  Amputating  by  Unequal  Flaps  of  Skin. — (For  description,  see 
page  314.) — Same  as  by  single  flap  of  skin. 

In  Amputating  by  the  Elliptical  Method. — (For  description,  see  page 
315.) — As  this  may  be  considered  a  variety  of  single  flap  amputation  (of 
either  skin  alone,  or  of  skin  and  muscle  combined),  the  manner  of  dealing 
with  the  muscle  is  here  the  same  as  in  that  operation. 

In  Amputating  by  Teale's  Method  of  Unequal  Rectangular  Flaps 
of  Skin  and  Muscle. — (For  description,  see  page  314.) — Upon  the  line 
of  the  retracted  skin  and  fascia,  the  muscles  are  cut  through  the  periosteum 
along  the  two  vertical  lines.  The  muscles  are  then  cut  through  the  periosteum 
transversely  along  the  free  margin  of  the  retracted  skin  and  fascia  representing 
the  end  of  the  longer  flap — all  of  the  soft  parts  are  then  dissected  up  above 
the  lower  limit  of  the  shorter  flap,  when  the  muscles  opposite  its  lower  limit 
are  transversely  divided  through  periosteum  to  bone. 

Method  of  Cutting  Flaps  from  Without  Inward. — In  this  method 
the  flaps  are  cut  by  dissection,  as  it  is  sometimes  called.     The  incision  out- 


DIVISION    OF    MUSCLES    IN    FLAP    METHODS    OF    AMPUTATION.     285 


lining  the  flap  having  been  made  through  skin  and  fascia,  the  surgeon,  standing 
to  the  outer  side  of  right  limbs  and  inner  side  of  left  limbs,  and  grasping  the 
limbs  between  saw-line  and  trunk,  proceeds  to  cut  the  muscle  portion  of 
the  flap.  A  scalpel  is  made  to  cut  the  muscles  along  the  line  of  retracted 
skin-and-fascia  flap,  the  point 
of  the  knife  entering  the 
muscles  at  the  upper  limit  of 
one  of  the  limbs  of  the  skin- 
and-fascia  flaps — follows  this 
margin  vertically  downward, 
passing  deeply  through  the 
muscles — as  the  free  border 
is  approached,  the  knife  is 
given  a  direction  obliquely 
inward,  so  as  to  broadly  and 
thickly  bevel  the  muscles 
here,  leaving  them  thinnest 
(though  not  thin)  along  this 
aspect  of  the  flap — continu- 
ing the  beveling  process 
across  the  entire  transverse 
width  of  the  free  end  of  the 
flap  and  well  around  its 
bluntly  rounded  corner  — 
thence  the  knife  passes  ver- 
tically up  the  opposite  limb 
of  the  flap,  sinking  deeply 
into  the  muscles,  though  the 
bone  need  not  be  fully 
reached  in  the  vertical  cuts  at 
the  first  stroke  (Fig.  283). 
As  in  cutting  skin-flaps,  the 
entire  incision  need  not  be 
made  at  one  stroke  of  the 
knife — but  is  better  made 
in  two  strokes  from  above 
downward.  The  surgeon 
now  grasps  the  partly  cut 
flap  with  the  fingers  of  his 
left  hand,  and,  while  draw- 
ing it  away  from  the  bone,  proceeds  to  fashion  the  rest  of  it  along  the  same 
lines  upon  which  it  was  begun,  beveling  it  toward  the  bone  by  successive  cuts 
of  the  knife — planning  that  the  base  of  the  flap  will  contain  the  full  thickness 
of  the  soft  parts  covering  the  bone — and  calculating  that  the  knife  will  come 
down  upon  the  bone  (or  bones)  far  enough  below  the  saw-line  (or  disarticula- 
tion-line)  to  provide  a  musculo-periosteal  (or  capsulo-periosteal)  covering. 
Where  two  flaps  are  cut,  the  second  is  cut  in  the  same  general  manner.  Care 
should  be  taken  that  the  muscles  are  thickly  and  bluntly  beveled,  else  a  thin, 
ill-nourished  ending  to  the  flap  is  apt  to  be  left.  No  attempt  is  made  to 
bevel  the  upper  part  of  the  sides  of  the  flap  (the  vertical  portions) — the  beveling 
beginning  only  just  above  the  rounded  corners.  By  cutting  on  a  line  with 
the  retracted  skin,  ample  covering  of  the  muscle-portion  of  the  flap  by  the 
skin-and-fascia  portion  is  provided  (Fig.  282). 

Method  of  Cutting  Flaps  from  Within  Outward. — In   this  method 


Fig.  281.— Division  of  Muscles  in  Amputation  by  Single 
Flap  Method. 


286 


AMPUTATIONS. 


the  flaps  are  cut  by  transfixion.  The  skin  and  fascia  should  always  be  cut 
first  and  from  without  inward,  as  the  first  step  of  every  flap  (as  well  as  of 
every  other  kind  of)  amputation — no  matter  what  the  method  of  doing  the 


Fig.  282.— Division  of  Muscles  in  Amputation  by  Double  Flap  Method. 

other  steps  of  the  operation.  If  this  be  not  done,  the  muscles  and  skin  will 
necessarily  be  cut  upon  the  same,  or  nearly  the  same,  level — with  the  inevitable 
result  that  there  will  be  a  deficiency  of  skin  to  cover  the  muscles,  owing  to 
the  greater  retraction  of  the  former.  Having,  therefore,  cut  the  skin  and 
fascia  flap  from  without,  the  surgeon  proceeds  to  cut  the  muscles  by  trans- 
fixion. A  long  knife  is  taken,  having  a  length  equal  to  at  least  one-and-a-half 
diameters  of  the  limb  at  the  site  in  question.     Marking  the  saw-line  with 


Fig.  283.— Method    of    Raising    Flaps    of    Skin    and  Muscle    by   Cutting   from   Without 

Inward. 

the  thumb  of  the  left  hand,  the  point  of  the  long  knife  (whose  sides  look 
upward  and  downward  and  whose  edge  points  toward  the  extremity  to  be 
removed)  is  entered  directly  in  the  center  of  the  lateral  aspect  of  the  limb 
(where  the  flaps  are  to  be  taken  from  the  anterior  and  posterior  aspects  of 
the  limb)  and  opposite  the  saw-line.  The  knife-point  should  be  so  placed 
and  pointed  as  to  avoid  important  vessels.  The  knife  is  then  carefully 
pushed  directly  forward,  until  its  point  strikes  the  center  of  the  lateral  aspect 
of  the  bone  (or,  if  two  bones,  of  that  one  nearer  the  operator) — the  handle  is 
then  lowered  while  the  forward  progress  of  the  knife  continues,  so  that  its 
point  is  made  to  hug  the  bone  closely  until  its  upper  margin  is  reached — 
the  handle  is  then  raised  so  as  to  cause  the  point  to  sink  and  follow,  as  nearly 
as  possible,  the  surface  of  the  bone  (or  bones)  on  the  opposite  side  (which, 


DIVISION    OF    MUSCLES    IN    FLAP    METHODS    OF    AMPUTATION.     287 

naturally,  can  be  less  closely  followed  than  the  nearer  quadrant  of  the  bone's 
circumference).  When  the  knife's  point  is  felt  to  have  reached  a  point  on 
the  far  side  of  the  limb  corresponding  with  the  center  of  the  bone,  the  handle 
is  then  lowered  to  a  horizontal  position  and  the  knife  thrust  on  forward  until 
it  protrudes  through  the  skin  on  the  far  side  of  the  limb.  The  surgeon  stops 
here  a  moment  to  calculate  the  line  along  which  the  cutting-edge  of  the  knife 
is  to  emerge — the  guide  to  which  being  the  line  of  the  retracted  skin  flap. 
With  a  slow  back-and-forth  sawing  movement,  the  knife  is  made  to  cut 
its  way  forward — hugging  the  bone  (or  bones)  closely  throughout  the  greater 
portion  of  its  way — until  near  the  free  end  of  the  flap,  when  it  is  made  to 
round  its  way  out  in  such  a  manner  as  to  cut  a  thickly  beveled  edge  of  muscle  on 


Fig.  284.T-METHOD  of  Raising  Flaps  of  Skin  and  Muscle  by  Cutting  from  Within 
Outward  (by  Transfixion) — cutting  upon  the  line  of  retracted  skin  and  fascia,  which  have  been 
previously  divided. 

a  line  with  the  retracted  free  edge  of  skin  (Fig.  284).  In  cutting  a  second  flap 
from  the  opposite  aspect  of  the  limb,  the  first  flap  is  retracted  out  of  the  way — 
the  knife  then  passes  over  the  cut  surface  of  the  muscle  along  exactly  the 
same  course  as  in  beginning  the  transfixion  of  the  first  flap — until  its  point 
strikes  the  center  of  the  lateral  aspect  nearer  the  surgeon  (at  exactly  the  same 
point  as  in  the  first  manoeuvre).  The  handle  is  now  raised,  to  cause  the  point 
to  follow  down  the  lower  quarter  of  the  circumference  of  bone  nearer  the 
operator — when  its  lower  margin  is  reached,  the  handle  of  the  knife  is  lowered 
and  the  knife  pushed  forward,  until  the  inferior  surface  of  the  bone  (or  bones) 
is  passed.  The  handle  is  now  still  further  lowered  and  the  knife  pushed 
forward,  so  as  to  cause  the  point  to  follow  the  further  inferior  quarter  of  the 
bone  and  emerge  opposite  the  center  of  its  lateral  aspect.  But  as  this  manoeuvre 
is  difficult  to  accomplish,  the  surgeon  generally  aids  the  knife  with  his  left 
hand,  by  partly  guiding  it  and  partly  depressing  the  remaining  soft  parts  on 
far  side  below  the  point  of  the  knife  so  that  its  edge  escapes  them.  Then 
with  a  similar  back-and-forth  movement,  at  first  hugging  the  bone,  the  knife 
is  made  to  cut  its  way  out  on  a  line  with  the  retracted  skin-flap.  In  order  to 
avoid  cutting  the  muscle-flaps  too  narrow  and  too  thin,  it  is  necessary  to  hug 
the  bone  (or  bones)  until  about  three-fourths  of  the  flap  is  cut  and  then 
abruptly  round  out  to  the  line  of  the  retracted  skin-flap.  Great  care  is  also 
necessary  to  avoid  piercing  the  main  vessels  in  making  the  transfixion — 
and  to  avoid  splitting  them  (whether  at  first  transfixed  or  not)  in  cutting 


288  AMPUTATIONS. 

forward  to  form  the  flap.  Therefore,  it  is  sometimes  necessary,  when  forming 
flaps  by  transfixion,  to  so  plan  them  that  they  will  not  be  precisely  antero- 
posterior, or  lateral — but  will  be  so  formed  as  to  be  least  likely  to  contain 
split  vessels.  Considerable  tissue  at  the  base  of  the  Hap  often  escapes  division 
in  cutting  by  transfixion  and  has  to  be  cut  subsequently.  The  method  of 
transfixion  may  be  varied  by  not  passing  the  knife  so  closely  to  the  bone- 
that  is,  by  transfixing  the  more  superficial  muscles  only,  retracting  these, 
and  then  cutting  the  deeper  muscles  circularly  at  the  saw-line.  A  further 
modification  of  the  transfixion  method  consists  in  cutting  through  skin-and- 
fascia  flap  from  without — then  transfixing  the  apex  of  the  muscle-flap — 
and  dissecting  up  the  remaining  soft  parts. 

Comparison  of  Methods  of  Cutting  Flaps. — (a)  The  method  of  cutting 
from  without  inward  enables  a  flap  to  be  cut  with  greater  precision — makes 
the  wounding  and  splitting  of  the  main  vessels  unlikely — and  provides  for  a 
more  accurate  calculation  of  covering  for  the  stump,  especially  as  to  the 
relation  between  the  amount  of  skin  and  muscle  covering.  It  is  the  method 
to  be  chosen  in  the  great  majority  of  cases,  (b)  The  method  of  cutting  flaps 
from  within  outward  (transfixion)  is  a  convenient  method  in  very  large 
limbs,  and  in  some  special  amputations,  and  where  speed  is  necessary.  Flaps 
thus  cut  are  apt  to  have  their  arteries  injured — are  apt  to  be  too  thinly  beveled 
at  their  free  ends — are  apt  to  be  too  narrow  throughout,  and  too  pointed 
at  their  ends — and,  generally,  less  judgment  can  be  exercised  in  their  fashion- 
ing. Even  in  the  larger  limbs  a  flap  can  be  more  satisfactorily  cut  from 
without  inward  than  by  transfixion.  Even  where  transfixion  is  used,  how- 
ever, the  skin  and  fascia  should  invariably  be  cut  from  without — and  the 
knife  should  come  out  on  a  line  with  this  retracted  skin. 

FREEING  AND  RETRACTING  OF  MUSCLES. 

In  Ordinary  Circular  Method. — After  the  division  of  the  more  super- 
ficial muscles  by  the  circular  sweep  of  the  knife,  it  may  be  found  that  here 
and  there  these  muscles  are  not  divided  to  an  equal  depth.  Such  unequal 
division,  wherever  found,  is  completed  by  a  few  strokes  of  the  edge  of  a 
small  knife.  This  layer  of  muscles  is  then  retracted  upward  until  the  level 
is  reached  for  the  circular  division  of  the  deeper  muscles. 

In  Circular  Amputation  a  la  Manchette. — Here  the  muscles  are 
divided  directly  to  the  bone,  on  the  line  of  the  reflected  cuff,  and  no  special 
freeing  or  retraction  of  the  muscles  is  done,  until  ready  to  make  the  musculo- 
periosteal  covering. 

In  Modified  Circular  Amputation. — The  muscles  are  here  freed  and 
retracted  as  in  the  ordinary  circular  amputation. 

In  Oval  Method  of  Amputation.— Here  the  muscles  are  divided  on  the 
line  of  the  oval — no  freeing  or  retraction  being  necessary  until  ready  to  make 
the  musculo-periosteal  flap. 

In  Racket  Method  of  Amputation. — Same  as  in  the  oval  method. 

In  Single,  or  Equal,  or  Unequal  Flaps  of  Skin  and  Muscle. — (A) 
When  Cut  from  Without; — The  fingers  of  the  left  hand  raise  the  flap  away 
from  the  bone,  while  the  surgeon  cuts  the  vertical  limbs  of  the  flap  to  the 
bone,  and  gradually  bevels  the  terminal  portion  of  the  flap  obliquely  upward 
towTard  the  bone.  (B)  When  Cut  from  Within  by  Transfixion; — No  freeing 
or  retraction  is  necessary,  until  ready  to  make  the  musculo-periosteal  covering. 
(The  fingers  of  the  left  hand  may  grasp  up  the  soft  parts  of  the  limb  and 
lift  them  away  from  the  bone  as  the  knife  cuts  its  way  out.) 

In  Single,  or  Equal,  or  Unequal  Flaps  of  Skin.— The  muscles  are 


MAKING    MUSCULO-PERIOSTEAL    COVERING.  289 

here  divided  on  one  level — no  freeing  or  retraction  being  necessary,  until 
ready  to  make  the  musculo-periosteal  covering. 

In  Elliptical  Method. — The  muscles  are  handled  as  in  an  amputation 
by  a  single  flap  of  skin  and  muscles. 

In  Unequal  Rectangular  Flaps  of  Skin  and  Muscle  (Teale's  Method). 
—The  muscles  are  here  handled  as  in  amputation  by  unequal  flaps  of  skin 
and  muscle. 

MAKING  MUSCULO-PERIOSTEAL,  OR    PERIOSTEO-CAPSULAR,  COVER- 
ING FOR  END  OF  BONE. 

Description. — A  covering  should  be  provided  for  the  end  of  the  ampu- 
tated or  disarticulated  bone,  or  bones,  which  will  consist  of  periosteum  and 
overlying  muscle,  raised  as  a  single  musculo-periosteal  or  periosteo-capsular 
flap  or  covering.  Care  should  be  exercised  in  raising  this  covering,  that 
muscle  is  not  first  raised  from  periosteum  and  periosteum  from  bone,  but 
that  muscle  and  periosteum  should  be  raised  in  one  adherent  layer.  Peri- 
osteum is  absent  over  cartilaginous  surfaces,  hence  a  pure  musculo-periosteal 
covering  is  not  to  be  gotten  in  a  disarticulation — but  as  much  of  the  capsule 
of  the  joint,  which  is  practically  a  continuation  of  the  periosteum,  should 
be  preserved  as  possible,  and  treated  in  the  same  way  as  the  periosteum, 
that  the  articular  end  of  the  proximal  bone  may  be  covered.  The  distinct 
advantages  of  a  musculo-periosteal  covering  for  the  end  of  the  bone  are  the 
following; — (1)  The  muscles  being  adherent  to  the  periosteum,  when  a 
covering  of  the  latter  is  stitched  over  the  bone,  a  thicker  and  more  fixed 
covering  to  the  end  of  the  bone  is  secured  than  could  be  otherwise  attained: 
— (2)  The  end  of  the  bone  being  covered  by  periosteum,  adhesion  of  the 
soft  parts  to  the  end  of  the  bone  is  far  less  likely,  the  parts  covering  the  bone 
generally  remaining  freely  movable,  and  are,  therefore,  both  better  nourished 
and  are  less  likely  to  become  painful; — (3)  The  medullary  cavity  of  the  bone 
being  shut  off  by  the  musculo-periosteal  covering,  is  much  less  apt  to  become 
involved  in  any  septic  process  which  may  arise  in  the  stump.  The  only 
objections  which  can  be  raised  to  a  musculo-periosteal  covering  are  the 
time  and  trouble  involved — which  should  not  be  allowed  to  weigh  against 
the  practical  advantages — nor  should  the  possible  formation  of  osteophytes  and 
proliferation  of  bone  from  the  turned-over  periosteum  be  seriously  regarded. 

Manner  of  Providing  Musculo-periosteal  Covering  in  all  Forms 
of  Circular  Amputation,  and  in  all  Double-flap  Amputations  Cut  from 
Without  Inward. — The  surgeon  should  plan  to  have  his  knife  pass  through 
the  deep  layer  of  muscles  surrounding  the  bone  in  such  a  way  as  to  come 
down  through  these  muscles  and  upon  the  periosteum  without  separating 
muscles  from  periosteum  (which  would  also  detach  the  vascular  supply 
of  the  periosteum),  and  at  such  a  level  on  the  bone  below  the  saw-line  as  to 
equal  a  full  half-diameter  of  the  bone  at  the  saw-line.  In  circular  amputa- 
tions this  final  cut  will  pass  transversely  through  the  muscles, — in  flap  ampu- 
tations, obliquely  through,  in  the  process  of  beveling.  As  soon  as  the  peri- 
osteum is  reached  in  this  final  incision,  all  the  soft  parts  are  carefully  retracted 
around  the  whole  circumference  of  bone  at  this  level,  especial  care  being 
taken  not  to  use  force  in  the  retraction,  thereby  separating  muscle  from 
periosteum  by  dragging  the  former  off  of  the  latter.  A  circular  incision 
is  now  made  through  the  periosteum  around  the  entire  circumference  of 
bone,  at  the  level  of  the  lightly  retracted  muscles — cutting  the  periosteum 
with  especial  firmness  where  closely  bound  to  the  lineae  aspera?.     The  peri- 

!9 


290 


AMPUTATIONS. 


osteum  is  then  detached  back  to  the  line  of  the  future  saw-cut,  by  means  of 
a  periosteal  elevator — care  being  exercised  not  to  push  the  muscles  off  the 
periosteum,  but  to  push  the  periosteum  back  from  the  bone  with  the  muscles 
attached  (Fig.  285). 

In  Flap  Amputations  by  Transfixion. — The  knife  should  be  entered  just 
far  enough  below  the  saw-line  to  equal  a  full  half-diameter,  or  more,  of  bone  at 
the  sawdine.  When  the  flaps  are  cut,  the  periosteum  is  divided  circularly 
at  this  level — and  then  the  periosteum  and  muscles  are  detached  back  to 


Fig.  285.— Raising  a  Musculo-periosteal  Covering — in  the  circular  method  of  amputation. 


the  sawdine — or  the  periosteum  may  be  raised  as  two  small  flaps,  their 
incision  beginning  at  the  sawdine  (Fig.  286). 

In  Oval  and  Racket  Modifications  of  the  Circular  Amputation. — 
The  freeing  back  of  the  muscles  should  be  stopped  at  a  level  equal  to  a  full 
half-diameter,  or  more,  of  the  bone  below  the  saw-line — the  periosteum  is 
here  circularly  divided — and  the  periosteum  and  muscles  detached  thence 
back  to  the  saw-line. 

In  Single-flap  Amputations  of  Skin  and  Muscle. — The  knife  comes 
down  upon  the  bone  one  full  diameter,  or  more,  of  bone  below  the  saw-line.  As 
the  two  vertical  limbs  of  the  flap  have  been  cut  down  to  the  periosteum  in  the 
earlier  part  of  the  operation,  a  musculo-periosteal  flap  is  now  marked  out, 
having  a  base  equal  to  half  the  circumference  of  the  bone  at  the  saw-line 
and  a  length  equal  to  one  full  diameter,  or  more,  of  the  bone  at  the  saw-line. 
The  periosteum  and  muscles  are  now  detached  back  to  the  line  of  bone-section 
— all  the  hitherto  undisturbed  parts  on  the  opposite  side  of  the  limb  are 
now  divided  transversely  to  the  bone — and  the  bone  sawed. 

In  Flap  Amputations  of  Skin  Only. — As  the  muscles  are  here  divided 
circularly,  the  musculo-periosteal  flap  is  provided  for  just  as  in  the  ordinary 
circular  amputation. 

In  the  Elliptical  Modification  of  the  Single-flap  Method. — The 
musculo-periosteal  covering  is  handled  as  in  the  single  flap  of  skin  and  muscle. 

In  Unequal  Rectangular  Flaps  of  Skin  and  Muscle  (Teale's  Method). 
— The  musculo-periosteal  covering  is  secured  as  in  amputation  by  unequal 
flaps  of  skin  and  muscle. 

In  Amputating  Limbs  with  Two  Bones. — The  musculo-periosteal 
covering  for  the  larger  bone  is  provided  as  described  in  the  single-bone  limbs. 


MAKING    MUSCULO-PERIOSTEAL    COVERING.  291 

The  musculo-periosteal  covering  for  the  smaller  bone  is  provided  in  the 
same  manner,  but  will  be  cut  at  a  higher  level  (as  it  is  circularly  divided,  or 
a  flap  is  cut,  which  will  be  equivalent  to  the  smaller  diameter  of  the  smaller 
bone).  Where  the  bones  are  of  the  same  size,  the  periosteum  is  divided 
at  the  same  level  in  each  case — which  may  also  be  done  when  the  bones 
are  of  unequal  size,  the  redundancy  of  periosteum  in  the  case  of  the  smaller 
bone  being  subsequently  removed  with  scissors,  if  necessary. 


Fig.  286.— Raising  a  Musculo-periosteal  Covering— in  the  flap  method  of  amputating. 

Note. — The  final  treatment  of  the  periosteal  covering  cannot  be  carried 
out  until  after  the  division  of  bone. 

Comment. — (1)  It  will  be  seen  that  in  circular  amputations  and  in  ampu- 
tations by  double  flaps,  the  musculo-periosteal  covering  is  furnished  from 
the  entire  circumference  of  the  bone — while  in  amputations  by  single  flaps, 
a  single  flap  of  musculo-periosteal  tissue  is  raised,  the  width  of  which  is 
equal  to  a  half-circumference  of  bone  and  a  length  equal  to  a  diameter  of 
bone.  (2)  As  there  is  comparatively  little  retraction  of  fibrous  periosteal 
tissue,  the  chief  retraction  taking  place  in  the  attached  and  overlying  muscles, 
a  length  for  the  musculo-periosteal  covering  of  one  full  diameter  of  the  bone 
(each  side  of  the  bone  hereby  furnishing  one-half  diameter)  will,  therefore, 
cover  the  end  of  the  bone,  but  none  too  fully — so  that  this  measurement 
should  be  made  very  full.  (3)  Where  it  is  difficult  to  detach  the  musculo- 
periosteal  covering  backward  after  simply  a  circular  division  of  the  periosteum, 
two  vertical  incisions  may  be  made  upon  the  lateral  aspects  of  the  bone, 
from  the  site  of  the  saw-line  to  join  the  circular  cut — which  will  make  the 
detachment  easier.  These  vertical  incisions  may,  indeed,  be  made  in  aD 
cases.  Even  where  the  vertical  incisions  are  not  made  in  detaching  the 
periosteum,  they  may  be  subsequently  made  before  adjusting  the  periosteal 
flaps  or  covering.  In  the  pure  flap  amputations  the  muscles  have  already 
been  divided  to  the  periosteum,  so  that  the  knife  easily  makes  the  two  vertical 
incisions  in  the  periosteum.  In  the  circular  amputation  where  it  is  necessary 
to  add  the  vertical  cuts  before  sawing  the  bone  (that  is,  in  order  to  reach  the 
saw  line),  the  point  of  the  knife  may  be  pushed  into  the  transversely  divided 
muscles,  in  the  long  axis  of  the  limb,  up  to  the  saw-line  (which  will  lie  only 
a  half-diameter  of  the  bone  above)  and  cut  downward  thence  to  join  the 
circular  cut.  (4)  In  the  case  of  the  two-bone  limbs,  the  interosseous  mem- 
brane is  also  freed  back  in  the  act  of  detaching  the  periosteum.  (5)  Some 
hold  that  the  periosteal  covering  is  without  value  in  the  adult  and  actually 
harmful  in  the  young,  owing  to  the  possibility  of  reproduction  of  bone  render- 


292 


AMPUTATIONS. 


ing  the  stump  conical.  The  former  is  an  error  of  observation.  The  latter 
must  be  very  rare,  the  epiphysis  being  responsible  for  the  chief  increase  of 
length  of  bone. 


Fig.  287.— Retraction   of   Soft   Parts   Preparatory  to   Sawing  of  Bone— in  the  case  of  a 
single-bone  limb.     A  single-tail  retractor  is  shown  above. 


RETRACTION  OF  SOFT  PARTS  PREPARATORY  TO  SAWING  THE 

BONE. 

All  the  soft  parts  overlying  the  bone  having  now  been  divided,  from  skin 
to    periosteum,    these    soft    parts  are    to    be   retracted  above    and    out   of 

the  way  of  the  saw- 
line,  which  should  be 
seen  to  be  clear  in  its 
entire  circumference 
before  making  the 
bone-section. 

In  Si  ngle-bone 
Limbs.  —  A  double- 
tailed  linen  retractor 
is  generally  used  to 
hold  the  soft  parts 
back  —  the  two  tails 
of  the  retractor  pass- 
ing around  the  bone, 
thus  supporting  the 
soft  parts  and  drawing 
them  upward  and  out 
of  the  way  (Fig.  287). 
In  Double -bone 
Limbs. — A  three-tailed  linen  retractor  is  usually  used — the  central  tail  pass- 
ing between  the  bones — the  outer  of  the  other  two  tails  on  the  outer  side  of 
the  outer  bone,  and  the  inner  on  the  inner  side  of  the  inner  bone  (Fig.  288). 
Comment.- — The  parts  may  also  be  retracted  by  the  hands,  or  by  various 
forms  of  metallic  or  other  retractors,  such  as  Cooper's  retractors  (Fig.  289). 

SAWING  THE  BONE,  OR  BONES. 

General    Considerations. — The    surgeon,    standing    to    the  outer  side 
of  right  limbs  and  to  the  inner  side  of  left  limbs,  grasps  the  limb  firmly  with 


Fig.  288.— Retraction  of  Soft  Parts  Preparatory  to 
Sawing  of  Bone — in  the  case  of  a  double-bone  limb.  A  double- 
tail  retractor  is  shown  above. 


SAWING    THE    BONE,    OR    BONES. 


293 


his  left  hand  just  above  the  saw-line.  An  assistant  supports  the  distal  portion 
of  the  limb,  holding  it  out  over  the  side  of  the  table,  and  on  an  exact  line 
with  the  level  at  which  the  limb  leaves  the  trunk,  in  the  case  of  the  arm  and 
thigh;  and  on  a  level  with  the  surgeon's  left  hand  in  the  case  of  the  forearm 


Fig.  28q. — Cooper's  Metallic  Amputation  Retractors. 

and  leg.  If  he  elevates  it  above  the  common  level,  he  will  bind  the  surgeon's 
saw  throughout  the  entire  transverse  section  (because  the  parallel  walls  of 
the  section  will  tend  to  approximate), — and  if  he  depresses  it  below  the  common 
level,  while  he  makes  it  easier  for  the  surgeon  to  saw,  he  is  apt  to  splinter 
the  bone  just  before  the  section  is  completed  (because  the  parallel  walls  of 
the  section  will  tend  to  diverge). 


Fig.  290.— Manner  of  Sawing  the  Bone — in  the  case  of  a  single-bone  limb. 


In  Single-bone  Limbs. — The  surgeon  places  the  edge  of  his  thumb- 
nail down  upon  the  bone  immediately  above  the  saw-line,  as  a  guide  to  the 
saw,  temporarily  loosening  but  not  entirely  relaxing  his  steadying  hold  with 
the  other  fingers  and  palm  upon  the  limb.  Holding  an  ordinary  amputating 
saw  in  his  right  hand,  he  deliberately  places  its  heel  against  his  thumb  and 
knuckles,  and  directly  over  the  saw-line — and,  with  a  fairly  slow  but  firm 
and  steadv  movement,  he  draws  the  saw  backward  from  heel  to  point,  thus 
grooving  the  bone  transversely.     If  this  groove  be  not  distinct  or  deep  enough, 


294 


AMPUTATIONS. 


the  first  movement  (from  heel  to  point)  may  be  repeated.  The  surgeon 
now  resumes  his  steadying  grasp  of  the  limb  with  his  left  hand  and  proceeds 
to  saw  the  bone  by  slow,  even,  steady,  back-and-forth  strokes  of  the  saw, 
traveling  the  entire  length  of  the  saw-blade  at  each  stroke — and  avoiding 
uneven  and  too  rapid  sawing,  the  latter  sometimes  generating  a  harmful 
degree  of  heat.  It  is  during  the  section  of  the  latter  part  of  the  bone  that 
the  assistant  is  most  careful  in  his  manner  of  holding  the  limb  and  the  surgeon 
in  his  use  of  the  saw.  Toward  the  last  the  strokes  of  the  saw  should  be 
slower,  shorter,  and  lighter,  and  the  limb  so  balanced  that  there  will  be  no 
cross-strain  anywhere  throughout  its  length — and  thus  are  the  chances  of 
splintering  minimized.  If  indicated,  the  larger  saw  may  be  removed  toward 
the  last  and  the  section  be  completed  with  a  lighter,  finer  saw,  but  this  is 
ordinarily  unnecessary.  As  the  bones  of  both  single-bone  limbs  are  nearly 
circular,  no  beveling  of  the  edges  is  needed  (Fig.  290) . 

In  Double-bone  Limbs. — The  general  manipulative  method  is  here 
the  same  as  in  the  single-bone  limbs.  The  saw  first  engages  the  heavier 
bone,  and,  having  passed  partly  through  this,  is  dropped  upon  the  lighter 
or  more  movable  bone — the  section  of  which  latter  bone  should  be  first  com- 
pleted, the  saw  all  the  while  cutting  the  heavier  bone  also,  which  it  finally 
completes  alone.  Where  both  bones  are  of  the  same  size  (as  the  middle 
of  the  forearm),  the  saw  grooves  the  one  nearer  the  operator  and  is  then 

dropped  upon  the  farther  one. 
Where  a  bone  presents  a  promi- 
nent ridge,  almost  or  quite  sub- 
cutaneous (as  the  anterior  border 
of  the  tibia),  this  would  become 
an  angular  projection  after  sec- 
tion of  the  bone  and  would  be 
apt  to  become  a  prominent  point 
of  pressure.  To  avoid  this,  this 
edge  of  bone  should  be  beveled — 
which  is  best  done  by  making  an 
oblique  saw-cut  from  above  down- 
ward, beginning  about  1.3  cm.  (£ 
inch)  above  the  saw-line  and  pass- 
ing obliquely  into  the  bone  at  such 
an  angle  as  to  be  about  6  or  8  mm.  (j  or  ^  inch)  below  the  level  of  the  bone  by  the 
time  it  has  reached  the  saw-line.  Having  made  this  1.3  cm.  (^  inch)  oblique 
saw-cut  into  the  bone,  the  saw  is  then  withdrawn  and  is  made  to  traverse 
the  bone  transversely  along  the  line  of  bone-section  in  the  ordinary  manner. 
When  the  saw,  traveling  transversely,  reaches  the  short  oblique  section, 
the  small  triangle  of  bone  will  drop  out — and  when  the  section  is  completed, 
the  prominent  edge  of  the  bone  will  be  found  beveled  (Fig.  291). 

Comment. — In  the  very  young,  and  especially  in  amputating  those  bones 
which  grow  chiefly  from  an  upper  epiphysis,  it  is  well  to  saw  the  bone  as  high 
as  possible — as  subsequent  growth  from  such  bones  may  require  reamputation. 


Fig.  291. — Manner  of  Sawing  the  Bones — 
in  the  case  of  a  double-bone  limb.  The  method  of 
beveling  a  prominent  margin  of  bone  is  also  here 
shown. 


REMOVING  SPLINTERED  BONE. 

If,  in  the  final  saw-section,  whether  by  splintering  or  a  transverse  snapping 
of  the  frail  bridge  of  bone,  a  fragment  of  bone  is  left  projecting  from  the 
stump,  or  any  other  projecting  irregularity  should  appear  upon  the  trans- 
versely divided  bone,  this  should  be  removed  down  to  a  level  with  the  face 
of  the  bone.     This  is  accomplished  by  grasping  the  spicula  of  bone  with 


LIGATIXG    ARTERIES    AXD    VEINS.  295 

bone-holding  forceps  (such  as  the  lion-jaw  type)  and  steadying  it,  while  the 
surgeon  removes  the  spicula  with  a  small,  fine  saw  (Fig.  292). 

Comment. — (1)  Bony  projections  are  often  crudely  crushed  off  with 
bone-cutting  forceps — this  is  quickly  done  and  is  a  temptation — but  is  not 
to  be  recommended,  as  necrosis  of  the  margin  of  the  bone  is  more  apt  to 
follow  crushing  than  sawing.     (2)  The  splinter  of  bone  may  be  upon  the 


292.-MANXER  of  Removing  a  Piece  of  Splintered  Bone. 


portion  of  bone  removed — there  will  then  be  a  corresponding  depression, 
with  probably  a  tearing  of  periosteum  and  muscles,  upon  the  bone  in  the 
stump — which  may  require  to  be  evened  off. 

LIGATING  ARTERIES  AND  VEINS. 

As  soon  as  the  bone  has  been  sawed,  all  the  chief  arteries  and  the  larger 
veins  should  be  tied.  The  arteries  are  tied  in  the  order  of  their  importance 
and  are  sought  in  their  known  positions.  They  have  frequently  retracted 
somewhat,  so  as  to  be  out  of  sight,  and  are  to  be  traced  by  their  known  rela- 
tions. The  stump  should  be  held  in  a  good  position  and  light — and,  if 
necessary,  dried  of  blood.  The  cut  ends  of  the  arteries  are  caught  by  catch- 
forceps  and  drawn  out  of  their  beds  by  the  surgeon — while  an  assistant 
ligates  the  larger  vessels  with  chromic  catgut,  tying  them  with  a  surgeon's 
knot.  The  larger  arteries  may  be  tied  with  the  stay-knot  of  Edmunds  and 
Ballance  (page  24).  All  the  vessels  should  be  clamped  before  any  are  tied. 
The  larger  arteries  should  be  drawn  out  of  their  sheath  before  being  tied. 
The  smaller  arteries  with  their  sheaths  may  be  included  in  the  ligature. 
Arteries  which  are  caught  with  difficulty  with  catch-forceps  may  be  taken 
up  with  a  tenaculum.  Very  small  vessels  may  be  compressed  or  twisted 
without  ligaturing.  The  chief  veins  should  be  tied — as  well  as  any  others 
which  are  seen  gaping.  All  vessels  should  be  tied  as  long  as  possible — and 
should  be  disturbed  in  their  sheath  as  little  as  possible.  Arteries  bleeding 
from  their  osseous  canals  in  the  end  of  the  bone  cannot  be  tied,  but  may  be 
controlled  by  plugging  the  vascular  canal  with  a  piece  of  catgut,  a  piece  of 
sterilized  wood,  or  with  Horsley's  antiseptic  wax,  or  Halsted's  gut-wool — 


296 


AMPUTATIONS. 


or  a  limited  portion  of  the  canal  may  be  crushed  in  upon  itself.  After  all 
known  vessels  are  tied,  the  Esmarch,  or  other  constrictor,  should  be  relaxed 
and  all  hitherto  untied  vessels  which  now  bleed  are  to  be  ligated  (Fig.  293,  A, 
B,  and  C). 

Comment. — (1)  See  that  the  first  knot  (friction-knot)  does  not  loosen 
before  the  second  knot  (surgeon's  knot)  is  complete — and  that  the  knot  is 
far  enough  from  the  end  of  the  vessel  not  to  slip  off.     (2)  Where  hemorrhage 


Fig.  293.— Stump  after  Amputating  through  Lower  Part  of  Right  Leg: — A,  Ligation  of 
anterior  tibial  artery;  B,  Clamping  of  posterior  tibial  artery;  C,  Plugging  vascular  canal  of  bone 
with  piece  of  catgut ;  D,  Cutting  off  tag  of  peroneus  longus  ;  E,  Cutting  anterior  tibial  nerve  short. 


is  apprehended,  vessels  may  be  taken  up  immediately  after  dividing  the 
soft  parts,  and  before  even  severing  the  bone.  Instead  of  taking  up  and 
tying  the  vessels  seriatim,  they  may  be  immediately  clamped,  one  after  another, 
and,  if  not  tied  at  once,  the  catch-forceps  may  be  retracted  with  the  flaps, 
or  with  the  circular  division  of  soft  parts,  and  the  bone  sawed,  after  which  the 
vessels  are  tied — relaxing  the  original  hold  where  vessel  and  sheath  are  in- 
cluded and  taking  up  vessel  alone.     (3)   Obstinate  oozing  may  generally  be 


SUTURING  OF  MUSCULO-PERIOSTEAL  COVERING.  297 

controlled  by  ligating  en  masse — or  by  douching  with  hot  saline  solution,  or 
by  pressure.  This  is  the  form  of  hemorrhage  which  is  more  apt  to  occur 
after  the  removal  of  the  constrictor. 


TREATMENT  OF  NERVES,  TENDONS,  AND  TAGS  OF  MUSCLE,  FASCIA, 

AND  SKIN. 

(1)  All  nerves  should  be  cut  as  short  as  possible,  to  avoid  entanglement 
and  pressure  in  the  process  of  cicatrization — to  accomplish  which  they  should 
be  caught  bv  forceps  and  drawn  well  out  and  then  cut  with  scissors  and 
allowed  to  retract  out  of  sight.  Where  the  flap  method  has  been  done  and 
it  is  likely  that  an  important  nerve  may  be  subjected  to  pressure  when  the 
flaps  are  bent  and  sutured  over  the  end  of  the  bone,  the  nerve  should  be  dis- 
sected out.  This  is  especially  the  case  in  the  method  of  single-flap  ampu- 
tation. Nerve  ends  are  apt  to  become  bulbous  in  any  event,  but  will  not 
be  troublesome  unless  subjected  to  pressure.  (2)  All  tendons  should  be 
caught  with  forceps,  steadied,  and  cut  short  under  slight  tension.  They  are 
difficult  to  cut  unless  steadily  held  and  slightly  stretched — when  they  may 
be  cut  with  scissors  or  a  very  sharp  knife.  Tendon-ends  possess  low  vitality, 
are  apt  to  slough,  fulfil  no  useful  purpose  in  the  stump,  and  make  but  poor 
covering.  (3)  All  tags  and  irregularities  of  muscle,  fascia,  and  skin  should 
be  evenlv  trimmed,  so  as  to  conform  with  the  general  contour.  (Fig.  293, 
E  and  D.) 

TRIMMING  OF  FLAPS. 

It  is  undesirable,  and  somewhat  unsurgical,  to  make  a  miscalculation  in 
the  length  or  contour  of  a  flap,  which  will  require  any  subsequent  trimming 
■ — but  where  a  flap  is  distinctly  too  long,  or  too  large,  or  misshapen,  it  is 
better  to  do  the  trimming  necessary  to  make  a  good  fit  than  to  suture  it  in 
place  as  it  is.  It  is  held  in  the  left  hand,  or  caught  with  forceps,  and  trimmed 
as  one  would  trim  a  piece  of  paper.  A  flap  may  be  trimmed  as  a  whole — or 
some  individual  tissue  composing  it  may  be  trimmed. 

RE-AMPUTATION  FOR  IMPROPERLY  MADE  FLAPS. 
It  is  even  more  unsurgical,  and  much  more  difficult  to  rectify,  to  find 
that  so  little  allowance  of  covering  has  been  made  that  the  end  of  the  bone 
either  cannot  be  covered  at  all,  or  cannot  be  covered  without  a  degree  of 
tension  calculated  to  endanger  the  flaps.  In  such  a  case  all  that  one  can 
do  is  to  amputate  at  a  higher  level.  If  only  a  slight  deficiency  of  covering 
exist,  the  end  of  the  bone  may  be  freed  of  its  soft  parts  by  retraction  and 
made  to  project  and  then  be  removed  by  the  saw.  Where  the  deficiency  is 
greater,  from  one  to  several  inches  of  the  soft  parts  may  also  have  to  be  re- 
moved, as  well  as  the  bone.  In  such  a  case  one  proceeds  very  much  as  in 
the  original  operation,  modified  by  the  needs. 


ADJUSTMENT  AND  SUTURING  OF  MUSCULO-PERIOSTEAL  OR 
PERIOSTEO-CAPSULAR  COVERING. 

The  first  step  in  the  closure  of  the  stump-tissues  is  the  adjustment  of  the 
musculo-periosteal  covering.  It  will  be  remembered  that  in  all  circular 
amputations,   and   in  all  double-flap  amputations  of  skin  and   muscle,   the 


298  AMPUTATIONS. 

musculo-periosteal  covering  was  made  by  a  circular  division  of  the  periosteum 
around  the  bone  one-half  of  a  full  diameter  of  the  bone  below  the  saw-line 
(thus  furnishing  a  full  diameter),  and  that  the  periosteum,  with  adherent 
muscles,  was  then  detached  in  one  layer  up  to  the  saw-line.  Therefore, 
after  the  bone  is  sawed  and  the  soft  parts  drop  down  around  its  cut  end, 
the  musculo-periosteal  covering  will  form  a  hollow  cylinder  projecting  from 
the  lower  surface  of  the  transversely  sawed  bone — the  periosteum  hanging 
down  around  the  bone  for  a  depth,  approximately,  of  a  half  diameter  of  the 
bone,  the  muscles  being  adherent  to  its  outer  side.  This  cuff  of  musculo- 
periosteal  covering  may  be  converted  into  two  small  flaps  by  cutting  along 
its  lateral  aspects  with  straight-pointed  scissors,  from  its  lower  free  margins 
up  to  the  bone.  The  corners  of  these  little  flaps  may  then  be  slightly  rounded, 
though  this  is  not  necessary.  These  two  flaps  are  then  dropped  over  the 
end  of  the  bone  and  their  edges  are  sutured  together  with  catgut,  the  sutures 
passing  through  periosteum  and  muscles.  While  the  above  method  makes 
a  neater  fit,  it  is  not  really  necessary  that  the  musculo-periosteal  covering 

should  be  slit  up  at  all  on  the 
sides — it  suffices  simply  to  ap- 
proximate the  edges  over  the 
bone  by  a  suture  running  either 
antero-posteriorly  or  trans- 
versely. Where  the  musculo- 
periosteal  covering  has  been 
raised  in  the  form  of  a  single 
flap  (as  in  the  amputation  by  a 
single  flap),  this  single  flap  of 
musculo-periosteal  covering  is 
dropped  over  the  end  of  the 
bone  and  its  margins  sutured 
to  the  cut  margins  of  the  peri- 
osteum around  the  rest  of  the 
ering.  circumference  of  bone,  including 

the  muscle  overlying  the  perios- 
teum. Where  the  bone-section  is  very  small,  it  is  often  difficult  to  adopt 
any  definite  plan  of  making  and  suturing  a  musculo-periosteal  flap,  the  per- 
iosteum being  torn  in  shreds  in  the  process  of  detachment.  In  such  cases 
the  mass  of  musculo-periosteal  tissue  is  simply  gathered  together  and  sutured 
over  the  end  of  the  bone.     (Figs.  294  and  302.) 

QUILTING  OF  MUSCLES. 

The  muscle  tissue  which  enters  into  the  covering  of  the  bone  should, 
where  possible,  be  approximated  and  sutured  into  apposition  by  buried 
chromic  gut  sutures,  placed  in  one  or  more  tiers,  by  means  of  either  buried 
simple  sutures,  or  buried  quilt-  or  mattress-sutures.  Thus  the  cut  aspects 
of  the  muscles  are  brought  into  contact, — less  tendency  for  them  to  retract 
away  from  the  end  of  the  bone  occurs, — in  the  process  of  cicatrization  they 
become  incorporated  in  the  general  pad  of  covering  which  forms  the  stump 
(even  though  the  muscle  tissue  itself  may  be  subsequently  replaced  by  fibrous 
tissue), — there  is  less  chance  of  adhesions  forming  between  bone  and  skin, — 
and,  altogether,  a  fuller,  softer,  better-formed  pad  of  covering  is  provided. 
These  advantages  more  than  counterbalance  the  only  two  disadvantages — 
namely,  of  time  and  trouble  involved.     By  the  process  of  quilting,  muscles 


QUILTING  OF  MUSCLES. 


299 


Fig.295.-Qu11.TiNG  of  Muscles  in  Circular 
Method  of  Amputation: — First  tier  of  sutures 
has  been  placed — and  is  being  buried  by  the  second 
tier. 


are  brought  and  held  in  contact  until  united,  which,  in  the  ordinary  method 
of  simply  dropping  muscles  over  the  ends  of  the  bones  and  depending  upon 
the  single  line  of  marginal  skin-sutures  to  approximate,  either  could  not  be 
made  to  come  into  contact  even  temporarily,  or,  if  so,  would  generally  retract 
apart  before  union. 

In  Circular  (Infundibuliform  Variety),  Modified  Circular,  Oval, 
and  Racket  Methods. — After  su- 
turing the  musculo-periosteal  cover- 
ing the  muscle  surfaces  are  brought 
into  contact  immediately  over  the 
musculo-periosteally  covered  end  of 
bone.  The  approximation  of  mus- 
cle tissue  over  the  bone  may  be 
made  in  the  way  in  which  the  mus- 
cles most  naturally  fall.  Other 
things  being  equal,  the  approxima- 
tion should  be  made  so  as  to  cause 
the  suture  line  to  be  parallel  with 
the  future  suture  line  of  the  integu- 
mentary coverings.  The  first  tier 
of  sutures  is  placed  nearer  the  bone, 
entering  and  leaving  the  muscle  tis- 
sue at  such  a  distance  from  the 
bone  as  to  secure  an  easy  ap- 
proximation of  the  muscle  substance 

over  the  end  of  bone.  This  first  row  of  sutures,  which,  if  of  the  simple 
form,  may  be  either  interrupted  or  continuous,  will  conceal  the  end  of  the 
bone.      A    second    tier,  especially    in    heavily    muscled    limbs,    or    in    thin 

limbs  with  large  muscle 
flaps,  should  be  applied 
—being  inserted  nearer 
the  edge  of  the  muscle 
tissue  than  the  first — 
and,  when  tied,  will  hide 
the  first  row  (Fig.  295). 
In  Circular 
Method  a  La  Man- 
chette. — As  the  mus- 
cles are  here  all  divided 
on  one  level,  and  that 
'\  level  is  that  of  the  re- 

tracted skin,  skin  and 
fascia  alone  cover  the 
end  of  the  bone,  and 
no  approximation  and 
quilting  of  the  muscles 
are  possible. 
In  All  Double-flap  Amputations  of  Skin  and  Muscle. — The  muscles 
are  quilted  in  the  same  manner  as  in  the  ordinary  circular  (infundibuli- 
form), the  process  of  muscle-quilting  being  easier  in  the  double-flap 
method  than  in  the  ordinary  circular,  as  the  muscles  are  adherent  to  the 
flaps  on  either  side  and  are  more  readily  held  in  approximation  while  being 
quilted  (Fig.  296). 


Fig.  296.— Quilting  of  Muscles  in  Flap  Method  of  Ampu- 
tation : — First  tier  of  buried  sutures  has  been  placed  and  tied — 
and  second  tier  is  being  placed. 


300  AMPUTATIONS. 

In  All  Double  Flaps  of  Skin. — No  quilting  of  muscles  is  here  possible 
— as  the  muscles  are  transversely  divided  on  a  level  with  the  retracted  skin- 
flaps. 

In  All  Single  Flaps  of  Skin  and  Muscle,  Including  the  Elliptical 
Method. — As  the  muscles  are  here  divided  obliquely  on  the  side  of  the  flap, 
and  transversely  on  the  opposite  side,  the  quilting  of  muscles  is  not  done 
as  in  the  above-described  methods  (where  the  lateral  aspects  of  the  muscles 
are  sutured  to  lateral  aspect,  or  ends  to  ends).  The  lateral  aspect  of  the 
muscles  in  the  present  instance,  some  of  which  aspect  is  made  up  by  the 
obliquely  beveled  muscles,  is  sutured  to  the  transversely  divided  muscles 
on  the  side  of  the  limb  opposite  to  the  flap — and  the  ends  of  the  muscles  in 
the  flap  are  sutured  to  the  circumferential  margin  of  the  transversely  divided 
muscles  in  the  stump.  As  the  base  of  the  flap  comes  from  a  full  half-cir- 
cumference of  the  limb,  the  bent-over  flap  is  only  approximated  to  the  opposite 
half  of  the  face  of  the  stump.  Where  the  elliptical  method  is  used  in  the 
neighborhood  of  an  articulation  (that  is,  in  a  disarticulation)  where  only 
tendons  pass  over  and  cover  the  joint,  no  quilting  is  possible.  It  is,  therefore, 
applicable  only  where  muscles  cover  bones,  which,  in  the  case  of  the  joints,  is 
only  at  the  shoulder  and  hip. 

DRAINAGE. 

No  drainage  is  necessary  in  amputating  through  sound  tissue  in  the 
continuity  of  a  limb.  Temporary  drainage  (for  two  or  three  days)  may  be 
instituted  in  disarticulating  through  the  larger  joints — to  provide  for  the 
escape  of  the  synovial  fluid  which  the  remaining  synovial  surfaces  will  go 
on  secreting  for  a  time.  Where  drainage  is  indicated,  it  is  sometimes  better 
to  make  a  counter-opening  than  to  attempt  to  drain  through  a  non-dependent 
suture-line.  Drainage  may  be  temporarily  used  where  bleeding  in  the 
stump-tissues  is  feared  after  prolonged  use  of  an  Esmarch,  or  for  other  reason. 
Drains  of  rubber-tubing,  glass,  gauze,  or  bone-tube  may  be  used. 


SUTURING  OF  THE  STUMP. 

The  suturing  of  the  edges  of  the  wound  should  be  done  with  silk  and  by 
means  of  interrupted  sutures.  Where  no  great  tension  is  likely  to  occur, 
silkworm-gut  may  be  used.  Catgut  is  also  employed.  The  parts  should 
come  together  without  tension.  The  interrupted  is  to  be  preferred  to  the 
continuous  form  of  suturing,  for  the  parts  may  be  thereby  more  accurately 
adjusted — and  if  it  become  necessary  to  open  any  part  of  the  wound  for 
drainage,  or  other  cause,  only  the  few  indicated  sutures  need  be  cut. 

In  Circular  Amputations. — It  is  optional  with  the  operator  as  to  whether 
the  soft  parts  are  so  approximated  as  to  result  in  a  line  of  sutures  running 
from  before  backward,  or  from  side  to  side.  The  former  is  to  be  preferred, 
as  the  lower  end  of  the  suture-line  (in  the  recumbent  position  of  the  patient) 
drains  the  wound  by  gravity,  in  case  drainage  be  necessary.  Where  skin 
and  muscle  come  evenly  to  the  edge  of  the  wound,  both  are  included  in  the 
sutures.  Where  skin  is  longer  than  muscle,  the  sutures  which  close  the 
wound  pass  through  skin  only — the  muscles  having  been  approximated  by 
their  own  buried  sutures. 

In  Flap  Amputations. — Here  the  direction  of  the  line  of  sutures  will  be 
determined  by  the  position  of  the  flaps.  Where  double  flaps  are  taken 
from  the  anterior  and  posterior  aspects  of  a  limb,  the  suture-line  will  run 


THE  EVOLUTION  OF  AMPUTATION  METHODS.  301 

from  side  to  side.  Where  double  flaps  are  taken  from  the  lateral  aspects 
the  suture-line  will  be  antero-posterior.  Where  a  single  flap  is  approximated 
to  the  opposite  side  of  the  limb,  its  margin  is  sutured  to  the  opposite  half- 
circumference.  Where  the  margin  of  the  flaps  is  composed  of  skin  and 
muscle,  both  are  included  in  the  sutures.  Where  the  skin  is  longer  than  the 
muscle,  the  skin  alone  is  included  in  the  suturing.  In  all  cases  the  muscle 
surfaces  are  supposed  to  have  been  quilted  together  prior  to  the  final  closure 
of  the  wound. 

Comment. — (1)  Owing  to  the  difficulty  of  equally  dividing  out  the  posi- 
tions for  sutures  where  a  large  wound  is  to  be  brought  together,  it  is  well 
to  begin  by  putting  in  a  central  suture  and  then  divide  each  remaining  half 
of  the  space  into  quarters  by  two  other  sutures — then  these  smaller  lengths 
can  be  sutured  with  interrupted  or  continuous  suture — the  former  being 
better,  as,  in  case  it  be  necessary  to  loosen  any  suture  for  suppuration,  or 
otherwise,  the  entire  line  need  not  be  loosened.  (2)  If  tension  upon  the 
edges  be  great,  a  few  tension-sutures  mav  be  used. 


DRESSING  OF  THE  WOUND. 

The  wound  and  stump  should  be  covered  with  absorbent  gauze — the 
entire  stump  enveloped  in  absorbent  cotton — which  should  be  snugly  bandaged 
to  the  end  of  the  stump  and  the  circumference  of  the  limb.  A  padded  poste- 
rior splint  should  be  incorporated  in  the  outer  layers  of  the  dressing,  pro- 
jecting beyond  the  stump  slightly — both  to  support  the  part;  protect  it  from 
injury;  and  control,  or  lessen,  the  muscular  startings  which  are  apt  to  occur. 
The  stump  should  rest  upon  an  inclined  plane,  outside  of  bed-covering. 


REMOVAL  OF  DRESSINGS. 

If  all  goes  well,  the  dressings  are  not  removed  until  about  the  tenth  day 
(or  from  the  tenth  to  the  fourteenth).  If  a  drainage-tube  be  used,  the  dress- 
ings are  often  changed  when  that  is  withdrawn — although  it  is  sometimes 
withdrawn  at  the  end  of  the  second  or  third  day — and  the  dressings  not 
removed  until  the  usual  time. 


THE  METHODS  OF  AMPUTATION. 
THE  EVOLUTION  OF  AMPUTATION  METHODS. 

The  methods  of  amputation  have  undergone  a  slow  process  of  evolution 
— which  may  be  briefly  stated  in  the  following  tabular  form  (modified  from 
Kocher). 

Circular  Incision. — The  fundamental  type  of  amputation.  Of  which 
there  are  two  varieties,  and  from  which  all  other  methods  of  amputation 
may  be  derived; — (a)  Transverse  circular  incision  (Fig.  297,  A);  (b)  Oblique 
circular  incision  (Fig.  297,  B). 

Racket  Incision. — Formed  by  the  addition  of  a  longitudinal  incision 
to  the  circular  incision,  (a)  If  the  longitudinal  incision  be  added  to  the 
transverse  circular  incision,  the  transverse  racket  incision  results  (Fig.  297, 
C);  (b)  If  the  longitudinal  incision  be  added  to  the  oblique  circular  incision, 
the  oblique  racket  incision  results  (Fig.  297,  D).     Xote — The  corners  of  the 


302  AMPUTATIONS. 

racket  incision  are  now  generally  rounded  off,  as  in  the  oval  method,  the 


Fig.297.— The  Evolution  of  Amputation  Methods: — I — A,  Transverse  circular  incision;  B, 
Oblique  circular  incision;  C,  Transverse  racket  incision;  D,  Oblique  racket  incision.  (Modified 
from  Kocher.) 

only  practical  difference  between  the  two,  as  now  usually  employed,  being 
that  the  queue  is  made  longer  in  the  racket  method. 

Oval  Incision. — Formed  by  the  shortening  of  the  queue  and  the  rounding- 


Fig.  298.— The  Evolution  of  Amputation  Methods  : — II— A,  Transverse  oval  incision  ; 
B,  Oblique  oval  incision;  C,  Equal  rectangular  flaps;  D,  Unequal  rectangular  flaps.  (Modified 
from  Kocher.) 

off  of  the  angles  of  the  racket  incision,     (a)  If  the  angles  of  the  transverse 
racket  incision  be  rounded,  the  transverse  oval  incision  results  (Fig.  298,  A); 


Fig.  299.— The  Evolution  of  Amputation  Methods: — III — A,  Equal  rounded  flaps  ;  B,  Unequal 
rounded  flaps.     (Modified  from  Kocher.) 


(b)  If  the  angles  of  the  oblique  racket  incision  be  rounded  off,  the  oblique  oval 
incision  results  (Fig.  298,  B). 


ORDINARY    CIRCULAR    AMPUTATION.  303 

Rectangular  Flaps. — Formed  by  adding  two  longitudinal  incisions  to  the 
circular  incision,  (a)  If  the  two  longitudinal  incisions  be  added  to  the  circular 
incision,  equal  rectangular  flaps  result  (Fig.  298,  C) ;  (b)  If  they  be  added  to 
the  oblique  circular  incision,  unequal  rectangular  flaps  result  (Fig.  298,  D). 

Rounded  Flaps. — Formed  by  rounding  the  angles  of  the  rectangular 
flaps,  (a)  If  the  angles  of  equal  rectangular  flaps  be  rounded,  equal  rounded 
flaps  result  (Fig.  299,  A) ;  (b)  If  the  angles  of  unequal  rectangular  flaps  be 
rounded,  unequal  rounded  flaps  result  (Fig.  299,  B). 

Elliptical  Method. — The  position  of  this  method,  in  the  process  of  evo 
lution,  will  be  described  further  on  (page  315). 


SUMMARY  OF  AMPUTATION  METHODS. 

Fundamental  Types. — Circular  Method;  Flap  Method. 

Modern  Types. — (a)  Circular  and  its  modifications;  (b)  Flap  and  its 
modifications;  (c)  Irregular  methods  of  amputation. 

As  to  Nature  of  Covering  of  Stump. — All  methods  of  amputation 
are  either — (a)  Skin  Coverings — that  is,  skin  and  fascia  alone  cover  the 
divided  muscles  and  bone,  as  in  the  cuff  method  of  the  circular  amputation, 
and  in  the  simple  skin-flap  in  the  flap  method  of  amputation; — or  (b)  Skin- 
and-muscle  Coverings — where  skin,  fascia,  and  muscles,  combined  and  un- 
separated,  including  the  periosteum,  cover  the  end  of  the  bone,  as  in  the 
ordinary  (infundibuliform)  circular  amputation,  and  in  flaps  of  skin  and 
muscle  in  the  flap  method  of  amputation. 


CIRCULAR  METHODS  OF  AMPUTATING. 

(a)  Ordinary  Circular  Method — (amputation  circulaire  infundibuli- 
forme); — (b)  Cuff  Method  of  Circular  Amputation — (amputation  a  la  nian- 
chette); — (c)  Modified  Circular  Method  of  Amputation — (mixed  method); — 
(d)   Oval  (or  Lanceolate)   Method;— (e)   Racket  Method. 


ORDINARY  CIRCULAR  AMPUTATION. 

(AMPUTATION  CIRCULAIRE  INFUNDIBULIFORME). 

General  Description. — The  soft  parts  are  divided  by  a  series  of  circular 
cuts,  retraction  of  the  parts  taking  place  between  each  circular  sweep  of  the 
knife,  so  that  they  are  cut  partly  through  at  different  levels — the  sawed  bone 
forming  the  apex  of  the  funnel  left  upon  the  proximal  end  of  the  limb,  and 
the  skin  margin  the  base — the  distal  part  removed  being  cone-shaped. 

Technic. — Stand  to  outer  side  of  right  and  inner  side  of  left  limbs,  so 
as  to  grasp  limb  between  trunk  and  amputation-site.  Determine  the  saw- 
line.  Fix  the  skin  incision  at  a  level  below  the  saw-line  equal  to  \  of  ih 
times  the  diameter  of  the  limb  (or  three-fourths  of  that  diameter)  at  the 
saw-line  (that  is,  at  11.5  cm.,  or  4J  inches,  below  the  saw-line,  if  the  diam- 
eter of  the  limb  at  the  saw-line  be  15.3  cm.,  or  6  inches)  (Fig.  300,  A). 
Grasp  the  limb  just  above  the  line  of  the  skin  incision  with  the  left 
hand  and  retract  the  skin  upward,  aided,  if  the  limb  be  large,  by  an 
assistant.  With  a  long  knife,  make  a  circular  incision,  at  the  skin-incision 
line,  through  skin  and  superficial  fascia,  entirely  around  the  limb.  Free 
skin  with  its  superficial  fascia  from  the  muscles  with  their  deep  fascia,  aiding 


3°4 


AMPUTATIONS. 


the  separation  in  the  interfascial  line  by  touches  with  a  scalpel,  where  neces- 
sary. Retract  the  skin  and  fascia  evenly  around  the  circumference  of  the 
limb.  Divide  the  more  superficial  layer  of  muscles  circularly,  on  a  level 
with  the  retracted  skin.  Retract  this  more  superficial  layer  of  muscles. 
Divide  the  remaining  deeper  muscles  circularly  on  a  level  with  the  retracted 
outer  layer  of  muscles — and  planning  to  come  down  upon  the  bone,  or 
bones,  far  enough  below  the  saw-line  to  allow  of  making  a  musculo-periosteal 
covering  for  the  bone  or  bones.  Retract  the  deeper  muscles  thus  cut.  Divide 
with  a  stout  knife,  the  periosteum  circularly  around  the  bone,  or  bones,  at  a 
distance  below  the  saw-line  equal  to  a  good  one-half  diameter  of  the  bone 


Figs.  300  and  301.— Ordinary  (Infundibular)  Form  of  Circular  Amputation  : — A,  Position 
of  incision  and  bone-section  ;  B,  Resulting  suture-line.  The  skin-incision  and  suture-line  here  are 
also  applicable  to  the  cuff  variety  of  the  circular  method. 


at  the  saw-line.  Push  up  the  periosteum  from  the  bone  with  periosteal 
elevator — keeping  the  muscles  adherent  to  the  periosteum.  Apply  linen 
(or  other)  retractors  to  the  soft  parts  and  draw  them  above  the  saw-line. 
Saw  the  bone,  or  bones.  If  splintering  occur,  grasp  the  spicula  with  forceps 
and  remove  with  finer  saw.  Allow  the  soft  parts  to  drop  over  the  end  of 
bone,  or  bones,  the  sawed  ends  of  which  will  form  the  apex  of  a  funnel — 
the  bone  being  covered  by  periosteum — periosteum  by  muscle — and  muscle 
by  fascia  and  skin  (Fig.  302).  Tie  the  vessels — cut  the  nerves  and  ten- 
dons short — and  remove  any  tags  of  connective  tissue  or  skin.  Suture 
the  musculo-periosteal  covering  over  the  end  of  bone,  or  bones.     Quilt  the 


CUFF  METHOD  OF  CIRCULAR  AMPUTATION. 


3°5 


muscles  together  in  one  or  two  layers.     Suture  the  skin  and  fascia  antero- 
posterior!}' (Fig.  301,  B) — and  apply  the  dressing  and  supporting  splint. 

Resulting  Stump. — Evenly  covered  on  all  sides  by  muscle  and  skin 
— the  bone  being  particularly  well  protected  and  on  a  higher  level  above  the 
surface  of  the  stump  than  in  any  other 
form  of  amputation.  The  scar  is  ter- 
minal— antero-posterior,  if  the  wound  be 
sutured  from  before  backward, — lateral, 
if  sutured  from  side  to  side  (Fig.  301,  B). 

Indications. — In  limbs  more  or  less 
evenly  surrounded  by  muscles: — lower 
part  of  forearm  (sometimes),  arm,  and 
thigh. 

Comment. — (1)  Owing  to  unequal 
skin  retraction  in  some  localities  (as  the 
antero-internal  aspect  of  the  arm  and 
thigh)  the  circular  incision  may  have  to 
be  planned  obliquely  and  only  become 
circular  after  the  incision  — and  may  also 
have  to  be  planned  lower.  (2)  A  pure 
ordinary  circular  (infundibuliform)  am- 
putation is  impossible  in  a  limb  of  rap- 
idly increasing  girth,  as  it  is  impossible 
to  retract  the  soft  parts.  A  single  lateral 
vertical  incision  through  skin  and  fascia, 
or  double  lateral  incisions,  may  become 
necessary  in  order  to  free  the  parts — 
when  it  ceases  to  be  a  typical  infundi- 
buliform amputation. 


Fig.  302.— Appearance  of  the  Parts 
Following  the  Infundibular  Form  of 
Circular  Amputation  :— A  funnel-shaped 
cavity  left  proximally,  and  a  cone-shaped 
mass  distallv. 


CUFF   METHOD  OF  CIRCULAR  AMPUTATION 

(CIRCULAR  AMPUTATION  A   LA  MANCHETTE). 

General  Description. — A  circular  division  of  the  skin  is  made,  which 
is  turned  over  and  upward  upon  itself  as  a  cuff — and,  upon  a  level  with  this 
retracted  cuff  of  skin  and  fascia,  the  muscles  are  divided  to  the  bone,  generally 
with  one  circular  sweep  of  a  long  knife. 

Technic. — The  steps  of  the  operation  are  similar  to  those  of  the  ordinary 
circular  amputation  (page  303)  up  to  the  completion  of  the  circular  incision 
through  the  skin  and  superficial  fascia.  The  skin  and  subcutaneous  tissue 
are  then  turned  back  upon  themselves  as  a  cuff — the  freeing  being  done 
by  means  of  the  fingers  of  the  left  hand,  aided  by  touches  of  a  scalpel,  until 
evenly  retracted  all  around.  On  a  level  with  the  retracted  cuff,  the  muscles 
are  circularly  divided  down  to  the  bone — the  site  at  which  this  division  takes 
place  being  such  as  will  allow  of  ample  and  easy  covering  of  the  transversely 
divided  muscle  by  the  skin  and  fascia — an  average  calculation  being  that 
about  one-third  of  the  total  distance  from  saw-line  to  line  of  skin  incision 
should  be  given  to  skin  and  fascia  alone.  The  subsequent  steps  of  the  opera- 
tion, including  the  musculo-periosteal  covering  for  the  bone,  being  the  same 
as  for  the  ordinary,  or  infundibuliform,  circular  amputation. 

Resulting  Stump. — Apt  to  be  more  or  less  irregular  in  contour  and  not 
so  well  padded,  owing  to  the  nature  of  the  parts  used  for  covering.  The 
scar  lies  as  in  the  ordinary  circular  amputation  (Fig.  301). 


306 


AMPUTATIONS. 


Indications. — Most  frequently  used  where  the  soft  coverings  are  more 
tendinous  than  muscular: — wrist,  lower  part  of  forearm,  ankle,  and  lower 
part  of  leg  (in  thin  subjects). 

Comment. — (i)  and  (2)  The  same  comments  made  under  (1)  and  (2) 
of  the  last  operation  apply  equally  here  (page  305).  (3)  Owing  to  the  greater 
proportion  of  skin  in  this  covering  and  the  division  of  muscles  in  one  layer, 
as  well  as  the  number  of  tendons  present  in  the  sites  where  this  method  is 
generally  used,  the  covering  of  the  bones  is  not  so  satisfactory  as  in  the  ordinary 
circular  method. 

MODIFIED  CIRCULAR  AMPUTATION 

(MIXED  METHOD). 

General  Description. — Two  equal  flaps,  composed  of  skin  and  fascia, 


Figs. 303  and  304.— Modified  Circular  Method  of  Amputation: — A,  Position  of  incision  and 
bone-section  ;  B,  Resulting  suture-line. 


of  varying  length,  and  having  bases  equal  to  one-half  of  the  circumference 
of  the  limb  at  their  upper  ends,  are  cut  and  dissected  up  a  short  distance — 
followed  by  a  circular  sweep  of  the  knife  through  the  retracted  superficial 
muscles — and  by  a  second  circular  sweep  at  a  higher  level,  through  the  re- 
tracted deeper  muscles — and  completion  of  the  operation  as  in  the  ordinary 
circular  amputation. 

Technic. — Having  fixed  upon  the  saw-line,  and  having  marked  a  point 
below  the  saw-line  equal  to  \  of  ih  diameters  of  the  limb  at  the  saw-line  (that 


OVAL  METHOD  OF  AMPUTATION.  307 

is,  three-fourths  of  the  diameter  at  the  saw-line),  two  equal  flaps  of  skin  and 
fascia  (of  this  length)  are  planned.  These  flaps  have  bases  equal  to 
one-half  the  circumference  of  the  limb  at  the  level  of  their  upper  limit 
— and  their  length  will  be  equal  to  one-third  or  one-half  of  the  total  distance 
between  saw-line  and  lowest  limit  of  skin-covering  (generally  one-third  in 
slender,  ill-formed  limbs,  and  often  one-half  in  large,  tapering  limbs).  The 
flaps  are  usually  lateral  ones,  but  may  be  anterior  or  posterior  (Fig.  303,  A). 
Retracting  the  skin  with  the  left  hand,  begin  the  incision  at  one  mid-lateral 
aspect  of  the  limb,  at  a  level  above  the  lowest  limit  of  the  skin  incision  equal  to 
one-third  or  one-half  (as  the  case  may  be)  of  the  distance  between  the  saw-line 
and  the  lowest  limit  of  the  skin  incision — pass  vertically  downward,  through 
skin  and  fascia,  until  nearly  at  the  level  of  the  lowest  skin  incision — thence 
round  forward  into  the  line  of  lowest  skin  incision,  in  a  bluntly  rounding 
manner — and  complete  the  opposite  end  of  the  same  flap  in  the  same  manner. 
Then  make  the  opposite  flap  in  the  same  way  as  the  first  one,  corresponding 
in  shape  and  size.  Dissect  these  flaps  of  skin  and  fascia  back  to  just  beyond 
their  bases.  While  the  flaps,  and  the  muscles  also,  are  retracted,  divide  the 
more  superficial  muscles  circularly — retract  these,  and  divide  the  deeper 
muscles  similarly — making  the  usual  provision  for  the  musculo-periosteal 
covering.  The  operation  is  completed  as  in  the  ordinary  circular  ampu- 
tation— the  skin  and  fascial  flaps  being  sewed  over  the  quilted  muscles — 
the  bone  being  at  the  apex  of  a  funnel  which  is  somewhat  shallower  than 
in  the  infundibuliform  variety  of  circular  amputation  (owing  to  the  muscles 
having  been  divided  at  a  higher  level). 

Resulting  Stump. — While  not  covering  the  end  of  the  bone  with  quite 
as  thick  a  padding  of  soft  parts,  its  general  features  are  the  same  as  those 
following  the  ordinary  circular  method.  The  main  part  of  the  scar  is  terminal, 
but  its  ends  are  apt  to  be  partly  lateral  (Fig.  304,  B). 

Indications. — This  is  the  form  of  circular  amputation  most  generally 
used  and  is  adapted  to  a  greater  number  of  sites  than  the  ordinary  circular, 
or  the  cuff  modification  of  the  ordinary  method. 

Comment. — (1)  The  skin-flaps  may  be  cut  of  unequal  lengths.  (2) 
The  muscles  may  be  divided  at  one  level.  (3)  This  form  of  circular  ampu- 
tation has  largely  replaced  either  of  the  other  forms. 


OVAL  METHOD  OF  AMPUTATION. 

General  Description. — A  modification  of  the  circular  method.  The 
skin  incision  is  in  the  form  of  an  oval,  with  one  of  its  ends  more  prolonged 
and  pointed — the  soft  parts  between  skin  and  bone  being  divided  by  cutting 
from  without  inward — and  the  lips  of  the  wound  being  sutured  in  a  single 
line  parallel  with  the  long  axis  of  the  wound. 

Technic. — This  amputation  being  generally  used  in  disarticulations,  the 
upper  or  pointed  end  of  the  oval  usually  begins  just  above  a  joint-line  and 
upon  its  outer  or  anterior  aspect — the  limbs  of  the  oval  parting  at  an  angle 
sufficient  to  include  the  head  of  the  distal  bone — and  sweeping  thence  in 
a  curve  down  the  lateral  aspects  of  the  limb — passing,  finally,  transversely 
toward  each  other — to  meet  upon  the  inner  or  under  surface  of  the  distal 
limb  and  at  a  distance  beneath  the  line  of  articulation  calculated  to  furnish 
sufficient  covering  for  the  head  of  the  proximal  one  of  the  bones  making  up  the 
joint  (Fig.  305,  A).  Having  completed  the  incision  through  skin  and  fascia,  one 
of  two  courses  may  then  be  adopted ; — (a)  The  incision  may  then  be  deepened 


308 


AMPUTATIONS. 


throughout  direct  to  the  bone,  by  cutting  from  without — the  deep  incision, 
from  the  point  where  the  arms  or  limbs  of  the  oval  begin  to  diverge,  following 
the  line  of  the  retracted  skin.     This  is  the  general  method  in  all  of  the  smaller 

disarticulations  and  in  most  of  the  larger, 
(b)  Or  the  joint  may  be  opened  by  the 
more  vertical  part  of  the  incision  and,  after 
disarticulation,  the  muscles  may  be  cut 
from  within  outward,  on  a  line  with  the  re- 
tracted skin.  Having  tied  the  vessels  and 
cut  the  nerves  and  tendons  short,  the  wound 
is  sutured  in  its  long  axis  (Fig.  307,  B). 

Resulting  Stump.— The  end  of  the 
bone  is  very  fully  covered  except  where 
the  head  or  articular  end  of  the  proximal 
bone  is  disproportionately  large.  The  scar 
is  termino-lateral  (Fig.  307,  B). 

Indications. — A  form  of  amputation 
generally  used  for  disarticulating  a  limb 
from  the  trunk,  or  a  smaller  limb  from 
a  larger  limb.  The  method  admits  of 
first  opening  the  joint  for  investigation 
before  finally  deciding  upon  amputation — 
and  it  also  admits  of  securing  the  vessels 
before  removing  the  limb. 

Comment. — The   suture-line   may  run 
antero-posteriorly   in    one     straight    line — 
or  the  free,    lower  convex   border   of   the 
flap  may    be    turned    over    and    sutured 
to  the  upper  angular  concavity  of  the  wound. 


Fig. 305.— Oval  Mkthod  of  Ampi 
TATion  : — A,  Form  and  position  of  oval 
B,  Resulting  suture-line. 


RACKET  METHOD  OF 
AMPUTATION. 

General  Description. — 
A  modification  of  the  cir- 
cular method.  The  same, 
in  principle,  as  the  oval  am- 
putation— with  the  addition 
of  a  longitudinal  vertical  cut 
prolonged  from  the  apex  of 
the  oval  forming  the  "  han- 
dle of  a  racket"  —  thus 
giving  a  better  exposure  of 
joints  without  sacrifice  of 
tissue  and  securing  a  better 
covering  for  the  bone  in  the 
upper  part  of   the   wound. 

Technic.  —  Practically 
similar  to  the  oval  amputa- 
tion, except  that  the  queue 
of  the  racket  begins  con- 
siderably farther  back  over 


Figs.  306  and  307.— Racket  Method  of  Amputation: — A 
Form  and  position  of  incision  ;   B,  Resulting  suture-line. 


AMPUTATION  BY  SINGLE  FLAP  OF  SKIN  AND  MUSCLES.  309 

the  head  of  the  proximal  bone  forming  the  joint — and  along  this  single 
straight  line  the  knife  travels  some  distance  before  the  arms  of  the  racket 
begin  to  diverge.  After  the  beginning  of  the  divergence  of  the  limbs  of  the 
racket,  the  operation  is  completed  as  in  the  oval  operation  (Fig.  306,  A). 

Resulting  Stump. — More  satisfactory  covering  is  secured  by  the  racket 
than  by  the  oval  method  of  amputating.  The  scar  is  termino-lateral  (Fig. 
307,  B). 

Indications. — Disarticulations  of  the  shoulder-  and  hip-joints,  and  of 
the  digits  from  the  hand  and  foot  (especially,  in  the  latter  instances,  where 
a  metatarsal  or  metacarpal  bone  is  removed  with  the  digit).  As  in  the  oval 
method,  but  to  a  much  greater  extent,  does  the  racket  method  admit  of  a  pre- 
liminary examination  of  the  joint  through  the  vertical  portion  of  the  incision, 
before  deciding  upon  amputation.  The  vessels  may  also  be  secured  before 
entirely  separating  the  limb.     The  muscles  in  the  stump  are  better  preserved. 

Comment. — (1)  The  queue  of  the  racket  should  be  placed,  if  possible, 
over  an  intermuscular  septum  and  be  deepened  in  the  septum.  (2)  Ampu- 
tation by  a  T-shaped  incision  is,  practically,  a  form  of  racket  incision.  (3) 
The  suture  line  may  run  antero-posteriorly  (or  from  the  outer  to  the  inner 
aspect  of  the  part),  which  is  to  be  preferred.  Or  the  upper  portion  of  the 
queue  may  be  sutured  in  this  manner  and  the  lower  convex  portion  of  the 
flap  brought  up  and  sutured  to  the  angular  concavity  formed  by  the  di- 
vergence of  the  lateral  limbs  of  the  racket. 


FLAP  METHODS  OF  AMPUTATING. 

(a)  Single  Flap  of  Skin  and  Muscles; — (b)  Single  Flap  of  Skin; — (c) 
Equal  Flaps  of  Skin  and  Muscles; — (d)  Equal  Flaps  of  Skin; — (e)  Unequal 
Flaps  of  Skin  and  Muscles; — (f)  Unequal  Flaps  of  Skin; — (g)  Elliptical 
Method; — (h)  Unequal  Rectangular  Flaps  of  Skin  and  Muscle. 


AMPUTATION  BY  SINGLE  FLAP  OF  SKIN  AND  MUSCLES. 

General  Description. — A  method  of  amputating  whereby  the  stump 
is  covered  with  a  single  flap  derived  from  one  aspect  of  a  limb — and  consists 
of  skin,  fascia,  and  muscles.  Such  an  amputation  involves  the  maximum 
sacrifice  of  bone. 

Technic. — Having  fixed  upon  the  saw-line  (or  line  of  disarticulation), 
a  point  is  determined  upon  below  this  line,  and  on  that  aspect  of  the  limb 
which  is  to  furnish  the  flap,  which  will  represent  a  distance  below  the  saw- 
line  equivalent  to  i|  diameters  of  the  limb  at  the  saw-line.  A  flap  is  then 
marked  out  with  a  base  equal  in  width  to  a  half-circumference  of  the  limb 
at  the  saw-line,  and  a  length  equal  to  i|  diameters  of  the  limb  at  that  line. 
(Fig.  308,  A).  Grasping  the  limb  as  in  the  ordinary  circular  amputation,  the 
knife  is  entered  at  the  far  upper  end  of  the  base  of  the  flap,  at  a  right  angle  to 
the  skin — and  passes  vertically  down  the  mid-axis  of  the  limb  to  near  the  lower 
limit  of  the  flap — where  it  forms  a  squarely  or  bluntly  rounded  corner  to  the  flap 
— thence  passes  transversely  along  the  lower  limit  of  the  flap — and  completes 
the  opposite  limb  of  the  flap  symmetrically  with  the  first  limb.  This  incision 
passes  through  skin  and  fascia.  When  this  integumentary  flap  has  retracted, 
the  muscles  are  cut  obliquely  on  a  line  with  its  retracted  edges,  so  directing 
the  knife  as  to  bluntly  bevel  the  muscular  portion  as  the  knife  cuts  its  way 


3io 


AMPUTATIONS. 


from  without  inward  and  upward.  This  incision  passes  obliquely  through  all 
the  muscles  and  is  planned  to  come  down  upon  the  bone  at  a  distance  beneath 
the  saw  dine  equivalent  to  a  good  diameter  of  the  bone  at  the  saw-line,  thus 
providing  for  a  musculo-periosteal  covering.  The  knife  is  then  carried  through 
the  periosteum  so  as  to  form  a  musculo-periosteal  flap  with  a  base  of  half 
the  bone  at  the  sawdine  and  a  length  of  once  the  diameter.  The  musculo- 
periosteal  covering  is  then  detached  back  to  the  saw-line.  Divide  the  hitherto 
undisturbed  soft  parts  on  the  opposite  side  of  the  limb  by  a  circular  sweep 
of  the  knife — passing  through  the  skin  and  fascia  of  the  half-circumference 


Figs. 308  and  309— Amputation  by  Single  Flap  of  Skin  and  Muscle  : — A,  Form  and  position  of 
incisions  ;  B,  Resulting  suture-line. 


a  little  below  the  level  of  the  base  of  the  single  flap — and  through  the  muscles 
on  a  level  with  the  base  of  that  flap,  including  the  periosteum.  Retract  all 
the  soft  parts  on  the  proximal  side  of  the  saw-line  and  divide  the  bone.  Suture 
the  musculo-periosteal  flap  over  the  bone,  the  free  edge  of  the  periosteal 
flap  being  sutured  to  the  half-circumference  of  the  opposite  aspect  of  the 
periosteum.  Quilt  the  lateral  and  terminal  aspects  of  the  cut  muscles  in  the 
flap  with  the  transversely  cut  ends  of  the  muscles  on  the  opposite  side  of  the 
limb.  Suture  the  terminal  and  lateral  aspects  of  the  skin  of  the  flap  tc  the 
transversely  divided  skin  of  the  opposite  side. 

Resulting  Stump. — The  stump  is  at  first  well  covered  with  muscle — 
and,  when  this  atrophies,  by  the  replacing  fibrous  tissue.  The  scar  is  lateral 
(Fig.  309,  B). 


AMPUTATION  BY  EQUAL  FLAPS  OF  SKIN  AND  MUSCLE.  311 

Indications. — Cases  of  injury  so  destroying  the  soft  parts  as  to  leave 
those  of  but  one  aspect  available.  Also  in  such  cases  as  Farabeuf's  amputa- 
tion of  the  upper  third  of  the  leg  by  a  single  external  flap  of  skin  and  muscles, 
or  Dubreuil's  disarticulation  at  the  wrist  by  a  single  external  flap  of  skin 
and  muscles. 

Comment. — (1)  In  all  flaps,  skin  must  be  longer  than  muscle.  (2) 
There  is  sometimes  an  excess  of  muscle  in  a  flap,  part  of  which  should  be 
removed  in  the  process  of  beveling — but  a  fully  muscled  flap  is  generally 
desirable.  (3)  A  flap  of  skin  and  muscle  is  more  apt  to  live  and  makes  a 
better  covering  than  one  of  skin  alone.  (4)  While  the  muscle  tissue  as  such 
may  not  remain  in  the  tissues  of  a  stump,  the  muscle-fibers  undergoing 
atrophy,  yet  the  fibrous  tissue  matting  and  padding  together  of  the  parts 
is  left  in  its  place.  (5)  A  single  flap  requires  the  maximum  sacrifice  of  limb, 
one  side  of  the  limb  furnishing  the  entire  covering  and  the  bone  being  con- 
sequently divided  at  a  higher  level. 


AMPUTATION  BY  SINGLE  FLAP  OF  SKIN. 

General  Description. — The  features  of  this  operation  are  practically 
the  same  as  those  of  the  amputation  by  a  single  flap  of  skin  and  muscles, 
except  that  the  covering  here  consists  entirely  of  skin. 

Technic. — Having  incised  through  skin  and  fascia,  this  integumentary 
flap  is  dissected  up  from  the  muscles  throughout,  including  all  overlving 
fascia,  and  is  retracted  above  the  saw-line  (or  disarticulation-line) — when 
the  bone  is  sawed  or  disarticulated,  and  the  flap  dropped  over  the  end  of 
the  limb — its  terminal  aspect  being  sutured  to  the  transversely  divided  skin 
of  the  opposite  side. 

Resulting  Stump. — -Very  thinly  covered,  but  as  the  skin  so  utilized  is 
generally  accustomed  to  pressure,  the  result  is  usually  satisfactory. 

Indications. — Such  localities  as  the  knee-joint  (disarticulation  by  a 
single  anterior  flap),  or  the  elbow-joint  (disarticulation  by  a  single  posterior 
flap). 

Comment. — (1)  As  this  method  is  generally  used  in  a  disarticulation,  a 
capsulo-periosteal  covering  may  sometimes  be  provided.  (2)  Nutrition  of 
a  single  flap  of  skin  and  muscle  is  more  difficult  to  maintain  than  in  the  more 
ordinary  methods — and  the  nutrition  of  a  flap  of  skin  alone  is  even  harder. 
(3)  Skin-flaps  are  more  used  now  than  formerly  because,  owing  to  rarer 
suppuration,  their  vitality  can  be  more  counted  upon. 


AMPUTATION  BY  EQUAL  FLAPS  OF  SKIN  AND  MUSCLE. 

General  Description. — Coverings  for  the  stump  are  gotten  from  two 
opposite  aspects  of  the  limb  in  the  form  of  two  flaps  composed  of  all  the 
soft  parts  covering  the  limb — having  equal  bases  and  lengths — and  the 
allowance  of  skin  being  sufficiently  in  excess  to  well  cover  the  muscles. 

Technic. — The  preliminaries  being  the  same  as  in  the  ordinary  circular 
amputation,  two  flaps  are  marked  out,  each  having  a  width  of  base  equal 
to  the  half-circumference  at  the  saw-line  and  a  length  equal  to  three-fourths 
of  the  diameter  of  the  limb  at  that  same  line  (Fig.  310,  A).  With  a  large  scal- 
pel, incise  along  the  outlined  flaps,  passing  through  skin  and  connective  tissue. 
When  these  integumentary  flaps  have  retracted,  proceed  to  form  the  remainder 
of  the  flaps — cutting  obliquely  along  the  margin  of  the  retracted  skin,  in  such 


312 


AMPUTATIONS. 


a  manner  that  the  flaps  will  be  bluntly  (not  thinly)  beveled,  directing  the 
knife  so  that  the  beveling  will  be  greatest  (though  not  thin  even  here)  at  the 
tip,  and  thickest  toward  the  base — and  coming  down  upon  the  bone,  or  bones, 
a  distance  below  the  saw-line  equal  to  a  full  diameter  of  the  bone  (or  of  the 
bigger  bone)  to  allow  for  musculo-periosteal  covering.  At  this  level  make 
a  circular  cut  around  the  bone  through  the  periosteum  with  a  heavy  knife 
— detach  the  musculo-periosteal  covering  of  the  bone  upward  to  the  saw-line 
— retract  the  soft  parts — divide  the  bone — suture  the  musculo-periosteal 
covering— quilt  the  muscles — and  suture  the  skin. 

Resulting  Stump. — As  a  rule,  excellently  covered  by  substantial  tissues. 
The  scar  is  termino-lateral  (Fig.  311,  B). 


Figs. 310  and  31 1.— Amputation  by  Equal  Mixed  Flaps: — A,  Form  and  position  of  incisions;  B 

Resulting  suture-line. 

Indications. — In  the  continuity  of  limbs  (between  joints)  where  the 
bone  or  bones  are  equally  covered  with  soft  parts. 

Comment. — (1)  The  simplest  form  of  making  double  flaps  is  by  two 
vertical  incisions  down  the  opposite  sides  of  what  has  been  begun  as  a  circular 
method.  (2)  One  flap  may  be  cut  from  without  inward,  and  the  other  by 
transfixion.  (3)  In  very  muscular  limbs  it  makes  the  meeting  of  skin  over 
muscles  easier  if  about  2.5  cm.  (1  inch)  of  skin  and  fascia  are  dissected  up 
from  the  muscle,  after  marking  out  and  dividing  the  skin  and  fascia,  and 
then  cutting  the  muscles  to  the  bone  in  a  beveling  fashion. 


AMPUTATION  BY  EQUAL  FLAPS  OF  SKIN. 

This  operation  is  the  same,  in  general  contour  and  dimensions  of  the 
flaps,  as  the  last — except  that  the  covering  here  consists  of  skin  only. 


AMPUTATION  BY  UNEQUAL  FLAPS  OF  SKIN  AND  MUSCLES.       313 

Technic. — Having  incised  through  skin  and  fascia,  upon  the  same  lines 
as  in  the  last  form  of  amputation,  the  two  equal  flaps  of  integumentary  tissues 
are  dissected  up  to  a  level  below  the  saw-line  which  will  allow  of  providing 
a  musculo-periosteal  covering — at  this  level  the  muscles,  after  retracting  the 
skin,  are  circularly  divided  down  to  the  bone — this  circular  incision  is  con- 
tinued, on  the  same  level  (one-half  diameter  of  the  bone  below  the  saw-line) 
around  and  through  the  periosteum — the  periosteum  is  then  retracted,  with 
the  overlying  muscles,  to  the  saw-line— and  the  bone  divided.  The  musculo- 
periosteal  covering  is  then  sutured  over  the  bone — and  the  skin  margins 
sutured  together. 

Resulting  Stump. — Thinly  covered,  no  muscle  being  present — but  is 
generally  satisfactory  in  the  localities  where  adopted.  The  scar  is  termino- 
lateral. 

Indications. — Where  a  satisfactory  muscle  covering  is  hard  to  secure — 
as  in  the  lower  third  of  the  forearm  and  leg  and  in  the  ringers — the  tendons 
predominating  in  these  localities. 


Figs.  312  and  313.— Amputation  by  Unequal  Mixed  Flaps:— A,  Form  and  position  of  incisions, 
and  line  of  bone-section  ;  B,  Resulting  suture-line. 


AMPUTATION  BY  UNEQUAL  FLAPS  OF  SKIN  AND  MUSCLES. 

General  Description. — Coverings  are  furnished  by  two  flaps  taken 
from  opposite  aspects  of  the  limb — each  flap  having  a  base  equal  to  one- 
half  circumference  of  the  limb  at  the  saw-line — and  one  flap  having  a  length 
greater  than  the  other.  One  flap  usually  furnishes  one-third  or  two-thirds 
of  the  covering,  and  the  opposite  flap  two-thirds  or  one-third — the  longer 


314  AMPUTATIONS. 

flap  generally  coming  from  that  aspect  of  the  limb  most  thickly  muscled. 
The  flaps  may  bear  any  relation  to  each  other  in  relative  length — but  the 
two  flaps  combined  furnish  a  covering  equivalent  to  i|  diameters  of  the 
limb  at  the  saw-line. 

Technic. — This  amputation  is  identical,  except  as  to  the  length  of  the 
flaps,  with  the  amputation  by  equal  flaps  of  skin  and  muscle  (Fig.  312,  A). 

Resulting  Stump. — Generally  well  covered.  With  scar  either  entirely 
lateral  or  partlv  lateral  and  partly  terminal,  dependent  upon  the  preponderance 
of  one  flap  over  the  other  (Fig.  313,  B). 

Indications. — Thigh  and  arm  throughout,  and  upper  parts  of  forearm 
and  leg. 

AMPUTATION  BY  UNEQUAL  FLAPS  OF  SKIN. 

General  Description. — Coverings  are  of  skin  and  fascia  alone  and 
are  furnished  by  the  two  opposite  aspects  of  the  limb,  in  the  form  of  two 
flaps  having  equal  bases  and  unequal  lengths.  This  amputation  is  identical 
throughout  with  the  amputation  by  equal  flaps  of  skin,  except  as  to  the 
length  of  the  flaps. 

AMPUTATION    BY   UNEQUAL   RECTANGULAR    FLAPS    OF    SKIN    AND 

MUSCLES. 

TEALE'S   METHOD. 

General  Description. — The  general  method  of  performing  this  operation 
is  similar,  in  principle,  to  that  for  amputation  by  unequal  flaps  of  skin  and 
muscles — with  the  exception  that  the  flaps  are  rectangular  (instead  of  rounded) 
and  of  special  dimensions. 

Technic. — Having  fixed  upon  the  saw-line,  two  flaps  are  marked  out, 
having  their  bases  at  that  line  and  extending  downward  as  described  below. 
Find  the  circumference  of  the  limb  at  the  saw-line.  The  longer  flap  is  to 
have  its  length  and  its  breadth  equal  to  a  half-circumference  at  the  saw-line. 
The  shorter  flap  is  to  be  one-fourth  of  the  length  of  the  longer,  and  its  breadth 
equal  to  the  remaining  half-circumference  at  the  saw-line.  The  longer  flap 
should  be  of  the  same  width  all  the  way  down.  The  shorter  flap  will  have 
a  width  at  its  free  end  equal  to  very  nearly  a  half-circumference  of  the  limb 
at  the  level  where  it  terminates  (as  that  level,  in  the  case  of  the  shorter  flap, 
is  so  short  a  distance  beneath  the  saw-line)  (Fig.  314,  A).  Having  marked  out 
these  flaps,  which  should  be  accurately  measured,  the  vertical  parts  of  the  inci- 
sion should  be  made  from  above  downward,  connected  at  their  lower  ends  by 
the  transverse  incision  which  marks  the  limit  of  the  longer  flap,  and  by  another 
transverse  incision  across  the  opposite  half-circumference  of  the  limb,  at  the 
proper  level,  marking  off  the  lower  limit  of  the  shorter  flap.  These  incisions 
at  first  involve  skin  and  fascia  only.  When  retraction  has  occurred  (making 
a  difference  in  the  transverse  incisions  only),  they  are  deepened  throughout 
to  the  periosteum.  The  vertical  limbs  of  the  flaps  are  first  cut  to  the  peri- 
osteum— then  the  lower  transverse  limit  of  the  longer  flap,  which  is  dissected 
up  above  the  lower  limit  of  the  shorter  flap — which  in  turn  is  cut  transversely 
to  the  periosteum  and  dissected  up.  When  a  level  below  the  saw-line  is 
reached  equal  to  a  half-diameter  of  the  bone  at  the  saw-line,  a  circular  incision 
is  made  through  the  periosteum  and  a  musculo-periosteal  covering  raised. 
All  the  soft  parts  are  now  retracted  above  the  saw-line  and  the  bone  divided. 
The  musculo-periosteal  covering  is  sutured.     The  longer  flap  is  bent  over 


ELLIPTICAL  METHOD  OF  AMPUTATION. 


315 


the  end  of  the  bone — its  end  being  sutured  to  the  end  of  the  shorter  flap — 
the  lateral  aspects  of  the  shorter  flap  are  sutured  to  the  lateral  aspects  of  the 
longer — and  the  lateral  aspects  of  the  bent-over  portion  of  the  long  flap  are 
sutured  to  the  contiguous  lateral  aspects  of  the  unbent  portion  of  the  long 
flap.  The  muscles  are  quilted  prior  to  suturing  the  skin.  The  part  is  well 
supported  by  splint,  with  only  light  pressure  over  the  bent  longer  flap. 

Resulting  Stump. — An  H -shaped  cicatrix  is  formed  upon  the  aspect 
of  the  limb  furnishing  the  shorter  flap.  The  end  of  the  bone  is  well  covered 
when  the  long  flap  contains  a  preponderance  of  muscle — less  well  covered 
when  containing  a  preponderance  of  tendons  (Fig.  315,  B). 


Figs.  314  and  315.— Amputation  by  Unequal  Mixed  Rectangular  Flaps  :— A,  Form  and  position 
of  incisions,  and  line  of  bone-section  ;  B,  Resulting  suture-line. 


Indications. — In  the  lower  part  of  the  leg  (where  the  longer  flap  is  taken 
from  the  anterior  aspect) — and  sometimes  in  the  lower  forearm  (where  the 
longer  flap  comes  from  the  posterior  aspect). 


ELLIPTICAL  METHOD  OF  AMPUTATION. 

General  Description. — This  is  not  a  distinct  form  of  amputation.  It 
may  be  considered  a  variety  of  the  circular  method  (an  oblique  circular), 
or,  equally,  a  variety  of  single-flap  amputation — and  may  be  held  in  an 
intermediate  position.  It  is  circular,  as  to  skin  incision;  and  flap,  as  to  its 
manner  of  covering  the  stump  and  in  the  suturing.  The  skin  incision  is  in 
the  form  of  an  ellipse,  or  a  lozenge,  the  upper  part  of  the  ellipse  being  upon 
one  aspect  of  the  limb  and  the  lower  part  upon  the  opposite — the  lateral 
limbs  of  the  figure  crossing  the  lateral  aspects  of  the  limb  to  be  amputated. 


316 


AMPUTATIONS. 


The  idea  of  the  ellipse  is  brought  out  by  imagining  the  outline  projected  upon 
a  fiat  surface. 

Technic. — Having  fixed  upon  the  saw-line  (or  line  of  disarticulation), 
a  point  is  determined  above  this,  on,  say,  the  posterior  aspect  of  the  limb, 
which  is  just  above  the  saw-line — this  becomes  the  highest  point  of  the  ellipse. 
The  point  marking  the  lowest  point  of  the  ellipse  is  placed  upon  the  opposite 
side  of  the  limb,  at  a  distance  below  the  saw-line  equal,  approximately,  to 
i£  diameters  of  the  limb  at  the  saw-line  (as  there  is  but  this  one  source  of 
covering).  Between  these  two  points  the  lateral  limbs  of  the  ellipse  pass, 
crossing  the  lateral  aspects  of  the  limb  to  be  operated  obliquely,  from  above 
downward,  and  so  planned  as  to  give  a  well-rounded  convex  termination  of  the 
ellipse  below  to  be  brought  up  and  fitted  into  a  corresponding  concavity  above 
(Fig.  316,  A).     The  incision  first  passes  around  the  outline  of  the  ellipse, 

through  skin  and  fascia  only. 
Around  the  lower  three- 
fourths  of  the  line  of  this 
retracted  skin  and  fascia  a 
second  incision  passes  through 
the  muscles  to  the  bone.  The 
soft  parts  (skin  and  muscles) 
forming  the  lower  part  of  the 
ellipse  (the  part  that  is  to 
remain  attached  to  the  limb 
which  is  to  be  retained)  are 
now  dissected  up  from  the 
bone  to  a  point  sufficiently 
below  the  upper  limit  of  the 
ellipse  to  allow  a  musculo- 
periosteal  or  capsulo-perios- 
teal  covering  to  be  raised,  and 
then  on  up  to  just  below  the 
upper  limit  of  the  ellipse  (that 
is,  to  the  saw-line  or  line  of 
disarticulation).  This  large 
single  mass  of  soft  parts  is 
well  retracted — and  the  mus- 
cles on  that  aspect  of  the  limb 
opposite  to  the  one  furnishing 
the  muscles  in  the  elliptical 
covering  are  circularly  divided — and  the  limb  sawed,  or  disarticulated,  pre- 
serving the  periosteum  in  the  usual  way.  The  lower  convexity  of  the  ellip- 
tical flap  is  now  sutured  into  the  upper  concavity  left  by  the  part  of  the  limb 
removed — the  musculo-periosteal,  or  capsulo-periosteal,  covering  and  the 
muscles  being  treated  in  the  general  manner  by  buried  gut  sutures — and  the 
skin  wound  closed. 

Resulting  Stump. — The  ellipse  is  generally  taken  from  a  locality  which 
affords  a  plentiful  covering  for  the  extremity,  which  is  thus  well  provided  for. 
The  scar  is  lateral  (Fig.  317,  B). 

Indications. — Chiefly  used  for  disarticulations — especially  at  the  elbow 
and  wrist,  and  in  the  supramalleolar  amputation. 

Comment. — The  muscle  portion  of  the  ellipse  may  be  cut  also  by  trans- 
fixion, although,  as  usual,  less  satisfactorily. 


B 


Figs.  316  and  317.— Amputation  by  the  Ellipticai 
Method  : — A,  Form  and  position  of  incision ;  B,  Re- 
sulting suture-line. 


SELECTION    OF    AMPUTATION    METHOD.  317 

OSTEOPLASTIC  AMPUTATIONS. 

Description. — An  osteoplastic  operation,  in  general,  consists  in  the  approx- 
imation of  fresh  sections  of  bone  to  each  other,  for  the  purpose  of  bringing 
about  union  between  their  opposed  surfaces.  In  an  osteoplastic  amputation, 
some  portion  of  a  distal  bone  is  raised  in  the  form  of  an  osseoperiosteal  flap, 
adherent  to  its  neighboring  soft  parts,  and  applied  to  the  sawed  aspect  of  the 
proximal  bone.  In  performing  osteoplastic  amputations  a  special  saw  should 
be  provided — a  bow-saw  with  a  scroll-blade  of  strong,  narrow,  thin  metal, 
which  can  be  turned  in  any  direction  while  in  the  act  of  making  bone-sections, 
such  as  the  Helferich  pattern  of  saw.  (A  saw  for  osteoplastic  work  is  now 
on  trial  which  is,  practically,  a  Gigli  saw  held  in  a  bow-handle.)  The  freshened 
surfaces  of  bone  are  variously  held  in  contact — the  edges  of  the  surrounding 
periosteum  may  be  sutured  together — the  bone  surfaces  may  be  wired,  pegged, 
or  nailed — or  the  bone  aspects  may  be  held  in  apposition  (especially  where 
there  is  no  strong  counter-pull)  by  the  simple  suturing  of  the  surrounding 
soft  parts  together. 

Objects  of  the  Osteoplastic  Method  of  Amputation. — (i)  Closure 
and  protection  of  the  medullary  canal; — (2)  Securing  of  a  solid  end  of  bone 
to  meet  pressure — brought  about  by  the  rounding  off  of  the  section  of  bone 
whose  surface  becomes  united  with  the  end  of  the  main  bone; — (3)  Avoidance 
of  adhesions  between  sawed  bone  and  soft  coverings — and,  by  retaining  the 
mobility  of  these  parts,  thereby  lessening  the  chance  of  neuralgia  and  ulcera- 
tion in  the  stump. 

Application  of  the  Osteoplastic  Method  of  Amputation. — Up  to  the 
present  time  the  chief  sites  at  which  this  method  of  amputation  has  been 
used  have  been  in  the  lower  extremity — that  is,  where  pressure-bearing  stumps 
are  sought.  The  following  are  examples  of  the  osteoplastic  method  of  ampu- 
tation;— Pirogoff's  osteoplastic  amputation  of  the  foot  (page  415) — Lister's 
modification  of  Carden's  transcondyloid  amputation  of  the  thigh  (page  440) — 
Gritti-Stokes's  supracondyloid  amputation  of  the  thigh  (page  441) — Sabane- 
jeff's  amputation  of  the  thigh  (Figs.  367,  368,  369) — Bier's  amputation  of  the 
leg  (Figs.  360,  361,  and  362). 

IRREGULAR  METHODS  OF  AMPUTATION. 

This  is  a  special  feature  of  modern-day  surgery.  Formerly  amputations 
were  done  upon  hard  and  fast  lines.  Now  there  is  a  marked  tendency  to 
allow  the  method  of  amputation  to  be  determined  by  the  special  features 
and  need  of  the  individual  case — and,  as  a  result,  irregular  amputations 
are  more  commonly  done,  which,  while  accomplishing  the  general  indica- 
tions, are  not  bound  by  any  set  rule,  shape,  or  measurement.  The  practical 
surgeon,  therefore,  should,  on  common-sense  ground,  adapt  his  method  of 
amputation  to  the  case  in  point,  rather  than  be  bound  by  any  fixed  form  of 
amputation.  The  greatest  field  for  irregular  forms  of  amputation  is  in 
cases  of  injury  and  deformity,  rather  than  in  disease. 

SELECTION  OF  AMPUTATION  METHOD. 

Many  considerations  enter  into  the  determination  of  the  best  method 
of  amputation  in  a  particular  case — and  the  choice  should  be  given  to  that 
method  which  promises  to  fulfil  the  greatest  number  of  the  following  features; — 

Characteristics  of  Good  Amputation  Methods. — (1)  Minimum  sacri- 


318  AMPUTATIONS. 

fice  of  healthy  tissue — (2)  Best  permanent  bone-covering — (3)  Small  wound 
area — (4)  Good  blood-supply  to  stump — (5)  Favorably  placed  cicatrix — (6) 
Efficient  drainage — (7)  Simplicity  of  method — (8)  Vessels  and  muscles  cut 
transversely — (9)  Possibility  of  getting  satisfactory  musculo-periosteal  covering 
— (10)  Ease  of  exposing  bone  at  saw-line — (n)  Ease  of  bringing  soft  parts 
together  over  bone  without  tension — (12)  Adjustability  of  artificial  limb— 
(13)  Largest  range  of  adaptability — (14)  Shapeliness  of  resulting  stump— 
(15)  Rapidity  of  method. 

Comment. — Circumstances  may  determine  the  selection  of  an  ampu- 
tation method  known  in  advance  not  to  be  the  best — for  instance,  owing 
to  the  increased  mortality  in  approaching  the  trunk,  a  limb  may  be  removed, 
in  a  case  where  the  vitality  of  the  patient  demands  that  every  chance  be 
given  him,  at  a  level  which,  while  increasing  his  chances  for  life,  may  not 
furnish  the  best  covering.  Again,  in  amputating  about  the  hand,  it  may 
conserve  the  interest  of  the  patient  better  to  be  satisfied  with  even  a  partial 
flap  and  allow  the  remainder  to  heal  by  granulation,  rather  than  remove 
an  additional  \  cm.  (\  inch)  of  an  important  finger.  Rapidity  of  method 
used  to  be  the  chief  consideration,  but  is  now  the  last  in  importance,  except 
in  special  instances — other  considerations  taking  precedence — the  operation 
being  done  with  deliberation  and  precision. 

Features  of  the  Circular  Method  of  Amputating. — (1)  Minimum 
sacrifice  of  bone  and  soft  parts  of  any  method. — (2)  Bone  especially  well 
covered  in  the  infundibuliform  variety.  Conical  stump  sometimes  follows 
retraction,  especially  in  the  cuff  and  modified  varieties  of  the  circular. — (3) 
Smallest  wound  area  of  any  method. — (4)  Tissues  of  stump  well  supplied 
with  blood. — (5)  Cicatrix  terminal. — (6)  Efficient  drainage  when  sutured 
antero-posteriorly. — (7)  Most  simple  of  any  method. — (8)  Main  vessels  and 
muscles  cut  transversely. — (9)  Musculo-periosteal  covering  well  provided. 
— (10)  Exposure  of  bone  at  saw-line  not  always  easy. — (n)  Not  always 
easy  to  bring  soft  parts  together  over  bone. — (12)  Terminal  cicatrix  favorable 
for  hollow  artificial  limbs;  unfavorable  for  solid  limbs  of  lower  extremity. — 
(13)  Unfavorable  for  amputation  following  injury  involving  the  aspects  of 
the  limb  to  unequal  heights. — (14)  Somewhat  greater  tendency  to  become 
conical. — (15)  Most  rapid  of  any  method. 

Features  of  the  Flap  Method  of  Amputating. — (1)  Greater  sacrifice 
of  bone  and  soft  tissues  (especially  in  unequal  flaps). — (2)  Coverings  of  bone 
can  be  more  largely  regulated  to  suit  demand.  Conical  stumps  less  apt  to 
follow  than  after  the  cuff  and  modified  forms  of  the  circular. — (3)  Greater 
wound  area. — (4)  In  long  flaps  the  blood-supply  may  not  be  so  satisfactory. — 
(5)  Terminal  or  termino-lateral  cicatrix — can  be  planned  as  desired. — (6) 
Drainage  as  efficient  as  in  the  circular  if  the  flaps  be  lateral.  Not  so  efficient 
if  the  flaps  be  antero-posterior. — (7)  Not  so  simple  as  the  circular. — (8) 
Muscles  divided  obliquely;  vessels  also,  and  latter  may  be  split  up. — (9) 
Musculo-periosteal  covering  well  provided. — (10)  Bone  easily  exposed  at 
the  saw-line. — (n)  Flaps  easily  brought  together  over  bone. — (12)  Terminal 
cicatrix  favorable  for  any  hollow  artificial  limb.  Terminal  portion  of  termino- 
lateral  cicatrix  pressed  upon  by  solid  lower  limb,  and  lateral  portion  pressed 
upon  by  any  hollow  artificial  limb. — (13)  Favorable  for  amputations  following 
injury  involving  the  aspects  of  the  limbs  unequally.  Adaptable  to  any  part 
of  any  limb. — (14)  Stump  apt  to  be  more  shapely  than  that  of  the  circular. — 
(15)  Less  rapid  than  the  circular. 

Circumstances  Influencing  Death-rate  After  Amputation. — The 
death-rate  is  greater; — (1)  The  nearer  the  amputation  is  to  the  trunk — (2) 


QUALITIES    OF    A    GOOD    STUMP.  319 

In  the  lower  than  in  the  upper  limbs — (3)  Fur  injury  than  for  disease — (4) 
In  men  than  in  women — (5)  Between  the  ages  of  five  to  fifteen  than  before 
or  after.  In  a  tabulation  of  3600  amputations  performed  by  himself,  Estes 
has  found  that,  as  far  as  the  upper  extremity  is  concerned,  there  is  no  appreci- 
able difference  in  fatality  following  amputations  through  the  various  parts  of 
the  hand,  forearm,  and  arm,  until  the  shoulder-joint  is  reached,  where,  naturally, 
the  maximum  mortality  for  the  upper  extremity  occurs.  In  the  case  of  the 
lower  extremity,  on  the  other  hand,  there  is  an  increase  in  mortality  from  ampu- 
tations from  the  foot  upward,  as  the  lower  limb  is  ascended,  reaching  the 
maximum  for  the  whole  body  at  the  hip-joint. 

Influence  of  Age  upon  Amputations. — The  young  and  old,  especially 
if  feeble,  stand  the  actual  operation  less  well  than  those  in  the  reverse  condi- 
tions— and  also  tolerate  the  subsequent  confinement  and  apparatus  less  well. 


PRIMARY,   INTERMEDIATE,   AND   SECONDARY   AMPUTATIONS. 

In  amputations  done  for  disease  the  time  for  operation  may  be  selected 
which  will  coincide  with  the  patient's  best  condition  to  meet  the  procedure. 
Amputations  done  for  injury  are  either  Primary  (performed  immediately  after 
the  reception  of  the  injury) — Intermediate  (in  the  course  of  wound-repair) 
and  Secondary  (after  healing).  In  primary  amputations  the  operation  should 
be  done  at  once,  if  the  general  condition  of  the  patient  permit.  If  the  con- 
dition of  shock  (from  psychical  effect  and  blood  loss)  contraindicate  imme- 
diate interference,  stimulation,  intravenous  infusion,  the  application  of  heat, 
and  the  like,  should  be  resorted  to,  and  the  limb  removed  during  the  reaction- 
ary period  (generally  within  thirty-six  hours).  If  the  condition  of  shock  is 
thought  to  be  kept  up  by  the  damaged  limb,  amputation  should  be  done  at 
once,  the  above  measures  of  revival  being  maintained  the  while. 


THE    AMPUTATION    STUMP. 
QUALITIES  OF  A  GOOD  STUMP. 

Firm  in  consistency — well  covered — insensitive — of  regular  and  symmetrical 
contour.  The  death-rate  and  the  quality  of  the  stump  determine  the  success 
of  any  form  of  amputation.  The  following  features  are  characteristic  of  a 
good  stump — and  also  indicate  the  changes  which  follow  successful  ampu- 
tation:— 

Skin. — Not  adherent,  except  at  cicatrix.  Capable  of  withstanding  (and, 
preferably,  accustomed  to  withstand)  pressure.  Plentifully  supplied  with 
blood. 

Muscles. — The  muscles  of  a  stump  are  not  retained  as  such — the  muscle 
tissue  disappears  in  greater  part  and  is  replaced  by  fibrous  tissue.  Ex- 
ceptionally some  muscle  tissue  remains  and  continues  to  function.  The 
mass  of  fibrous  tissue  which  replaces  it,  however,  serves  a  useful  purpose 
in  padding  over  the  end  of  the  bone.  In  brief,  muscle  tissue  tends  to  de- 
crease— and  fibrous  tissue  to  increase.  Muscles  and  tendons  either  become 
incorporated  in  the  cicatrix,  form  new  attachments  to  bone,  or  retract  out 
of  the  way. 

Bone. — The  ends  of  the  bones  become  rounded  and  the  medullary 
canals  closed  bv  fibrous  tissue.     The  end  of  the  bone  may  either  dwindle 


320  AMPUTATIONS. 

and  atrophy,  or  the  periosteum  may,  exceptionally,  deposit  an  excess  of  bone. 
The  shaft  of  the  bone  in  an  amputated  limb  also  atrophies  somewhat. 

Cartilage. — Following  a  disarticulation,  the  articular  cartilage  left 
atrophies  and  sometimes  entirely  disappears. 

Nerves. — Also  atrophy  to  a  greater  or  less  extent.  The  ends  generally 
become  bulbous,  but  give  no  trouble  unless  they  become  adherent  to  bone 
or  cicatrix. 

Vessels. — Share  in  the  general  atrophy,  and  dwindle  to  a  size  com- 
mensurate with  the  parts  to  be  supplied.  Ligated  trunks  become  obliterated 
to  their  nearest  branch.     Collateral  circulation  is  established. 


CHARACTERISTICS  OF  A  BAD  STUMP. 

In  contradistinction  to  the  general  qualities  of  a  good  stump,  a  bad  stump 
may  be  flaccid,  scantily  covered,  sensitive,  of  irregular  contour — and  may 
be  further  characterized  by  the  following  conditions: — 

Skin. — Thin,  scanty,  tightly  drawn,  adherent,  puckered — cold  or  purple 
from  improper  circulation— ulcerated  from  the  same  cause,  or  from  trophic 
changes — involved  with  corns — and  may  become  malignant. 

Muscles. — See  the  changes  mentioned  in  the  last  section. 

Connective  Tissue. — Bursae  may  form. 

Bone. — Osteitis,  periosteitis,  and  necrosis  may  occur. 

Two  special  forms  of  bad  stump  are  met: — 

Painful  Stump. — May  be  due  to  osteitis  or  periosteitis— but  is  generally 
due  to  compression  of  the  nerve.  The  nerve  may  be  directly  pressed  upon 
by  new  bone  or  fibrous  tissue — may  be  stretched  over  the  stump — or  may 
be  the  seat  of  neuritis.  The  end  of  a  painful  nerve  is  generally  bulbous — 
but  not  necessarily — for  often  normal-looking  nerve-ends  are  sensitive,  and 
bulbous  ones  non-sensitive. 

Conical  Stump. — The  end  of  the  bone  forms  the  apex  of  a  cone  which 
may  be  the  result  of  one  or  more  of  the  following  causes — (i)  Flaps  cut  too 
short — or  bone  too  long. — (2)  Sloughing  or  suppuration  of  the  soft  parts. — 
(3)  Post-operative  contraction  of  muscles. — (4)  Growth  of  the  bone  from 
an  active  epiphysis  in  the  young. 

Comment. — Unfavorable  changes  are  less  apt  to  occur  in  case  of  primary 
union  than  in  the  reverse. 


CONDITIONS  INFLUENCING  VITALITY  OF  STUMP. 

(1)  Blood-supply — full  or  scant,  impeded  or  unobstructed  by  position 
of  stump-covering. — (2)  Compression  by  bandage,  dressing  or  splint. — (3) 
Tightness  and  unnatural  position  of  flaps,  as  compared  with  easy  and  natural 
position. — (4)  Full  allowance  of  skin  and  non-separation  of  skin  from  muscle, 
as  compared  with  the  reverse. — (5)  Long  and  loose  tendons  and  aponeuroses. 
(6)  Too  rapid  sawing  of  bone. — (7)  Finally,  site  of  amputation,  manner  of 
performing  the  operation,  prior  local  condition,  prior  constitutional  con- 
dition, and  after-treatment — all  influence  the  vitality  of  the  stump. 

Comment.— The  chief  dangers  to  be  avoided,  are — over-tension  in  the 
skin  and  muscle  covering — insufficient  blood-supply — rough  projections  of 
bone  and  laceration  of  the  parts — and  inclusion  of  nerves  in  the  cicatrization. 

Immediate  Complications  of  Amputations. — Spasm  of  muscles;  hemor- 
rhage from  nutrient  artery  of  bone,  and  general  post-operative  hemorrhage. 


FUNCTION    OF    AMPUTATION    STUMPS.  32 1 

CONTRACTILITY  OF  THE  TISSUES  OF  THE  STUMP. 

Skin. — The  average  contractility  of  the  skin  is  equivalent  to  about  one- 
third  of  its  length.  It  is  most  contractile  where  thinnest — where  the  sub- 
cutaneous tissue  is  least — where  its  attachment  to  underlving  parts  is  least 
— where  it  is  least  stretched  by  movements — and  where  the  process  of  healing 
has  been  longest.     It  is  least  contractile  where  the  opposite  conditions  exist. 

Muscles. — The  extremes  of  muscular  contractility  vary  from  a  slight 
separation  of  divided  parts  up  to  a  retraction  of  four-fifths  of  their  length. 
Contractility  is  primary,  where  it  occurs  at  the  time  of  the  operation — and 
secondary,  where  it  occurs  subsequent  to  the  operation.  Muscles  contract 
most — which  are  freest  between  origin  and  insertion — which  have  long 
fibers — and  where  the  process  of  healing  has  been  longest.  The  larger  the 
muscle,  the  greater  the  amount  left  in  the  flap,  and  the  younger  and  healthier 
the  subject,  the  greater  the  contraction.  Muscles  contract  least  where  the 
conditions  are  the  reverse  of  those  just  mentioned. 

Skin,  Fascia,  and  Muscles. — The  average  contractility  of  the  mixed 
tissues  of  a  flap,  or  covering,  is  generally  equivalent  to  about  one-third  of 
the  length  of  the  flap,  or  covering.  Additional  length,  however,  should  be 
allowed,  in  calculating  the  length  of  coverings — (1)  When  the  transverse 
section  of  the  bone  is  large  as  compared  with  the  transverse  section  of  the 
soft  parts — (2)  When  the  amputation  is  considerably  below  the  origin  of  the 
muscle  involved — (3)  When  secondary  retraction  is  expected. 


POSITION  OF  STUMP-CICATRICES. 

The  cicatrix  should  be  so  placed  as  to  be  the  least  exposed  to  pressure 
after  the  healing  of  the  wound. 

With  Reference  to  Their  Position. — Scars  may  be  Terminal — at  the 
end  of  the  stump; — Lateral — on  one  or  more  sides  of  the  stump; — Termino- 
lateral — occupying  the  end  and  side  of  the  stump. 

With  Reference  to  Their  Production. — The  following  methods  of 
amputation  produce  the  following  kinds  of  scars; — Circular  is  followed  by 
terminal  scar; — Elliptical,  by  lateral  scar,  if  the  ellipse  be  oblique,  and  terminal 
if  the  ellipse  be  nearly  horizontal; — Oval,  by  termino-lateral; — Racket,  by 
termino-lateral; — Single  flap,  by  lateral  scar; — Double  flap,  by  terminal  scar, 
if  the  flaps  be  equal,  and  lateral  if  the  flaps  be  unequal. 

Comment. — (1)  Other  things  being  equal,  that  method  of  amputation 
should  be  chosen  which  will  bring  the  scar  in  the  most  favorable  position 
for  that  particular  case — and  especially  with  reference  to  the  subsequent 
functioning  of  the  stump  and  its  adaptability  to  an  artificial  limb.  (2)  In 
amputating  in  some  situations  the  muscles  of  one  group  being  so  much  stronger 
than  those  of  another,  will  often  draw  a  scar,  terminal  at  the  time  of  opera- 
tion, much  higher  up  upon  one  aspect  than  it  will  be  drawn  on  the  opposite 
aspect.     Calculations  for  such  an  occurrence  have,  therefore,  to  be  made. 


FUNCTION  OF  AMPUTATION  STUMPS. 

In  the  Upper  Extremity. — The  chief  function  of  the  stump  in  the  upper 
extremity  is  range  of  movement  and  power  to  wield  an  artificial  limb,  rather 
than  to  bear  pressure  and  weight.     As  the  chief  pressure  of  an  artificial  limb 


322  AMPUTATIONS. 

comes  upon  the  lateral  aspects  of  the  stump,  the  scar  of  the  stump  in  the 
upper  extremity  is  best  when  terminally  placed. 

In  the  Lower  Extremity. — The  chief  function  of  the  stump  in  the  lower 
extemity  is  to  bear  pressure  and  weight.  As  the  chief  pressure  of  a  solid 
artificial  limb  comes  upon  the  end  of  the  stump,  the  scar  of  the  stump  in  the 
lower  extremity  is  best  when  laterally  placed — in  those  cases  in  which 
a  solid  artificial  limb  is  to  be  worn.  As,  however,  most  modern  artificial 
limbs  for  the  lower  extremity,  for  the  better  classes,  are  hollow,  there  is  not 
now  made  the  same  difference  as  formerly. 

The  Modern  Type  of  Artificial  Limb. — While  the  above  was  particu- 
larly true  of  the  older,  cruder  forms  of  artificial  limbs  (and  is  still  true  of  the 
peg-leg),  the  modern  forms  of  artificial  limbs  are  nearly  always  made  upon 
the  basis  of  a  light,  hollow  cone,  and  are  so  adjusted  as  to  largely  adapt 
themselves  to  the  conditions  found — and,  generally  speaking,  most  of  the 
pressure  is  of  the  lateral  aspects  of  the  stump  and  living  limb  against  the 
sides  of  the  hollow  cone  of  the  artificial  limb — so  that  pressure  is  exercised 
upon  the  lateral  aspects  of  the  living  stump  and  limb  rather  than  upon  the 
end — and  in  the  lower  as  well  as  in  the  upper  extremity. 

Comment. — A  function  of  the  stump  of  the  upper  extremity,  especially 
about  the  hand,  and  more  particularly  of  a  woman,  is  to  be  as  symmetrical 
and  shapely  as  possible,  in  the  case  of  partial  sacrifice  of  that  member.  While 
in  the  case  of  a  laborer  it  would  certainly  be  better  to  sacrifice  appearance 
to  strength  and  utility,  one  might  be  urged  to  sacrifice  strength  for  appearance 
in  the  case  of  a  woman  of  the  non-working  class. 


SITE   OF  AMPUTATION  IN  CONNECTION  WITH  THE  RESULTING 
STUMP   AND   ITS   ADAPTABILITY  TO  AN  ARTIFICIAL  LIMB. 

The  choice  of  the  site  of  amputation  is  determined  by  the  resulting  mortality 
and  the  fitness  of  the  stump  for  an  artificial  limb.  Concerning  the  effect  of 
the  amputation  site  upon  mortality,  see  Circumstances  Influencing  the  Death- 
rate  after  Amputation  (page  318). 

In  general,  the  longer  the  stump,  the  more  useful  the  limb. 

Considerable  responsibility  rests  with  the  surgeon  in  choosing  the  site  and 
technic  of  operation,  which  will  leave  the  patient  the  best  stump,  circumstances 
considered,  adaptable  to  an  artificial  limb. 

While  formerly  it  was  taught  to  save  every  fraction  of  limb  possible,  it  is 
now  regarded  as  better  for  the  patient's  interest  to  select  that  site  and  form  of 
amputation  furnishing  a  stump  best  suited  to  take  an  artificial  limb  of  the 
widest  range  of  function. 

In  planning  the  form  of  skin  covering,  it  is  to  be  remembered  that  if  the 
scar  be  not  terminal,  it  should  be  somewhat  posterior  or  lateral,  rather  than 
anterior,  as  the  movement  to  force  an  artificial  limb  forward  causes  the  appa- 
ratus to  press  upon  an  anterior  scar.  For  the  same  reasons  the  ends  of  divided 
bones  which  lie  near  the  skin,  which  is  generally  their  anterior  aspect,  should 
be  rounded,  so  as  not  to  be  pressed  by  the  false  limb. 

In  calculating  an  efficient  stump  distal  to  a  joint,  sufficient  length  below 
the  joint  must  be  provided  to  bear  upon  and  wield  or  swing  the  artificial  limb. 
Every  additional  inch  is  here  a  matter  of  importance. 

The  primary  function  of  the  upper  artificial  limb  is  for  prehension — of  the 
lower,  to  bear  weight  and  admit  of  locomotion. 


SURGICAL    ANATOMY    OF    THE    FINGERS.  323 

As  the  main  growth  in  the  length  of  the  humerus  and  femur  is  from  the 
upper  epiphysis,  amputation  through  the  shaft  of  these  bones,  in  the  young, 
will  almost  certainly  be  followed  by  a  conical  stump,  which  will  often  require 
re-amputation. 

In  the  lower  extremity  an  osteoplastic  amputation  is  preferable,  where 
feasible — especially  in  operating  for  disease,  where  a  deliberate  calculation 
can  be  made. 

The  general  tendency  of  the  day,  in  operating  about  the  foot,  is  to  regard  the 
foot  as  a  whole,  irrespective  of  joint-lines,  and  to  amputate  along  improvised 
lines  adapted  to  the  special  case. 

Classical  and  irregular  amputations  through  the  tarsus,  though  condemned 
by  artificial-limb  makers,  and  though  supposed  by  some  to  yield  too  large  a 
proportion  of  sensitive  stumps,  should  be  performed  in  preference  to  ampu- 
tations above  the  ankle. 

The  lower  third  of  the  leg  is  the  place  of  election  in  amputating  through  the 
leg — rather  than  the  formerly  given  "hand's  breadth"  below  the  knee-joint. 
In  the  latter  case  too  limited  a  length  of  bone  is  left  for  good  leverage  in  adapt- 
ing a  false  limb.  The  site  of  choice  is  at  the  junction  of  the  middle  and  lower 
thirds  of  the  leg — thus  leaving  room  for  an  artificial  ankle-joint. 

Under  no  circumstances  amputate  through  the  tibia  higher  than  8  cm. 
(3  inches)  below  its  superior  articular  surface. 

In  amputating  in  the  neighborhood  of  the  knee-joint,  one  of  the  osteoplastic 
operations  by  which  a  piece  of  bone  from  the  tibia  is  approximated  to  the  sawn 
end  of  the  femur  in  the  condyloid  region  serves  an  useful  purpose,  furnishes 
a  stump  that  will  bear  pressure  well,  and  generally  leaves  room  for  the  artificial 
knee-joint  in  approximately  a  normal  position. 

Amputation  through  the  thigh  8  cm.  (3  inches)  above  the  knee-joint  gives 
ample  room  for  an  artificial  joint  in  a  normal  position. 

Amputations  through  the  thigh  higher  than  its  middle  do  not  furnish  as 
satisfactory  stumps  as  those  at  and  below  this  level. 

In  operating  above  the  knee,  however,  it  is  to  be  borne  in  mind  that  the 
weight  is  also  borne  by  the  ischio-perineal  region. 


AMPUTATIONS  AND  DISARTICULATIONS  OF  THE  UPPER 

EXTREMITY. 

SURGICAL  ANATOMY  OF   THE  FINGERS. 

Bones. — Third,  second,  and  first  phalanges  of  the  fingers; — and  second 
and  first  phalanges  of  the  thumb. 

Articulations  and  Ligaments. — (a)  Second  Interphalangeal  Articula- 
tions; anterior;  two  lateral;  capsule.  Posterior  ligament  not  present — place 
supplied  by  united  tendons  of  extensor  communis  digitorum  and  extensor 
indicis,  for  index; — extensor  communis  digitorum  for  middle  and  ring; — 
united  tendons  of  extensor  communis  digitorum  and  extensor  minimi  digiti, 
for  little  finger,  (b)  First  Interphalangeal  Articulations; — anterior  (glenoid); 
two  lateral;  capsule.  Posterior  ligament  not  present — place  supplied  by 
extensor  longus  pollicis  (extensor  secundi  internodii  pollicis)  for  thumb; — 
united  tendons  of  extensor  communis  digitorum  and  extensor  indicis,  for 
index; — extensor  communis  digitorum,  for  middle  and  ring; — united  tendons 
of  extensor  communis  digitorum  and  extensor  minimi  digiti,  for  little  finger, 
(c)     Metacarpo-phalangeal    Articulations; — anterior;    two    lateral;    capsule. 


324  AMPUTATIONS. 

Posterior  ligament — not  present  as  distinct  ligament — place  supplied  by 
scattered  fibers  from  one  lateral  ligament  to  opposite  lateral  ligament;  ex- 
tensor brevis  pollicis  (extensor  primi  internodii  pollicis) ;  extensor  longus 
pollkis  (extensor  secundi  internodii  pollicis),  for  thumb; — and  the  same 
ligaments  for  the  other  fingers  as  those  for  the  first  interphalangeal  joints. 

Sesamoid  Bones. — Two  on  palmar  surface  of  metacarpophalangeal 
joint  of  thumb,  developed  in  inner  and  outer  heads  of  flexor  brevis  pollicis, 
which  here  replace  the  anterior  ligament.  One  or  two  on  palmar  surface 
of  metacarpophalangeal  joint  of  index  and  little  fingers.  Rarely  one  on 
palmar  surface  of  metacarpophalangeal  of  middle  and  ring  fingers.  Rarely 
one  on  palmar  surface  of  interphalangeal  joint  of  thumb. 

Muscles  and  Tendons. — (A)  Of  Fingers  in  General; — (a)  On  palmar 
aspect; — flexor  sublimis  digitorum;  flexor  profundis  digitorum.  (b)  On 
dorsal  aspect  of  index; — united  tendons  of  extensor  communis  digitorum 
and  extensor  indicis;  first  dorsal  interosseous  (abductor  indicis).  On  dorsal 
aspect  of  middle  finger; — extensor  communis  digitorum;  second  dorsal 
interosseous;  third  dorsal  interosseous.  On  dorsal  aspect  of  ring  finger; — 
extensor  communis  digitorum;  fourth  dorsal  interosseous;  second  palmar 
interosseous.  On  dorsal  aspect  of  little  finger; — united  tendons  of  extensor 
communis  digitorum  and  extensor  minimi  digiti;  fourth  lumbrical;  third 
palmar  interosseous,  (c)  On  ulnar  aspect  of  little  finger; — abductor  minimi 
digiti;  flexor  brevis  minimi  digiti.  (B)  Of  Thumb; — (a)  On  palmar  aspect; 
— flexor  longus  pollicis.  (b)  On  dorsal  aspect; — extensor  brevis  pollicis 
(extensor  primi  internodii  pollicis) ;  extensor  longus  pollicis  (extensor  secundi 
internodii  pollicis).  (c)  On  radial  aspect; — abductor  pollicis;  outer  head  of 
flexor  brevis  pollicis.  (d)  On  ulnar  aspect; — inner  head  of  flexor  brevis 
pollicis;  adductor  obliquus  pollicis;  adductor  transversus  pollicis. 

Sheaths  (Thecae). — Processes  of  palmar  fascia  extending  down  fingers 
from  palm  of  hand  to  bases  of  last  phalanges,  being  attached  to  lateral  margins 
of  first  phalanges,  and  forming  sheaths  for  flexor  tendons. 

Synovial  Membranes. — (a)  Of  index,  middle,  and  ring  fingers; — extend 
from  base  of  last  phalanges  up  to  bifurcation  of  palmar  fascia,  namely,  about 
opposite  necks  of  metacarpals  (corresponding,  approximately,  to  middle 
crease  on  palm  of  hand,  for  index,  and  to  lowest  crease  for  middle  and  ring), 
(b)  Of  thumb  and  little  finger; — extend  from  base  of  last  phalanges  to  and 
into  great  synovial  sac  of  hand. 

Nails. — Overlie  the  soft  parts  covering  the  distal  two-thirds  of  the  last 
phalanges  on  their  dorsal  aspect. 

Arteries. — (a)  Palmar  Supply; — Four  palmar  digital  branches  of  super- 
ficial arch;  radialis  indicis  of  deep  arch;  princeps  pollicis  of  deep  arch,  (b) 
Dorsal  Supply; — Second  and  third  dorsal  interosseous  branches  of  posterior 
radial  carpal  branch  of  radial;  first  dorsal  interosseous  (metacarpal)  branch 
of  radial;  dorsalis  indicis  branch  of  radial;  dorsalis  pollicis  branch  of  radial. 

Veins. — (a)  Superficial; — digital  (one  on  each  side),  (b)  Deep; — venae 
comites. 

Lymphatics. — One  lymphatic  vessel  on  dorsal  and  one  on  palmar  aspect 
of  each  side  of  each  finger. 

Nerves. — (a)  Median  supplies — thumb,  index,  middle,  and  ring  fingers, 
(b)  Ulnar  supplies — ring,  little,  and  middle  (sometimes),  (c)  Radial  supplies 
— thumb,  index,  middle,  and  ring. 


GENERAL   CONSIDERATIONS    IN   FINGER   AMPUTATIONS.  325 


SURFACE  FORM  AND  LANDMARKS  OF  THE  FINGERS. 

The  proximal  ends  of  the  phalanges  form  the  knuckles — and  therefore 
the  joint-line  is  beyond  the  knuckle.  The  interphalangeal  joint-lines  are 
found,  with  approximate  accuracy,  by  flexing  the  distal  phalanges  at  a  right 
angle  with  the  proximal  phalanges  (or  metacarpals) — and  then  prolonging 
the  mid-lateral  axis  of  the  proximal  bone  forward — this  line  will  pass  through 
the  center  of  the  joints.  More  accurately,  the  last  interphalangeal  joint  is 
2  mm.  (yV  inch),  the  first  interphalangeal  joint  4  mm.  (^  inch),  and  the  meta- 
carpophalangeal joint  8  mm.  (J  inch)  beyond  the  prominence  of  the  knuckle. 

The  sesamoid  bones  can  be  felt  in  front  of  the  metacarpo-phalangeal 
joint  of  the  thumb. 

The  palmar  aspects  of  the  fingers  are  crossed  by  three  series  of  transverse 
folds; — the  highest  are  single  for  the  index  and  little  fingers,  double  for  the 
middle  and  ring — and  are  nearly  2  cm.  (f  inch)  below  the  metacarpo-phalan- 
geal joints; — the  middle  are  double  for  all  the  fingers — and  are  directly 
opposite  the  first  interphalangeal  joints; — the  lowest  are  single  for  all  the 
fingers — and  are  a  little  above  the  second  interphalangeal  joints.  The 
thumb  has  two  folds — the  higher,  single,  crosses  the  metacarpo-phalangeal 
joint  obliquelv; — the  lower,  single,  directly  opposite  the  first  interphalangeal 
joint. 

The  free  margin  of  the  webs  of  the  fingers  is  about  2  cm.  (f  inch)  below 
the  metacarpo-phalangeal  joints. 

The  lateral  ligaments  of  the  joints  are  nearer  the  palm  than  the  dorsum. 

The  sheaths  of  the  flexor  tendons  extend  from  the  metacarpo-phalangeal 
joints  to  the  proximal  ends  of  the  third  phalanges — are  least  distinct  opposite 
the  joints — gape  when  cut — and  lead  into  the  palm  of  the  hand. 

The  digital  arteries  bifurcate  about  8  mm.  (J  inch)  above  the  free  margin 
of  the  webs  of  the  fingers. 

The  epiphyses  form  the  heads  of  the  four  inner  metacarpals,  the  base 
of  the  first,  and  the  bases  of  all  the  phalanges — all  joining  the  shaft  about 
the  twentieth  year. 

The  skin  of  the  palm  is  thick,  dense,  and  adherent — that  of  the  dorsum, 
thin  and  loosely  connected  to  the  fascia. 


GENERAL    SURGICAL   CONSIDERATIONS    IN    AMPUTATIONS   OF   THE 

FINGERS. 

Minimum  sacrifice  of  tissue  is  the  rule  in  all  amputations  about  the  fingers 
— especially  in  thumb,  index,  and  little  fingers — so  that  there  may  be  left 
some  length  of  digit,  no  matter  how  short,  to  approximate  to  other  digits 
and  objects  grasped.  The  basal  principle  here  is — (a)  Save  a  stump,  no 
matter  how  imperfect — (b)  provided  tendons  remain  connected  to  it,  or  can 
be  sutured  to  it — (c)  and  sound  skin  can  be  found  to  cover  it.  Indeed,  the 
last  may  be  dispensed  with,  if  there  seem  fair  chance  that  granulation  will 
cover  over  the  part.  Amputations  here,  especially  in  cases  of  injury,  are 
often  irregular  operations,  and  amount  to  little  more  than  trimming  of  mangled 
parts — as  a  bony  stump  of  irregular  form,  provided  flexion  and  extension 
exist,  is  better  than  a  shorter  stump  of  more  symmetrical  contour. 

Since  the  bones  of  the  fingers  are  large,  as  compared  with  the  surrounding 
soft  parts,  an  ample  allowance  of  covering  should  be  made. 


326  AMPUTATIONS. 

In  the  interphalangeal  region  the  joints  are  concave  from  side  to  side, 
with  the  concavity  toward  the  finger-tips.  In  the  metacarpo-phalangeal 
region  the  convexity  is  toward  the  tips. 

Owing  to  the  function  of  the  fingers,  cicatrices  should  be  planned  to  fall 
out  of  the  way  of  pressure — should  not  be  terminal  or  palmar — and  are  best 
placed  on  the  dorsum. 

The  stump  of  a  phalanx  is  often  considerably  in  the  way  unless  the  flexor 
and  extensor  tendons  can  act  upon  it.  Formerly  all  of  a  finger  below  the 
center  of  the  middle  phalanx  (where  the  superficial  flexor  is  attached)  was 
sacrificed.  Now,  however,  the  flexor  tendon  is  sutured  into  the  mouth  of 
the  cut  theca  and  periosteum,  or  even  the  flap,  thereby  securing  control 
of  the  phalangeal  stump. 

The  fibrous  sheaths  of  the  flexor  tendons  gape  open  when  cut  across 
and  their  channels  lead  directly  into  the  palm  of  the  hand,  and  those  of  the 
thumb  and  little  finger  into  the  great  synovial  sac  beneath  the  annular  ligament 
of  the  wrist,  furnishing  a  ready  avenue  for  possible  infection.  They  should, 
therefore,  be  closed  by  two  or  three  catgut  sutures,  passed  from  the  palmar 
to  the  dorsal  aspect  of  the  sheath  with  a  curved  needle,  whenever  cut  in  the 
course  of  an  amputation  about  the  fingers.  But  when  cut,  especially  when 
the  finger  is  extended,  the  flexor  tendons  draw  up  into  the  sheath  out  of 
sight,  and  if  the  sheaths  were  then  sutured  the  action  of  the  flexor  tendons 
upon  the  phalangeal  stump  would  be  lost.  Therefore,  to  give  the  flexor 
tendons  a  firm  hold  upon  the  part,  the  sutures  should  include  flexor  tendon, 
theca,  and  periosteum — passing,  in  order,  from  before  backward,  through 
anterior  wall  of  theca,  flexor  tendon  (if  distal  to  center  of  middle  phalanx), 
or  tendons  (if  proximal  to  center  of  middle  phalanx),  and  posterior  wall  of 
theca,  which  is  blended  with  the  periosteum.  Where  the  theca  is  imperfect, 
the  tendons  should  be  sutured  to  neighboring  periosteum,  glenoid  ligament, 
adjacent  fibrous  tissue,  or  into  the  tissues  of  the  flap.  Thus  the  mouth  of 
the  sheath  is  closed  by  the  tendon  while  anchoring  the  latter  to  the  part. 
This  sheath  is  absent  over  the  terminal  phalanx  and  over  the  distal  inter- 
phalangeal joint — and  is  indistinct  over  the  metacarpo-phalangeal  joint. 
Where  absent,  the  flexor  tendons  should  be  sutured  into  the  neighboring 
structures,  as  just  described.  Where  the  periosteum  is  to  be  included  in  the 
suture,  it  should  be  stripped  back  before  dividing  the  bone. 

If  the  base  of  the  terminal  phalanx  be  saved,  the  attachment  of  the  deep 
flexor  is  preserved.  If  the  upper  third  of  the  second  phalanx  be  saved,  the 
attachment  of  the  superficial  flexor  is  preserved.  If  the  amputation  be 
through  the  first  interphalangeal  joint,  or  proximal  to  it,  both  flexor  tendons 
will  be  lost — unless  they  are  sutured  into  the  neighboring  structures  as  just 
described  (into  theca,  periosteum,  or  flaps). 

The  best  form  of  amputation  for  all  parts  below  the  metacarpo-phalangeal 
joint  is  one  in  which  a  palmar  flap  predominates — furnishing  a  covering 
of  thick,  sensitive  skin  accustomed  to  pressure — and  a  cicatrix  on  the  dorsum. 

In  disarticulations  by  the  palmar  flap  method,  a  slight  downward  con- 
vexity given  to  the  transverse  dorsal  incision  gives  a  better  apposition  with 
the  palmar  flap  than  would  a  straight  transverse  incision  over  the  dorsum 
of  the  joint. 

Disarticulation  is  best  accomplished  from  the  dorsum,  after  flexing  the 
joint — cutting,  in  order,  through  the  following  structures — skin;  fascia; 
extensor  tendons  (attached  to  the  bases  in  the  interphalangeal  joints,  and 
forming  the  posterior  ligaments  of  the  joints);  dorsal  portion  of  the  capsule; 
the  knife  passing  thence  behind  the  base  of  the  distal  bone  and  cutting  the 


AMPUTATION    THROUGH    LAST    PHALANX    OF    FINGERS.  327 

lateral  ligaments  from  within  outward;  anterior  portion  of  capsule,  from 
within;  and  anterior  ligament,  also  from  within. 

The  glenoid  ligament,  the  fibro-cartilaginous  plate  which  is  mainly  attached 
to  the  base  of  the  distal  bone,  should  be  left  in  the  stump. 

A  longitudinal  cut  made  in  the  mid-lateral  aspect  of  the  finger  will  have 
the  digital  arteries  on  the  palmar  side. 

All  flaps  should  be  cut  from  without  inward — none  by  transfixion. 

The  heads  of  the  metacarpals  should  be  preserved,  especially  in  those 
who  require  strength  in  their  hands.  Their  removal  weakens  the  hand.  If  left 
in,  they  and  their  soft  overlying  parts  eventually  atrophy  to  some  extent  and 
the  gap  is  not  so  apparent.  If  removed,  somewhat  greater  symmetry  is 
acquired  at  the  cost  of  strength. 

Musculo-periosteal  coverings  in  these  small  amputations  through  the 
phalanges  are  often  difficult  to  provide,  but  should  be  provided  where  possible 
— even  a  periosteo-capsular  covering  in  disarticulating. 

In  making  all  palmar  incisions,  the  part  should  be  extended — and  flexed 
while  making  dorsal  incisions.     The  fullest  coverings  will  be  thus  secured. 

Guard  against  making  flaps  too  narrow  and  pointed — the  heads  of  the 
bones  to  be  covered  are  all  large,  following  disarticulation. 

All  incisions  outlining  the  different  amputations  pass  through  only  skin 
and  fascia  at  first. 

All  ligatures  should  be  catgut — and  the  skin  sutures  either  silk  or  silkworm- 
gut. 

In  all  amputations  about  the  fingers  the  stump  should  be  snugly  dressed 
and  bandaged,  and  an  anterior  splint  should  be  included  in  the  dressing. 


AMPUTATION  THROUGH  LAST  PHALANX  OF  FINGERS,  IN  GENERAL. 

Best  Form. — Palmar  Flap. 

Comment. — The  palmar  flap  method  furnishes  the  best  form  of  covering 
— and,  owing  to  the  presence  of  the  nail,  is  about  the  only  available  form 
of  amputation   in   this   locality. 


AMPUTATION  THROUGH  LAST  PHALANX  OF  FINGERS 

BY   PALMAR   FLAP. 

Description. — Single  palmar  flap  of  all  tissues  down  to  bone. 

Position  (for  all  Amputations  about  the  Fingers). — Patient  on  back; 
upper  extremity  held  out  from  body,  or,  better,  supported  on  a  small  table; 
hand  pronated  and  fingers  flexed  while  dorsal  incisions  are  made,  and  hand 
supinated  and  fingers  extended  during  palmar  incisions.  Assistant  stands 
in  front  of  surgeon,  between  him  and  shoulder  of  patient — steadying  the  hand 
with  both  of  his  own  and  holding  the  adjacent  fingers  out  of  the  way.  Surgeon 
holds  digit  to  be  removed  with  thumb  and  forefinger  of  left  hand — with 
back  of  thumb  downward  and  his  hand  pronated  during  palmar  incisions — ■ 
and  with  his  thumb  upward  and  his  hand  supinated  during  dorsal  incisions. 

Landmarks. — The  space  is  so  limited  that  the  saw-line  can  only  be 
placed  between  the  matrix  of  nail  and  proximal  end  of  second  phalanx. 

Incision. — (1)  Palmar  incision — from  saw-line  downward  along  lateral 
aspect  of  phalanx,  midway  between  dorsal  and  palmar  surfaces,  around  the 
center  of  the  pulp,  and  back  to  the  saw-line  on  the  opposite  side.     (2)  Dorsal 


328 


AMPUTATIONS. 


incision — connects  upper  ends  of  palmar  incision,  passing  transversely  over 
the  dorsum  with  slight  downward  convexity.  (For  principle,  see  Fig.  318,  C, 
and  319,  B,  where  disarticulation  at  the  last  interphalangeal  joint  is  shown.) 


Fig.  318.— Amputations  about  the  Finger  :— A,  Through  first  phalanx,  by  equal  palmar  and 
dorsal  flaps  ;  B,  At  first  interphalangeal  joint,  by  long  palmar  and  short  dorsal  flaps  ;  C,  At  second 
interphalangeal  joint,  by  palmar  flap. 

Operation. — Having  outlined  these  incisions,  carry  the  palmar  incision 
to  the  bone — dissect  up  all  palmar  tissues  down  to  the  bone — deepen  the 
dorsal  incision  to  the  bone — retract  the  soft  parts,  in  the  entire  circumference 
- — and  saw  the  phalanx  with  a  light  saw,  while  holding  the  tip  of  the  phalanx 


Fig.  319. — Amputations  about  the  Thumb: — A,  Disarticulation  of  thumb  at  carpo- 
metacarpal joint  by  oval  incision;  B,  Disarticulation  at  metacarpophalangeal  joint  by  oblique 
palmar  flap;  C,  Disarticulation  at  interphalangeal  joint  by  palmar  flap. 

with  bone-holding  forceps  (as  there  is  generally  too  little  room  for  the  fingers 
of  the  operator  to  grasp).  Ligate  the  palmar  digital  artery  on  each  side. 
Suture  the  deep  flexor  tendon  to  the  periosteum  or  flap.  Suture  the  palmar 
flap  to  the  transverse  dorsal  line. 


DISARTICULATION    THROUGH    SECOND    JOINT    OF    FINGERS.         329 

DISARTICULATION  AT  SECOND  INTERPHALANGEAL  JOINT  OF 
FINGERS,  IN  GENERAL. 

Best  Method. — Palmar  Flap. 

Other  Methods. — Short  Dorsal  and  Long  Palmar  Flaps. 
Comment. — Even  where  the  double  flap  method  is  adopted,  the  covering 
must  be  almost  entirely  palmar,  owing  to  the  position  of  the  nail. 


DISARTICULATION    THROUGH    SECOND    INTERPHALANGEAL    JOINT 

OF  FINGERS 

BV  PALMAR  FLAP 

Position. — As  for  amputation  through  last  phalanx  (page  327). 

Landmarks. — Second  interphalangeal  joint-line. 

Incisions. — (1)  Palmar  incision — begins  opposite  the  joint-line,  midway 
between  dorsal  and  palmar  surfaces — passes  down  lateral  aspect  for  a  distance 
equal  to  i|  diameters  of  the  finger  at  the  disarticulation-line — crosses  palmar 
aspect  with  bluntly  rounded  corners — and  passes  upward  to  the  corresponding 
point  on  the  opposite  side  of  the  finger.  (2)  Dorsal  incision — connects  upper 
end  of  palmar  incision  by  a  transverse  incision  made  over  dorsum  of  joint, 
with  slight  downward  convexity  (Fig.  318,  C). 

Operation. — Having  outlined  these  incisions  through  skin  and  fascia, 
carry  the  palmar  incision  to  the  bone  on  a  line  with  the  retracted  skin — and 
dissect  the  soft  parts  up  from  the  bone.  Deepen  the  dorsal  incision  to 
the  bone,  along  the  line  of  retracted  skin — open  the  joint  from  the  dorsum 
and  disarticulate  from  within  outward.  There  is  no  theca  here  to  close. 
Suture  the  deep  flexor  tendons  into  the  neighboring  tissues.  Ligate  the  two 
digital  arteries.     Suture  the  palmar  flap  to  the  dorsal  line. 

Comment. — The  joint  is  sometimes  first  disarticulated  by  a  transverse 
dorsal  incision — and  the  palmar  flap  then  cut  from  within  outward — but 
with  less  satisfactorv  result. 


DISARTICULATION    THROUGH    SECOND    INTERPHALANGEAL    JOINT 

OF  FINGERS 

BY  SHORT  DORSAL  AND  LONG  PALMAR  FLAPS. 

Position — Landmarks. — As  in  the  last  operation. 

Incisions. — (1)  Palmar  flap — little  more  than  length  of  diameter  of 
finger  at  disarticulation-line — begins  at  disarticulation-line,  in  mid-lateral 
aspect  of  finger — passes  directly  down  the  finger  for  the  above  distance — 
crosses  the  palm  with  bluntly  rounded  corners— and  passes  up  the  finger  to 
the  corresponding  site  upon  the  opposite  side.  (2)  Dorsal  flap — one-third 
the  length  of  the  palmar — beginning  and  ending  at  the  same  points  as  the 
palmar — and  crossing  the  dorsum  with  bluntly  rounded  corners  at  the  above 
distance  below  the  upper  limit.      (For  principle,  see  Fig.  318,  B.) 

Operation. — Carry  these  incisions  to  the  bone  on  the  lines  of  retracted 
skin,  completing  the  palmar  incision  first — dissect  the  soft  parts  from  the 
bone  up  to  the  joint-line — open  the  dorsal  aspect  of  the  joint  and  disarticulate 
— completing  the  operation  as  in  the  above  method. 


330  AMPUTATIONS. 

AMPUTATION    THROUGH    SECOND    PHALANX    OF    FINGERS,    IN 

GENERAL. 

Best  Methods. — Palmar  Flap;  Short  Dorsal  and  Long  Palmar  Flaps. 

Other  Methods. — Equal  Dorsal  and  Palmar  Flaps;  Equal  Lateral 
Flaps;  Single  External  Flap  (for  index);  Single  Internal  Flap  (for  little  finger); 
Circular;  Oblique  Circular;  Dorsal  Flap. 

Comment. — Any  single  flap,  unless  taken  from  the  palm,  brings  part  of 
the  scar  into  the  palm.  A  dorsal  flap  gives  a  palmar  scar.  All  equal  flap 
methods  and  circular  methods  give  terminal  scars. 


AMPUTATION    THROUGH    SECOND    PHALANX    OF    FINGERS 

BY  PALMAR  FLAP. 

Position. — As  for  amputation  through  last  phalanx  (page  327). 

Landmarks. — Lines  of  proximal  and  distal  joints. 

Incisions. — (1)  Palmar  incision — begins  opposite  saw-line  in  mid-lateral 
aspect  of  finger — passes  vertically  downward  a  distance  equivalent  to  ij 
diameters  of  the  finger  at  the  saw-line — crosses  the  palmar  aspect  with  bluntly 
rounded  corners — passes  vertically  upward  in  the  mid-lateral  aspect  of  the 
opposite  side  to  a  point  corresponding  with  the  one  of  beginning.  (2)  Dorsal 
incision — connects  the  upper  limits  of  the  limbs  of  the  palmar  incision, 
passing  transversely  across  the  dorsum  with  slight  downward  convexity. 
(For  principle,  see  Fig.  318,  C.) 

Operation. —The  above  incisions  are  now  deepened  to  the  bone,  the 
palmar  first  and  then  the  dorsal,  on  a  line  with  the  retracted  skin.  The 
soft  parts  are  dissected  off  the  bone  back  to  the  saw-line  and  are  retracted 
while  the  bone  is  being  sawed.  Ligate  the  digital  arteries.  In  amputating 
distally  to  the  upper  third  of  the  second  phalanx,  the  superficial  flexor  tendon 
will  retain  its  attachment.  The  deep  flexor  tendon  will,  however,  be 
severed  and  should  be  sutured  into  the  mouth  of  the  fibrous  sheath  (which 
ends  at  the  middle  of  the  second  phalanx)  and  into  neighboring  periosteum 
and  soft  parts,  if  necessary — the  closure  of  the  sheath  being  accomplished 
in  the  process  of  anchoring  the  deep  flexor  tendon.  The  flap  is  then 
sutured  in  the  usual  way. 


AMPUTATION  THROUGH  SECOND  PHALANX  OF  FINGERS 

BY  SHORT  DORSAL  AND  LONG  PALMAR    FLAPS. 

Position — Landmarks. — As  in  the  last  operation. 

Incisions. — (1)  Palmar  Flap — (2)  Dorsal  Flap — both  outlined  exactly 
as  in  the  disarticulation  through  the  second  interphalangeal  joint  by  short 
dorsal  and  long  palmar  flaps — with  the  necessary  calculations  for  the  change 
in  position  (page  327).     (For  principle,  see  Fig.  318,  B.) 

Operation. — For  the  technic  of  the  operation,  see  the  disarticulation 
just  mentioned.  For  the  manner  of  dealing  with  the  structures  encountered, 
see  the  operation  last  described. 


AMPUTATION    THROUGH    FIRST    PHALANX    OF    FINGERS.  33 1 


DISARTICULATION    AT    FIRST    INTERPHALANGEAL    JOINT    OF 
FINGERS,  IN  GENERAL. 

Best  Methods. — Same  as  mentioned  under  amputation  through  second 
phalanx  (page  330). 

Other  Methods. — Same  (page  330). 
Comment. — Same  (page  330). 


DISARTICULATION  AT  FIRST  INTERPHALANGEAL  JOINT  OF  FINGERS 

BY  PALMAR  FLAP. 

Position. — As  in  amputation  through  last  phalanx  (page  327). 

Landmarks. — First  interphalangeal  joint-line. 

Incisions. — As  for  disarticulation  at  second  interphalangeal  joint  by 
palmar  flap  (page  329).     (For  principle,  see  Fig.  318,  C.) 

Operation. — Same,  in  principle,  as  the  disarticulation  at  the  second 
joint  of  the  fingers.  Both  flexor  tendons  are  here  severed  below  their  inser- 
tions, and  the  use  of  the  proximal  phalanx  would  be  much  interfered 
with  unless  these  tendons  were  securely  attached  to  the  sheath,  periosteum, 
or  glenoid  ligament  of  the  stump. 

DISARTICULATION    AT    FIRST    INTERPHALANGEAL    JOINT    OF 

FINGERS 

BY  SHORT  DORSAL  AND  LONG  PALMAR    FLAPS. 

Position — Landmarks. — As  in  the  last  operation. 

Incision. — Same  as  in  disarticulation  at  the  second  interphalangeal  joint 
(page  329).     (For  principle,  see  Fig.  318,  B.) 

Operation. — Same  as  in  the  operation  just  referred  to  (page  329).  For 
treatment  of  the  flexor  tendons,  see  disarticulation  at  first  interphalangeal 
joint  by  a  palmar  flap  (page  $^,  1) . 


AMPUTATION  THROUGH  FIRST  PHALANX  OF  FINGERS ,  IN  GENERAL. 

Best  Methods. — Palmar  Flap;  Short  Dorsal  and  Long  Palmar  Flaps. 

Other  Methods. — Same  as  mentioned  under  amputation  through  second 
phalanx  (page  330).     To  which  list  may  be  added  the  oval  method. 

Comment. — Same  as  made  under  the  operation  just  referred  to  (page 
33o)- 

AMPUTATION    THROUGH    FIRST    PHALANX    OF    FINGERS 

BY  PALMAR  FLAP. 

Position. — As  for  amputation  through  last  phalanx  (page  327). 

Landmarks. — Lines  of  metacarpophalangeal  and  first  interphalangeal 
joints. 

Incisions — Operation. — Same  as  for  amputation  through  second  phalanx 
(page  330).  For  reference  to  flexor  tendons,  see  under  disarticulation  at 
first  interphalangeal  joint  by  palmar  flap  (page  331). 


332  AMPUTATIONS. 

AMPUTATION  THROUGH  FIRST  PHALANX  OF   FINGERS 

BY  SHORT   DORSAL  AND  PALMAR    FLAPS. 

Position — Landmarks. — As  in  the  above  operation. 

Incision — Operation. — As  for  amputation  through  the  second  phalanx 
by  the  same  method  (page  330).  For  reference  to  treatment  of  the  flexor 
tendons  and  sheaths,  see  under  disarticulation  at  first  interphalangeal  joint 
by  palmar  flap  (page  331). 


DISARTICULATION    OF    FINGERS   AT    METACARPO-PHALANGEAL 
JOINTS,  IN  GENERAL. 

Best  Methods. — Oval  Method  (for  fingers  in  general  and  for  thumb); 
Externo-palmar  Flap  of  Farabeuf  (for  index) ;  Interno-palmar  Flap  of  Fara- 
beuf  (for  little  finger);  Oblique  Palmar  Flap  (for  thumb). 

Other  Methods. — Equal  Lateral  Flaps;  Circular  Incision,  joined  by 
vertical  dorsal  queue;  Palmar  Plap;  Large  External  and  Small  Internal 
Flaps  (for  index);  Large  Internal  and  Small  External  Flaps  (for  little  finger). 

Comment. — The  first  four  are  the  best  in  the  sites  indicated  and  are 
superior  to  the  others  mentioned.  The  oblique  palmar  flap  for  the  thumb 
gives  the  best  covering  where  sufficient  tissue  exists. 


DISARTICULATION  OF  FINGERS,  IN  GENERAL,  AT  METACARPO- 
PHALANGEAL JOINT. 

BY  OVAL  METHOD. 

Description. — The  queue  is  placed  over  the  dorsum  of  the  joint  and 
the  center  of  the  oval  passes  across  the  palmar  aspect  at  the  web-line. 

Position. — As  for  amputation  through  the  last  phalanx  (page  327). 

Landmarks. — Head  of  metacarpal;  metacarpo-phalangeal  joint-line; 
web  of  finger. 

Incision. — Begins  just  above  head  of  metacarpal,  on  its  dorsal  aspect 
(in  the  position  corresponding  with  its  neck) — passes  down  the  median  dorsal 
aspect  over  the  prominence  of  the  knuckle,  to  just  beyond  the  base 
of  the  first  phalanx  (which  is  about  midway  between  the  metacarpo- 
phalangeal joint-line  and  the  free  edge  of  the  web) — at  this  point  the  hitherto 
median  incision  diverges  into  two  symmetrical  limbs — each  sweeping  across 
the  dorso-lateral  aspect  of  the  finger  to  just  below  the  junction  of  the  finger 
with  the  web — and  thence  transversely  across  the  palmar  surface  in  the 
line  of  the  crease,  on  a  level  with  the  free  border  of  the  web,  coming  to  the 
opposite  side  just  below  the  junction  of  the  web  with  the  finger.  This  rather 
extensive  incision  is  best  made  with  three  strokes — from  commencement  to 
web  of  one  side — from  point  of  divergence  of  median  line  to  web  of  opposite 
side — and  across  palmar  surface  connecting  the  two  limbs  (Fig.  320,  H,  and 
321,  E). 

Operation. — The  above  incision  through  skin  and  fascia  is  now  deepened. 
The  palmar  portion  is  cut  to  the  bone  while  the  finger  is  forcibly  extended. 
The  lateral  portions  are  carried  to  the  bone,  cutting  the  lumbricales  and 
interossei.  The  soft  parts  are  retracted  to  the  joint-line.  The  extensor 
tendons  are  then  cut  and  the  joint  thus  entered  from  the  dorsum — the  lateral 


METACARPO-PHALANGEAL    DISARTICULATION    OF    THUMB.  333 

ligaments  and  glenoid  ligament  being  cut  from  within  and  the  disarticulation 


Fig. 320.—  Amputations  about  the  Fingers,  Hand,  and  Wrist  : — A,  Through  second  phalanx 
of  little  finger,  by  single  internal  flap  ;  B,  At  first  interphalangeal  joint,  by  oval  method  ;  C,  Through 
second  phalanx,  by  equal  lateral  flaps;  D,  Through  second  phalanx  of  index,  by  single  external  flap  ; 
E,  Through  first  phalanx,  by  oblique  circular;  F,  Through  first  phalanx,  by  ordinary  circular ;  G, 
At  metacarpophalangeal  joint  of  little  finger,  by  interno-palmar  flap;  H,  At  metacarpophalangeal 
joint,  by  oval  method  ;  I,  At  metacarpophalangeal  joint  of  index,  by  externo-palmar  flap  ;  J,  Of  little 
finger  at  carpo-metacarpal  joint,  by  racket  method  ;  K,  Same  of  ring  finger;  L,  Of  middle  finger  and 
part  of  metacarpal,  by  racket  method  ;  M,  Of  two  inner  fingers  at  carpo-metacarpal  joints,  by  racket 
method  ;  N,  Of  thumb  at  carpo-metacarpal  joint,  by  racket  method  ;  O,  Through  metacarpophalan- 
geal joint  of  thumb,  by  oblique  palmar  flap ;  P,  P,  At  wrist-joint,  by  external  flap. 


completed.     The  two  digital  arteries  are  tied  and  the  synovial  sheath  closed. 
The  edges  of  the  sides  of  the  oval  are  sutured  in  one  vertical,  antero-posterior 


,334  AMPUTATIONS. 

line,   in   continuation  with  the  queue  of    the  incision.     The  splint  applied 
should  include  the  wrist-joint. 

Comment. — (i)  The  joint  may  be  opened  from  the  palmar  surface,  by 
cutting  the  glenoid  ligament  transversely  against  the  base  of  the  metacarpal. 
In  either  case,  the  glenoid  ligament  is  retained.  (2)  No  attempt  is  made  to 
attach  the  flexor  tendons,  as  the  entire  finger  is  removed  and  there  would 
be  nothing  for  them  to  flex.  (3)  The  lower  end  of  the  vertical  cicatrix  is 
eventually  drawn  up  out  of  the  way  of  palmar  pressure.  (4)  If  it  be  desired 
to  remove  the  head  of  the  metacarpal,  prolong  the  queue  of  the  incision 
upward — free  the  neck  of  the  bone  of  soft  parts,  hugging  the  bone  in  the 
process — retract  the  soft  parts — and,  while  partly  lifting  the  metacarpal 
from  its  bed  by  traction  upon  the  finger,  if  still  attached,  or  by  grasping  the 
head  of  the  bone  with  bone-forceps,  if  disarticulation  have  occurred,  pass 
a  chain  or  Gigli  saw  beneath  the  bone  and  make  a  section,  so  as  to  bevel  the 
bone  obliquely  from  behind  downward  and  forward,  and  from  the  inner- 
or  outer  aspect  toward  the  median  aspect  (Fig.  321,  C  and  D).  (5)  Where 
the  skin  of  the  palm  is  very  dense  and  hard,  as  in  laborers,  an  awkward  pro- 
jection of  skin  may  be  left  on  the  palmar  surface  of  the  convexity  of  the  oval, 
which  can  be  removed  and  make  the  suturing  more  satisfactory  by  cutting 
out  a  V-shaped  portion  from  the  palmar  aspect.  This,  however,  amounts, 
practically,  to  lateral  flaps,  and  brings  part  of  the  scar  into  the  palm.  (6) 
Avoid  cutting  into  the  web. 


DISARTICULATION  OF  THUMB  AT  METACARPO-PHALANGEAL  JOINT 

BV  OVAL  METHOD. 

Position. — As  in  amputation  through  last  phalanx  (page  327). 

Landmarks. — Neck  of  first  metacarpal;  metacarpo-phalangeal  joint. 

Incision. — Begins  on  dorsal  aspect  of  neck  of  metacarpal,  to  ulnar  side 
of  median  line — passes  directly  down  over  head  of  bone  and  along  median 
aspect  of  extensor  tendons,  or  slightly  to  ulnar  side,  to  just  beyond  the  base 
of  the  metacarpal — thence  the  median  incision  diverges — each  limb  passing 
obliquely  across  the  dorso-lateral  borders  of  the  thumb,  so  as  to  cross  and 
meet  upon  the  palmar  aspect  opposite  the  center  of  the  first  phalanx  (Fig. 
3i9,  A). 

Operation. — Deepen  this  incision  to  the  bone  along  the  line  of  the  re- 
tracted skin — dividing  the  extensor  brevis  pollicis  and  extensor  longus  pollicis 
opposite  the  metacarpo-phalangeal  joint,  and  the  flexor  longus  pollicis 
opposite  the  middle  of  the  first  phalanx.  The  sesamoid  bones  are  to  be 
detached  from  the  base  of  the  first  phalanx  and  left  in  the  stump.  As  far 
as  possible  the  muscles  which  are  attached  to  the  base  of  the  first  phalanx 
(extensor  brevis  pollicis,  adductor  obliquus  pollicis,  adductor  transversus 
pollicis,  abductor  pollicis,  flexor  brevis  pollicis),  as  well  as  the  long  flexors 
and  extensors,  should  be  sutured  into  the  tissues  of  the  stump — as  considerable 
range  of  movement  is  thereby  secured  for  the  metacarpal  bone,  whereby 
it  may  offer  counterpressure  to  the  fingers.  Close  the  synovial  sheath.  Tie 
the  dorsalis  pollicis  and  two  branches  of  the  princeps  pollicis.  Suture  the 
oval  in  a  single  straight  line  in  continuation  of  the  queue. 

Comment. — The  head  of  the  metacarpal  is  large  and  requires  ample 
covering. 


METACARPOPHALANGEAL    DISARTICULATION    OF    INDEX-FINGER.       335 
DISARTICULATION  OF  THUMB  AT  METACARPO-PHALANGEAL  JOINT 

BY  OBLIQUE  PALMAR  FLAP  —  (FARABEUF). 

Description. — This  method  consists  of  two  U-shaped  incisions,  the 
dorsal  having  its  convexity  upward,  the  palmar  having  its  convexity  down- 
ward— the  limhs  of  each  U  passing,  and  obliquely  meeting,  on  the  lateral 
aspects  of  the  thumb. 

Position. — As  for  amputation  through  the  last  phalanx  (page  327). 

Landmarks. — Lines  of  the  metacarpophalangeal  and  interphalangeal 
joints. 

Incision. — The  convexity  of  the  dorsal  U  is  upward  and  corresponds 
with  the  dorsal  aspect  of  the  metacarpophalangeal  joint.  The  convexity 
of  the  palmar  U  is  downward  and  is  placed  just  above  the  interphalangeal 
joint-line.  Between  these  two  rounded  extremities  the  lateral  limbs  pass 
in  an  oblique  direction  along  the  lateral  borders  of  the  thumb,  becoming 
continuous  with  each  other  (Fig.  320,  O,  and  319.  B). 

Operation. — This  incision  is  deepened  throughout  to  the  bone,  along 
the  line  of  the  retracted  skin — the  extensor  brevis  pollicis  and  extensor  longus 
pollicis  are  divided  over  the  metacarpophalangeal  joint,  and  the  flexor 
longus  pollicis  about  the  center  of  the  first  phalanx — the  soft  parts  are  freed 
back  to  the  joint-line — the  sesamoid  bones  are  detached  from  the  base  of 
the  first  phalanx  and  left  in  the  Map — the  joint  is  entered  from  above  and 
disarticulation  completed.  The  dorsalis  pollicis  and  the  two  branches  of 
the  princeps  pollicis  are  to  be  tied.  The  synovial  sheath  is  closed.  The 
convexity  of  the  palmar  flap  is  sutured  into  the  concavity  of  the  dorsal  wound 
— bringing  the  cicatrix  well  on  to  the  dorsum  and  out  of  the  way  of  pressure 

Comment. — As  the  head  of  the  metacarpal  is  disproportionately  large, 
an  additional  allowance  of  covering  must  be  made. 


DISARTICULATION  OF  INDEX-FINGER  AT  METACARPO-PHALANGEAL 

JOINT 

P.V  EXTERNO-PALMAR   FLAP— (FARABEUF). 

Description. — This  is  really  an  oval  method,  so  modified  as  to  bring 
the  cicatrix  upon  the  interno-dorsal  aspect  of  the  metacarpophalangeal 
region — so  that  fingers  and  objects  opposed  to  that  aspect  may  not  come 
into  contact  with  the  scar. 

Position. — As  for  amputation  through  last  phalanx  of  finger  (page  327). 

Landmarks. — Metacarpophalangeal  joint-line;  middle  of  first  phalanx; 
web. 

Incision. — Begins  at  metacarpophalangeal  joint-line,  immediately  over 
the  median  aspect  of  the  extensor  tendon — passes  vertically  down  the  median 
dorsal  aspect  of  the  finger,  in  the  above  relation  to  the  extensor  tendon,  to 
the  center  of  the  first  phalanx — thence  sweeps  across  the  lateral  and  palmar 
aspects  to  the  web — and  thence  passes  in  a  straight  line,  by  the  shortest 
route,  up  the  inner  side  of  the  finger  to  the  place  of  beginning  (Fig.  320,  I). 

Operation. — This  superficial  incision  is  deepened  to  the  bone — the  soft 
parts  retracted  to  the  joint-line — disarticulation  effected — and  the  operation 
completed  as  in  the  simple  oval  method.  The  digital,  dorsalis  indicis,  and 
radialis  indicis  arteries  are  to  be  tied.  The  flexor  sheath  is  to  be  closed — 
and  the  parts  so  sutured  as  to  cause  the  cicatrix  to  occupy  the  position  of  the 
straight  portion  of  the  incision,  upon  the  interno-dorsal  aspect. 


336  AMPUTATIONS. 

Comment. — (i)  The  placing  of  the  incision  over  the  median,  or  even 
slightly  to  the  ulnar,  rather  than  the  radial  aspect  of  the  extensor  tendon 
(as  recommended  by  Farabeuf),  gives  ampler  covering,  and  a  greater  cer- 
tainty of  the  scar  falling  well  to  the  ulnar  side.  (2)  If  the  head  of  the  meta- 
carpal be  removed,  it  is  exposed  as  mentioned  under  the  oval  method  (page 
334,  Comment). 

DISARTICULATION  OF  LITTLE  FINGER  AT  METACARPOPHALANGEAL 

JOINT 

BV  INTERNO-PALMAR  FLAP— (FARABEUF). 

Description. — This,  also,  is  a  modification  of  the  oval  method,  so  cal- 
culated as  to  bring  the  cicatrix  upon  the  externo-dorsal  aspect  of  the  meta- 
carpophalangeal region — that  non-scar  tissue  may  come  into  contact  with 
objects  which  press  the  stump. 

Position — Landmarks. — As  in  the  last  operation. 

Incision. — Begins  at  the  metacarpo-phalangeal  joint-line,  immediately 
over  the  median  aspect  of  the  extensor  tendon — passes  vertically  down  the 
dorsal  aspect  of  the  finger,  in  the  above  relation  to  the  extensor  tendon,  to 
the  center  of  the  first  phalanx — thence  sweeps  across  the  lateral  and  palmar 
aspects  of  the  finger  to  the  web — and  thence  passes  in  a  straight  line,  by  the 
shortest  route,  up  the  radial  side  of  the  finger  to  place  of  beginning  (Fig. 
320,  G). 

Operation. — The  steps  of  the  disarticulation  are  completed  as  in  the 
corresponding  operation  just  described  upon  the  thumb,  the  reverse  of  which 
this  is,  in  every  respect.  Two  digital  arteries  are  to  be  tied.  The  parts 
are  to  be  so  sutured  as  to  cause  the  cicatrix  to  occupy  the  position  of  the 
straight  portion  of  the  incision,  upon  the  externo-dorsal  aspect  of  the  region, 
buried  in  the  groove  formed  by  the  adjacent  finger. 

Comment. — (1)  Carrying  the  incision  over  the  median  aspect  of  the 
extensor  tendon  insures  more  covering  than  if  the  incision  passed  down  the 
ulnar  aspect,  as  recommended  by  Farabeuf — and  also  makes  it  more  certain 
that  the  scar  will  fall  well  to  the  radial  side  of  the  stump,  out  of  the  way  of 
pressure.  (2)  If  it  be  desired  to  remove  the  head  of  the  metacarpal,  it  is 
exposed  as  described  under  the  oval  method  of  disarticulating  the  fingers  in 
general — the  bone  being  here  beveled  from  ulnar  to  radial  aspect,  and  from 
dorsum  to  palm. 


SURGICAL  ANATOMY  OF  THE  HAND. 

Bones. — (a)  Metacarpals,  of  thumb  and  fingers; — (b)  Carpals; — First 
Row;  scaphoid,  semilunar,  cuneiform,  pisiform; — Second  Row;  trapezium, 
trapezoid,  os  magnum,  unciform. 

Articulations  and  Ligaments. — (A)  Metacarpophalangeal  Articula- 
tions;— See  description  under  Surgical  Anatomy  of  Fingers.  (B)  Meta- 
carpals with  each  other  (Intermetacarpal) ; — (a)  Carpal  ends  of  four  inner 
metacarpals; — dorsal,  palmar,  and  interosseous  ligaments,  and  synovial 
membrane; — (b)  Digital  ends  of  four  inner  metacarpals; — transverse  meta- 
carpal ligaments  (on  palmar  aspect).  (C)  Inner  Metacarpals  with  the 
carpus; — dorsal,  palmar,  and  interosseous  ligaments,  and  synovial  membrane. 
(D)  Metacarpal  of  thumb  with  trapezium; — capsular  ligament.  (E)  Articu- 
lations of  second  row  of  carpals  with  each  other; — three  dorsal,  three  palmar, 
and  three  interosseous  ligaments,  between  trapezium  and  trapezoid,  between 


SURGICAL    ANATOMY    OF    THE    HAND.  337 

trapezoid  and  os  magnum,  and  between  os  magnum  and  unciform;  and 
synovial  membrane  between  each.  (F)  Articulations  of  carpals  of  first  row 
with  each  other; — two  dorsal  ligaments  between  scaphoid  and  semilunar, 
and  between  semilunar  and  cuneiform;  two  palmar  ligaments  between  scaphoid 
and  semilunar,  and  between  semilunar  and  cuneiform;  two  interosseous 
ligaments  between  scaphoid  and  semilunar,  and  between  semilunar  and 
cuneiform;  capsular  ligament  between  cuneiform  and  pisiform;  two  palmar 
ligaments  between  pisiform  and  unciform  process  of  unciform,  and  between 
pisiform  and  fifth  metacarpal;  and  synovial  membrane  between  each  bone. 
(G)  Articulations  of  two  rows  of  carpals  with  each  other  (medio-carpal) ; — 
palmar,  dorsal,  external  lateral  and  internal  lateral  ligaments,  and  synovial 
membrane  (between  each  row). 

Anterior  Annular  Ligament. — (a)  Attachments; — Internally;  pisiform 
and  unciform  process  of  unciform  bone.  Externally;  tuberosity  of  scaphoid 
inner  part  of  anterior  surface,  and  ridge  on  trapezium.  Superiorly;  con 
tinuous  with  deep  fascia  of  forearm.  Inferiorly;  continuous  with  palmar 
fascia,  and  furnishing  attachment  to  some  of  muscles  of  thumb  and  little 
finger,  (b)  Structures  passing  superficial  to  anterior  annular  ligament  (from 
without  inward) ;  radial  vessels  and  nerve,  flexor  carpi  radialis,  palmaris 
longus,  ulnar  vessels  and  nerve,  flexor  carpi  ulnaris.  (c)  Structures  passing 
beneath  anterior  annular  ligament  (from  above  downward) ;  flexor  sublimis 
digitorum,  median  nerve,  flexor  profundus  digitorum,  flexor  longus  pollicis. 

Posterior  Annular  Ligament. — (a)  Attachments; — Internally;  styloid 
process  of  ulna,  cuneiform  and  pisiform  bones.  Externally;  outer  margin 
of  radius  and  elevated  ridge  on  its  posterior  surface.  Superiorly;  continuous 
with  deep  fascia  of  forearm,  (b)  Tendons  passing  beneath  posterior  annular 
ligament  (in  six  compartments,  from  without  inward) ; — (1)  extensor  ossis 
metacarpi  pollicis  and  extensor  brevis  pollicis;  (2)  extensor  carpi  radialis 
longior  and  brevior;  (3)  extensor  longus  pollicis;  (4)  extensor  communis 
digitorum  and  extensor  indicis;  (5)  extensor  minimi  digiti;  (6)  extensor 
carpi  ulnaris. 

Synovial  Sacs. — Two  synovial  sacs  lie  beneath  the  anterior  annular 
ligament,  one  for  the  flexor  sublimis  digitorum  and  flexor  profundus  digitorum, 
and  one  for  the  flexor  longus  pollicis.  Both  extend  upward  for  3  to  4  cm. 
(ij  to  ij  inches)  above  the  anterior  annular  ligament.  That  for  the  flexor 
longus  pollicis  extends  downward  to  last  phalanx  of  thumb.  That  for  the 
flexor  tendons  of  fingers  divides  into  four  processes;  the  one  for  the  little 
finger  generally  extending  to  base  of  last  phalanx; — those  for  index,  middle, 
and  ring  fingers  ending  about  middle  of  the  metacarpals — and  are  thus 
separated  by  about  1.3  cm.  (J  inch)  from  the  great  synovial  sac.  Thus  there 
is  an  open  channel  from  the  ends  of  the  thumb  and  little  fingers  to  a  point 
3  or  4  cm.  (1 J  to  1  ^  inches)  above  the  anterior  annular  ligament. 

Muscles  and  Tendons. — (i)  Of  palmar  aspect : — (a)  Superficial 
Muscles  from  Forearm; — Flexor  carpi  radialis;  palmaris  longus;  flexor  carpi 
ulnaris;  flexor  sublimis  digitorum.  (b)  Deep  Muscles  from  Forearm; — 
Flexor  profundus  digitorum;  flexor  longus  pollicis.  (c)  Short,  small  Muscles 
of  Thumb; — Abductor  pollicis;  opponens  pollicis  (flexor  ossis  metacarpi 
pollicis);  flexor  brevis  pollicis;  adductor  obliquus  pollicis;  adductor  trans- 
versa pollicis.  (d)  Short,  small  Muscles  of  Little  Finger; — palmaris  brevis; 
abductor  minimi  digiti;  flexor  brevis  minimi  digiti;  opponens  minimi  digiti 
(flexor  ossis  metacarpi  minimi  digiti).  (e)  Short  Central  Muscles  of  Hand; 
— four  lumbricals;  three  palmar  interossei.  (2)  Of  dorsal  aspect :— (a) 
Superficial  Muscles  from  Forearm; — Extensor  communis  digitorum;  extensor 


33%  AMPUTATIONS. 

minimi  digiti;  extensor  carpi  ulnaris.  (b)  Deep  Muscles  from  Forearm;— 
Extensor  ossis  metacarpi  pollicis;  extensor  brevis  pollicis  (extensor  primi 
internodii  pollicis);  extensor  longus  pollicis  (extensor  secundi  internodii 
pollicis);  extensor  indicis;  extensor  carpi  radialis  longior;  extensor  carpi 
radialis  brevior.  (c)  Small  Muscles  of  Dorsal  Aspect  of  Hand; — four  dorsal 
interossei. 

Attachment  of  Muscles  to  Bases  of  Metacarpals. — To  first;  extensor 
ossis  metacarpi  pollicis.  To  second;  extensor  carpi  radialis  longior;  flexor 
carpi  radialis.  To  third;  extensor  carpi  radialis  brevior.  To  fifth;  extensor 
carpi  ulnaris;  some  fibers  of  flexor  carpi  ulnaris. 

Arteries. — (a)  Palmar  supply: — (i)  From  Radial; — anterior  radial 
carpal;  superficialis  yoke;  deep  arch;  princeps  pollicis;  radialis  indicis;  three 
palmar  interossei;  three  superior  (posterior)  communicating  (perforating); 
three  inferior  (anterior)  communicating  (perforating);  palmar  carpal  re- 
current. (2)  From  Ulnar; — anterior  interosseous;  anterior  ulnar  carpal; 
superficial  palmar  arch;  four  palmar  digital;  deep  palmar  (communicating); 
three  palmar  interossei  (from  deep  arch,  common  to  radial  and  ulnar) ;  three 
superior  (posterior)  communicating  (perforating)  (also  common  to  radial); 
three  inferior  (anterior)  communicating  (perforating)  (also  common  to 
radial);  palmar  carpal  recurrent  (also  common  to  radial),  (b)  Dorsal 
supply  : — (i)  From  Radial; — radial;  posterior  radial  carpal;  dorsalis  pollicis; 
dorsalis  indicis;  metacarpal  (first  dorsal  interosseous);  second  and  third 
dorsal  interosseous;  three  superior  (posterior)  communicating  (perforating); 
three  inferior  (anterior)  communicating  (perforating).  (2)  From  Ulnar; — 
posterior  ulnar  carpal;  metacarpal. 

Veins. — (a)  Superficial; — Dorsal  Venous  Plexus — from  which  arise  super- 
ficial radial  vein,  and  anterior  and  posterior  superficial  ulnar  veins; — Anterior 
Median  Plexus — from  which  arise  superficial  median  vein,  (b)  Deep;  Two 
venae  comites  for  each  artery. 

Lymphatics. — Pass  up  the  forearm  from  the  lymphatic  palmar  arch, 
and  from  the  dorsal  plexus  of  lymphatics. 

Nerves. — (a)  From  Median; — Median  and  following  branches;  outer 
and  inner  palmar  cutaneous;  muscular  branches;  five  digital  branches;  (b) 
From  Ulnar; — Ulnar  and  following  branches;  palmar  cutaneous;  dorsal 
cutaneous;  superficial  palmar  branch;  deep  palmar  branch,  (c)  From 
Radial; — external  branch;  internal  branch. 


SURFACE  FORM  AND  LANDMARKS  OF  THE  HAND. 

Carpal  bones — two  subcutaneous  eminences  may  be  felt  upon  the  palmar 
aspect  of  the  hand  just  below  the  wrist — the  outer  (just  beneath  the  radial 
styloid  process)  due  to  the  tuberosity  of  the  scaphoid  and  ridge  on  the  trape- 
zium (the  ridge  being  just  beneath  the  former) — the  inner,  due  to  the  pisiform 
bone  The  unciform  process  of  the  unciform  lies  below  and  slightly  internal 
to  the  pisiform.  No  other  carpal  bones  are  recognizable  on  the  palmar 
surface — and  only  the  cuneiform  on  the  dorsum. 

Metacarpal  bones — The  heads  of  the  metacarpals  form  the  knuckles. 
The  dorsal  surface  of  the  fifth,  and  the  heads  of  all,  are  subcutaneous — all  the 
other  aspects  of  the  remainder  are  covered  by  muscles  or  tendons.  The  base 
of  the  metacarpal  of  the  thumb  can  be  felt — and  the  sesamoid  bones  opposite 
the  metacarpo-phalangeal  joint. 

Skin-folds  (creases)  of  the  hand — (a)  Superior  fold — begins  at  wrist, 
between  thenar  and  hypothenar  eminences,  and  runs  to  the  outer  border 


SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT    HANDS.        339 

of  the  hand  at  the  base  of  the  index-finger — and  is  formed  by  the  adduction 
of  the  thumb,  (b)  Middle  fold — begins  at  outer  border  of  hand  where  supe- 
rior fold  ends,  and  runs  inward  and  slightly  upward  and  ends  at  outer  limit 
of  hypothenar  eminence — and  is  formed  by  the  simultaneous  flexion  of  the 
metacarpophalangeal  joints  of  the  first  and  second  fingers — and  about 
corresponds,  opposite  the  third  metacarpal,  to  the  lower  portion  of  the  super- 
ficial palmar  arch,  (c)  Inferior  fold — begins  opposite  the  cleft  between 
the  index  and  middle  fingers  and  runs  almost  transversely  to  the  ulnar  margin 
of  the  hand,  crossing  the  lower  part  of  the  hypothenar  eminence — and  is 
formed  by  the  flexion  of  the  middle,  ring,  and  little  fingers.  It  crosses  the 
necks  of  the  three  inner  metacarpals,  and  approximately  indicates  the  upper 
limit  of  the  synovial  sheaths  of  the  flexor  tendons  of  the  three  outer  fingers. 
Midway  between  this  fold  and  the  free  margins  of  the  webs  are  the  meta- 
carpophalangeal joints. 

Line  of  carpo-meta carpal  joints — from  base  of  fifth  metacarpal,  to  carpo- 
metacarpal joint-line  of  thumb  (both  of  which  may  be  recognized).  The 
inner  portion  of  this  line  is  regular,  the  outer  portion  irregular. 

Line  of  metacarpophalangeal  joint-line — found  by  flexing  the  first 
phalanges  at  a  right  angle  with  the  metacarpals — and  then  prolonging  the 
mid-lateral  axis  of  the  metacarpals  forward — which  lines  will  pass  through 
the  center  of  the  joints. 

Free  edges  of  webs  of  fingers,  on  palmar  aspect,  are  about  2  cm.  (f  inch) 
below  the  metacarpophalangeal  joints. 

Muscles — The  muscles  of  the  thenar  (thumb)  eminence — and  .those  of 
the  hypothenar  (little  finger)  eminence  are  recognizable,  and  also  the  ad- 
ductor transversus  pollicis.  The  lumbricals  form  soft  eminences  behind  the 
clefts  of  the  fingers — and  the  dorsal  interossei  form  similar  soft  eminences 
between  the  metacarpals.  The  position  of  many  of  the  extensor  tendons 
can  be  recognized  by  both  sight  and. touch — and  some  of  the  flexor  tendons 
can  be  detected  by  touch  while  in  the  act  of  movement. 

Vessels — the  superficial  palmar  arch  is  on  a  level  with  the  lower  border 
of  the  outstretched  thumb,  passing  down  from  the  wrist  on  the  outer  side 
of  the  pisiform.  The  deep  palmar  arch  lies  about  1.3  cm.  (h  inch)  nearer 
the  wrist,  crossing  the  shafts  of  the  second,  third,  and  fourth  metacarpals 
near  their  bases. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT 

THE  HANDS. 

A  finger  may  be  removed  with  a  part,  or  the  whole,  of  its  metacarpal. 
In  the  middle  metacarpals,  the  removal  of  a  part,  where  possible,  is  better 
than  a  disarticulation  at  the  carpo-metacarpal  joint — as  the  end  of  the  bone 
is  not  apt  to  get  into  the  way,  and  the  strength  of  the  hand  is  greater.  In 
the  case  of  the  thumb  and  little  finger,  however  (which  are  the  fingers  most 
frequently  removed,  because  most  exposed  to  injury),  it  is  best  to  remove  the 
entire  metacarpal — the  retention  of  a  part  of  the  outer  metacarpals  being 
of  little  value,  and  often  in  the  way — and  its  removal  not  weakening  the  hand 
as  much  as  the  loss  of  an  inner  one. 

If  but  a  part  of  the  metacarpal  of  the  thumb  or  little  finger  be  removed, 
however,  the  remaining  portion  should  be  beveled  obliquely  away  from  the 
position  of  most  pressure. 

The  metacarpals  should  be  divided  in  their  continuity  by  a  Gigli  saw 
It  is  easier,  but  less  surgical,  to  divide  them  with  bone-cutting  pliers. 


34° 


AMPUTATIONS. 


Fig.  321. — Amputations  about  Hand  and  Wrist: — A,  Disarticulation  of  two  inner  fingers, 
together  with  their  metacarpals,  by  curved  racket  incision;  B,  Disarticulation  at  wrist  by  equal 
anterior  and  posterior  flaps;  C,  D,  Oblique  section  of  second  and  fifth  metacarpals  as  sometimes 
practised  in  disarticulation  at  metacarpo-phalangeal  joints  of  first  and  fourth  fingers;  E,  Amputa- 
tion of  part  of  metacarpal  by  oval  method  as  sometimes  performed  in  disarticulation  at  the 
metacarpo-phalangeal  joints  of  the  innermost  and  outermost  fingers. 

Additional  advantages  in  amputating  a  finger  and  part  of  its  metacarpal, 
over  disarticulating  a  finger  and  all  of  its  metacarpal,  are  the  following; — 
deep  palmar  arch  is  not  exposed;  synovial  sacs  of  flexor  tendons  may  escape, 


AMPUTATION    OF    FINGER    WITH    PART    OF    ITS    METACARPAL.      341 

if  the  bone  be  divided  above  its  center;  carpo-metacarpal  synovial  sacs  are 
not  opened;  and  tendons  attached  to  bases  of  metacarpals  are  not  lost. 

Where,  in  disarticulating  at  the  carpo-metacarpal  articulation,  the  joint- 
line  is  not  easily  located  before  incising,  begin  the  incision  as  high  as  thought 
to  be  the  articular  line,  and  then  verify  the  line  by  inserting  the  tip  of  the 
index-finger  into  the  wound,  while  the  opposite  hand  manipulates  the  special 
finger  whose  metacarpal  forms  part  of  the  articulation. 

As  the  metacarpal  of  the  thumb  and,  according  to  some,  of  the  little  finger 
do  not  communicate  with  the  large  synovial  sac  of  the  carpal  bones,  they 
can  be  removed  in  their  entirety  with  little  danger  of  infection — but,  in  un- 
clean cases,  the  removal  of  the  second,  third,  and  fourth  metacarpals  in  their 
continuity  is  preferable  to  a  disarticulation  at  the  carpo-metacarpal  line, 
with  the  likelihood  of  general  infection. 

The  synovial  sheaths  should  be  closed  with  gut-suture  when  cut.  But 
where  large  synovial  sheaths  and  extensive  articular  surfaces  are  opened  up, 
drainage  for  twenty-four  or  forty-eight  hours  is  indicated. 

In  partial  amputations  of  the  hand,  the  flexor  and  extensor  tendons  should 
be  cut  long  enough  to  be  sutured  into  the  wound,  so  as  to  retain  flexion  and 
extension  of  the  stump. 

The  main  dangers  in  amputating  and  disarticulating  about  the  hand 
are  wounding  of  the  deep  palmar  arch  or  termination  of  the  radial,  and  in 
opening  the  synovial  sheath  of  the  palm  or  fingers. 

The  stump  should  be  dressed  upon  a  splint  which  will  immobilize  the 
wrist. 


AMPUTATION  OF  FINGERS,    IN   GENERAL,  WITH   PARTS  OF   THEIR 

METACARPALS. 

Methods. — Racket  Method — best  for  single  fingers,  in  general,  as  well  as 
for  thumb  and  little  finger;  and  also  for  two  or  three  continguous  inside 
fingers.  Equal  Dorsal  and  Palmar  Flaps — best  for  the  three  inner  fingers. 
Anterior  Ellipse  (sometimes  called  a  Short  Palmar  Flap) — best  for  all  the 
fingers,  not  including  the  thumb. 

General  Indications. — Traumatism  and  infection. 


AMPUTATION   OF   A   FINGER.   IN  GENERAL,  WITH  PART  OF  ITS 

METACARPAL, 

BY  RACKET   METHOD. 

Description. — The  finger  is  removed  as  one  continuous  whole  at  the 
line  of  section  of  the  metacarpal. 

Position. — Same  as  for  amputation  through  last  phalanx  (page  327). 

Landmarks. — Outline  of  dorsal  aspect  of  metacarpal;  carpo-metacarpal 
joint;  webs  of  fingers. 

Incision. — Begins  over  dorsum  of  metacarpal,  a  short  distance  above 
the  point  at  which  the  bone  is  to  be  sawed — passes  thence  downward  over 
the  middle  of  the  dorsal  aspect  until  the  neck  of  the  metacarpal  is  reached 
— whence  the  median  line  diverges  into  two  limbs,  each  limb  passing  down 
the  dorso-lateral  aspect  of  the  finger  to  just  below  the  junction  of  the  web  and 
finger — whence  each  limb  crosses  immediately  in  front  of  the  digito-palmar 
crease  to  meet  in  the  center  of  the  palmar  aspect  of  the  finger  (Fig.  320,  L). 


342  AMPUTATIONS. 

Operation.— This  incision  is  rleepened  to  the  bone  on  the  line  of  the 
retracted  skin.  The  extensor  tendons  are  divided  near  the  upper  end  of 
the  vertical  incision.  The  sides  of  the  shaft  of  the  metacarpal  are  carefully 
cleared,  hugging  the  bone  in  the  process.  The  region  of  the  metacarpo- 
phalangeal joint  is  also  freed  and  the  flexor  tendons  divided  near  the  neck 
of  the  metacarpal,  while  the  finger  is  forcibly  extended.  The  shaft  of  the 
metacarpal  is  further  cleared  up  to  the  saw-line,  the  finger  being  held  in 
extreme  extension.  The  Gigli  or  chain  saw  is  now  passed  beneath  the  meta- 
carpal, while  the  soft  parts  are  held  out  of  the  way,  and  the  bone  sawed  so 
as  to  bevel  it  from  below  upward  and  toward  the  dorsum.  The  digital 
arteries  are  divided  and  are  to  be  tied.  The  synovial  sheath  of  the  flexor 
tendons  should  be  closed  with  gut  sutures.  The  wound  is  sutured  in  a  single 
median  line  upon  the  dorsal  aspect. 


AMPUTATION  OF  THUMB  WITH  PART  OF  ITS  METACARPAL 

BY  RACKET    METHOD. 

Description — Position — Landmarks. — As  for  amputation  of  a  finger 
with  part  of  its  metacarpal  (page  341). 

Incision. — As  in  disarticulation  of  thumb  with  its  entire  metacarpal,  by 
the  racket  method  (page  345) — except  that  the  queue  of  the  incision  only 
extends  up  to  a  little  above  the  sawdine. 

Operation. — As  for  amputation  of  a  finger  with  part  of  its  metacarpal 
(page  341).  The  metacarpal  should  be  beveled  from  above  downward  and 
inward. 

AMPUTATION  OF  LITTLE  FINGER  WITH  PART  OF  ITS  METACARPAL 

BY  RACKET   METHOD. 

Description — Position — Landmarks. — As  for  amputation  of  a  finger 
with  part  of  its  metacarpal  (page  341). 

Incision. — As  in  disarticulation  of  little  finger  with  its  entire  metacarpal, 
by  the  racket  method  (page  344) — except  that  the  queue  of  incision  begins 
just  above  sectiondine  of  bone. 

Operation. — As  for  amputation  of  a  finger  with  part  of  its  metacarpal, 
by  the  racket  method.  The  metacarpal  should  be  beveled  from  above 
downward  and  toward  the  radial  side. 


AMPUTATION   OF   TWO   CONTIGUOUS   INSIDE   FINGERS   WITH   PART 
OF  THEIR  METACARPALS 

BY  RACKET   METHOD. 

Similar,  practically,  to  the  disarticulation  of  two  contiguous  inside  fingers 
with  their  entire  metacarpals,  by  the  racket  method  (page  346). 


AMPUTATION    OF    THREE    INSIDE    FINGERS    WITH    PARTS    OF 
THEIR  METACARPALS 

BY  RACKET   METHOD. 

See  the  disarticulation  of  the  three  innermost  fingers  with  their  entire 
metacarpals  by  the  racket  method  (page  346). 


DISARTICULATION    OF    FINGERS    WITH    ENTIRE    METACARPALS.         343 

AMPUTATION    OF    THREE    INNERMOST    FINGERS    WITH    PARTS    OF 
THEIR  METACARPALS 

BY  EQUAL  DORSAL  AND   PALMAR  FLAPS. 

See  the  disarticulation  of  the  three  innermost  fingers  with  their  entire 
metacarpals,  by  the  method  of  equal  dorsal  and  palmar  flaps  (page  346) . 

AMPUTATION    OF    ALL    THE    FINGERS    (EXCLUDING  THE    THUMB), 
WITH  PARTS  OF  THEIR  METACARPALS, 

BY  ANTERIOR    ELLIPSE. 

See  the  corresponding  disarticulation  of  all  the  fingers,  exclusive  of  the 
thumb,  with  their  entire  metacarpals,  bv  an  anterior  ellipse  (or  short  palmar 
flap,  as  it  is  sometimes  called)  (page  348). 


Fig.  322. — Showing  the  Relations  or  the  Various  Metacarpal  to  the  Correspond" 
tng  Carpal  Bones,  as  Guides  in  Disarticulating  the  Metacarpals  from  the  Carpals 
and  the  Adjacent  Metacarpals. 


DISARTICULATION  OF  FINGERS,  IN  GENERAL,  WITH  THEIR  ENTIRE 

METACARPALS. 

Methods. — Racket  Method — best  for  the  fingers  in  general,  including 
thumb,  index,  and  little  fingers — and  also  used  for  the  two  or  three  inside 
fingers.  Equal  Dorsal  and  Palmar  Flaps — best  for  three  innermost  fingers. 
Anterior  Ellipse  (Short  Palmar  Flap) — best  for  all  the  fingers,  exclusive  of 
thumb — and  also  best  for  all  the  fingers  including  thumb.  Palmar  Flaps — ■ 
sometimes  used  for  the  thumb,  but  inferior  to  the  racket.  Circular  Method 
— sometimes  used  for  all  the  fingers,  with  or  without  the  thumb. 

Comment. — Preservation  of  the  carpus  is  desirable,  especially  if  the 
flexor  and  extensor  tendons  are  so  sutured  into  the  wound  that  considerable 
range  of  movement  may  be  secured  for  the  stump  wielding  the  artificial 
limb.     Fig.  322  shows  the  intercarpal  and  carpo-metacarpal  joints. 


344 


AMPUTATIONS. 


DISARTICULATION  OF  AN   INNER  FINGER  WITH   ITS  METACARPAL 

BY  RACKET    INCISION. 

Description. — The  finger  is  removed  as  one  continuous  whole  at  the 
carpometacarpal  articulation. 

Position. — As  for  amputation  through  the  last  phalanx  (page  327). 

Landmarks. — Outline  of  dorsal  aspect  of  carpo-metacarpal  articulation, 
and  metacarpal  bone. 

Incision — Begins  just  above  the  carpo-metacarpal  joint — passes  down 
the  median  dorsal  aspect  of  the  metacarpal  until  its  neck  is  reached — thence 
diverges  into  two  limbs,  each  limb  running  over  the  dorso-lateral  aspect  of 
the  finger  to  just  below  the  junction  of  the  web  and  finger — whence  each 
limb  crosses  the  digito-palmar  crease  to  meet  in  the  center  of  the  palmar 
aspect  of  the  finger.  If  necessary  for  the  purpose  of  aiding  disarticulation 
at  the  carpo-metacarpal  joint,  a  short  transverse  incision  may  be  made  at  a 
right  angle  to  the  upper  end  of  the  queue  (Fig.  320,  K). 

Operation. — This  incision  is  now  deepened  on  a  line  of  the  retracted 
skin  and  fascia.  The  shaft  of  the  metacarpal  and  the  metacarpophalangeal 
joint  are  carefully  cleared,  hugging  the  bones  as  closely  as  possible,  while 
an  assistant  keeps  the  finger  in  the  position  of  extreme  extension.  The  extensor 
tendons  are  divided  as  near  the  upper  limit  of  the  queue  as  possible — the 
flexor  tendons  near  the  neck  of  the  metacarpal.  The  sides  of  the  metacarpal 
are  now  bared  up  toward  the  carpo-metacarpal  articulation,  using  especial 
care  in  the  palmar  region.  The  ligaments  of  the  intermetacarpal  joints 
and  carpo-metacarpal  joints  are  divided  by  carefully  thrusting  a  knife  between 
the  sides  of  the  bases  of  the  metacarpals  and  between  the  metacarpals  and 
the  carpal  bones,  working  from  the  dorsum  of  the  hand.  The  disarticulation 
is  completed  by  forcibly  turning  back  the  finger  upon  the  dorsum  of  the 
hand,  completing,  with  the  knife,  the  division  of  any  undivided  ligaments, 
insertions  of  tendons,  or  palmar  structures.  The  synovial  sheaths  of  the 
flexor  tendons  should  be  sutured  with  catgut,  if  possible.  Tie  the  two  digital 
arteries — and  suture  the  wound  in  a  single  median  line  upon  its  dorsal  aspect. 


DISARTICULATION  OF  INDEX-FINGER  WITH  ITS  METACARPAL 

BY  RACKET    INCISION. 

Description. — The  steps  of  this  operation  are  practically  the  same  as 
for  the  corresponding  operation  upon  an  inner  finger.  The  incision  is  in 
the  mid-dorsal  line.  The  addition  of  a  short  transverse  incision  at  a  right 
angle  to  the  upper  end  of  the  queue  is  especially  advisable  here,  owing  to 
the  width  of  the  base  of  the  second  metacarpal.  The  outer  (radial)  of  the 
diverging  limbs  below  should  follow  the  dorsal  aspect  a  little  further  down 
before  sweeping  over  the  lateral  aspect  than  does  the  inner  (ulnar)  limb,  in 
order  to  bring  the  scar  more  out  of  the  way  of  pressure.  The  index  should 
be  extended  and  abducted  in  clearing  and  disarticulating.  Tie  the  digital, 
radialis  indicis,  and  dorsalis  indicis  arteries — and  suture  the  wound  in  a  ver- 
tical dorsal  line. 


DISARTICULATION    OF    LITTLE    FINGER    WITH    ITS    METACARPAL 

BY  RACKET  INCISION. 

Description. — The  steps  of  the  operation  are  essentially  similar  to  those 
for  the  removal  of  an  inner  finger  with  its  metacarpal  by  the  racket  incision. 
It  is  better  to  place  the  incision  in  the  mid-dorsal  aspect  than  toward  the 


DISARTICULATION    OF    THUMB    WITH    ITS    METACARPAL.  345 

inner  (ulnar)  side  of  the  metacarpal,  as  objects  less  easily  press  such  a  scar. 
At  the  upper  extremity  of  the  queue  a  short  transverse  incision  may  be  added, 
not  crossing  the  upper  end  of  the  queue  (as  in  the  case  of  the  inner  fingers), 
but  running  from  the  upper  end  of  the  queue  at  a  right  angle  toward  the 
ulnar  aspect  of  the  hand,  over  the  carpo-metacarpal  joint — to  allow  of  readier 
disarticulation.  The  inner  (ulnar)  of  the  diverging  limbs  below  should 
follow  the  dorsal  aspect  a  little  further  down  before  sweeping  over  the  lateral 
border  than  does  the  outer  (radial)  limb — in  order  to  bring  the  scar  more 
out  of  the  way  of  pressure.  The  little  finger  should  be  extended  and  ab- 
ducted (from  the  median  line  of  the  hand)  in  clearing  and  disarticulation. 
Carefully  close  the  large  synovial  sac  of  the  little  finger,  if  opened.  Preserve 
the  hypothenar  muscles  as  far  as  possible  and  suture  into  the  wound.  Suture 
the  wound  in  a  single  dorsal  line  (Fig.  320,  J). 


DISARTICULATION  OF  THUMB  WITH  ITS  METACARPAL 

BY  RACKET    INCISIOX. 

Description. — Removal  of  the  thumb,  together  with  its  metacarpal,  at 
the  carpo-metacarpal  joint. 

Position. — Same  as  for  the  fingers,  except  that  the  hand  is  held  midway 
between  pronation  and  supination. 

Landmarks. — Outline  of  the  dorsal  aspect  of  the  metacarpal,  and  the 
carpo-metacarpal  joint. 

Incision. — Begins  just  above  the  carpo-metacarpal  joint-line,  in  the 
mid-dorsal  aspect  of  the  metacarpal — passing  into  the  "snuff-box,"  if  at  all, 
with  great  care  and,  at  first,  very  superficially,  on  account  of  the  radial  artery. 
The  incision  then  passes  down  the  center  of  the  dorsum  of  the  thumb  to  the 
neck  of  the  metacarpal — and  here  divides  into  the  two  limbs  of  an  oval, 
which  part  to  encircle  the  head  of  the  metacarpal,  crossing  the  palmar  aspect 
of  the  thumb  on  a  level  with  the  free  edge  of  the  web — the  outer  (radial)  of  the 
diverging  limbs  following  the  dorsal  aspect  a  little  further  down  before  sweep- 
ing over  the  lateral  aspect  than  does  the  inner  (ulnar)  limb  (Fig.  320,  N). 

Operation. — This  incision  is  deepened  on  the  line  of  the  retracted  skin 
and  fascia.  The  extensor  tendons  of  the  first  and  second  phalanges  are 
cut  as  long  as  possible,  so  as  to  be  sutured  into  the  wound.  The  dorsum 
and  sides  of  the  metacarpal  are  cleared  of  soft  parts,  hugging  the  bone.  The 
thumb  is  extended  and  abducted  and  the  muscles  attached  to  the  base  of 
the  first  phalanx  are  divided  near  the  sesamoid  bones,  preserving  the  thenar 
muscles  as  far  as  possible.  The  palmar  aspect  of  the  metacarpal  is  cleared 
while  an  assistant  rotates  the  thumb  from  side  to  side,  working  as  near  the 
bone  as  possible.  The  flexor  longus  pollicis  tendon  is  divided  low  down,  so 
that  it  may  be  sutured  into  the  wound.  Disarticulation  is  accomplished 
by  severing  the  binding  ligaments  and  the  extensor  ossis  metacarpi  pollicis, 
while  the  thumb  is  flexed  into  the  palm — opening  the  joint  from  the  dorsum, 
the  thumb  being  then  rotated  in  different  directions  to  complete  the  dis- 
articulation. Suture  the  sheath  of  the  flexor  tendon.  Tie  the  arteria  princeps 
pollicis,  or  its  two  branches,  and  the  dorsalis  pollicis.  Quilt  the  muscles, 
suturing  the  flexor,  extensor,  and  thenar  tendons  and  muscles  into  the  wound. 
The  cicatrix  will  run  in  a  dorsal  median  line. 


346  AMPUTATIONS. 


DISARTICULATION    OF    TWO    CONTIGUOUS    INSIDE    FINGERS    WITH 
THEIR  METACARPALS 

BY  RACKET    INCISION. 

Description. — The  operation  is  the  same,  in  principle,  as  that  for  the 
removal  of  a  single  finger  and  its  metacarpal.  A  vertical  incision  begins 
just  above  the  carpo-metacarpal  joint-line  and  between  the  bases  of  the  two 
contiguous  metacarpals — passes  down  the  back  of  the  hand  midway  between 
the  two  metacarpals  for  about  one-half  of  their  length — then  divides  into 
the  two  limbs  of  an  oval,  or  racket — the  radial  limb  passing  to  the  radial  side 
of  the  outer  of  the  two  fingers  to  be  removed — the  ulnar  limb  to  the  ulnar 
side  of  the  inner  of  the  two  fingers  to  be  removed — to  the  junction  of  the 
fingers  and  webs — thence  both  limbs  cross  and  meet  beneath  the  fingers 
in  the  digito-palmar  crease.  The  incision  is  deepened — the  metacarpals 
cleared — the  tendons  cut  long — disarticulation  accomplished — and  the  opera- 
tion completed  just  as  in  the  disarticulation  of  a  single  finger  and  its  meta- 
carpal. The  flexor  and  extensor  tendons  are  to  be  sutured  into  the  wound. 
(Fig.  320,  M.) 

DISARTICULATION  OF  THREE  INSIDE  FINGERS  WITH  THEIR  META- 
CARPALS 

BY  RACKET   INCISION. 

Description. — Same,  in  the  main,  as  the  disarticulation  of  any  two 
contiguous  inside  fingers  with  their  metacarpals — except  that  the  vertical 
incision  begins  just  above  the  carpo-metacarpal  joint  line,  over  the  center 
of  the  base  of  the  central  one  of  the  three  metacarpals — passes  down  this 
metacarpal  for  about  one-third  of  its  length — and  thence  diverges,  the  radial 
limb  to  the  radial  side  of  the  outer  finger,  and  the  ulnar  limb  to  the  ulnar 
side  of  the  inner  finger — both  limbs  passing  to  the  junction  of  the  fingers 
with  the  webs — and  thence  crossing  and  meeting  in  the  digito-palmar  crease 
beneath  the  central  finger.  The  operation  is  completed  as  in  the  last — three 
fingers  and  their  metacarpals  being  removed  instead  of  two. 


DISARTICULATION    OF    THREE    INNERMOST    FINGERS  WITH  THEIR 

METACARPALS 

BY  EQUAL  DORSAL  AND  PALMAR  FLAPS. 

Description. — Corresponding  incisions  are  made  upon  palmar  and 
dorsal  aspects  of  the  hand,  furnishing  symmetrical  flaps. 

Position. — As  in  operations  upon  the  fingers  (page  327). 

Landmarks. — Carpo-metacarpal  articulations  of  third,  fourth,  and  fifth 
metacarpals;  middle  palmar  crease. 

Incision. — (1)  Palmar  incision — begins  just  below  the  base  of  the  fifth 
metacarpal — passes  downward  and  outward  across  the  palm,  parallel  with 
but  just  below  the  middle  palmar  crease,  until  opposite  the  center  of  the 
ring-finger  or  just  beyond — and  is  thence  directed  to  the  junction  of  the 
outer  side  of  the  middle  finger  and  web.  (2)  Dorsal  incision — corre- 
sponds with  the  palmar  incision   (Fig.  323,  A). 

Operation. — The  above  incisions  are  deepened  on  the  line  of  the  retracted 
skin  and  fascia.  The  metacarpal  bones  are  bared  to  their  joint-lines,  which 
is  more  easilv  done  in  the  case  of  the  fourth  and  fifth,  the  third  being  exposed 


DISARTICULATIONS    OF    FINGERS    WITH    THEIR    METACARPALS. 


347 


by  upward  and  outward  retraction  of  the  soft  parts.  The  nerves  are  cut 
as  near  the  line  of  disarticulation  as  possible.  The  flexor  and  extensor 
tendons  are  cut  long,  so  as  to  be  sutured  into  the  wound.  Care  is  taken 
not  to  wound  the  deep  arch.  Tie  the  interosseous  branches  of  the  deep  arch, 
and  the  palmar  digital  branches  of  the  superficial  arch,  or  the  arch  itself,  if 
wounded.  Suture  the  synovial  sheaths  where  opened.  The  muscles  of  the 
hypothenar  eminence  are  left  in  the  palmar  flap  as  far  as  possible  and  are 
quilted  to  the  fascia  of  the  dorsal  region,  where  there  are  no  muscles.     The 


Fig.  323.— Amputations  about  the  Hand  : — A,  Disarticulation  of  three  inner  fingers,  with  their 
metacarpals,  by  equal  dorsal  and  palmar  flaps;  B.  Disarticulation  of  all  the  fingers,  except  thumb, 
with  their  metacarpals,  by  anterior  ellipse;  C,  Disarticulation  at  wrist-joint,  by  circular  method. 
(Dorsal  view.) 


flexor  and  extensor  tendons  are  also  sutured  into  the  wound.  The  dorsal  and 
palmar  flaps  are  united  by  suture  extending  along  the  ulnar  side  of  the  hand. 
Comment. — In  the  unusual  cases  where  this  operation  is  done,  injury 
has  generally  been  the  cause,  and  its  extent  upon  the  dorsum  and  palm  will 
determine  the  outline  of  the  coverings.  Where  both  are  equally  involved 
the  above  coverings  will  have  to  be  taken — but  if  the  predominant  covering 
could  be  gotten  from  the  palm,  so  as  to  make  a  larger  palmar  and  smaller 
dorsal  flap,  the  scar  would  lie  on  the  dorsal  aspect  and  be  out  of  the  way  of 
pressure,  which  would  be  preferable. 


348  AMPUTATIONS. 

DISARTICULATION    OF    ALL    FINGERS,    EXCLUDING    THUMB,  WITH 
THEIR  METACARPALS 

PA'  ANTERIOR  ELLIPSE. 

Description. — This  is,  practically,  a  palmar  covering,  whose  convex 
anterior  border  fits  into  the  concave  wound  on  the  dorsum  of  the  hand.  It 
is  sometimes  called  the  short  palmar  flap  method. 

Position. — As  in  the  amputations  upon  the  fingers  in  general  (page  327). 

Landmarks. — Base  of  fifth  metacarpal  (marking  the  point  at  which  the 
ellipse  crosses  the  ulnar  border  of  the  hand);  point  midway  between  the 
central  crease  of  the  hand  and  the  level  of  the  outstretched  thumb  (marking 
the  point  at  which  the  ellipse  crosses  the  radial  border  of  the  hand);  the 
carpometacarpal  joint-line. 

Incisions. — Palmar  incision — passes  between  the  two  above  points,  with 
a  downward  convexity,  whose  lowest  part  reaches  below  the  middle  of  the 
metacarpals.  Dorsal  incision — also  passes  between  the  same  two  points, 
with  an  upward  convexity,  whose  highest  part  corresponds  with  the  bases 
of  the  two  inner  metacarpals  (Fig.  323,  B). 

Operation. — These  incisions  are  deepened  to  the  bone.  The  flexor 
and  extensor  tendons  are  cut  long.  The  soft  parts  are  cleared  up  to  the 
carpo-metacarpal  joint-line — the  metacarpals  are  disarticulated  from  the 
carpals,  and  the  second  metacarpal  from  the  first  metacarpal,  cutting  the 
dorsal  ligaments  by  flexing  and  the  palmar  ligaments  by  extending  the  hand. 
Tie  the  palmar  digital,  palmar  interosseous,  dorsalis  indicis,  radialis  indicis, 
and  palmar  arches,  if  severed.  Close  the  flexor  sheaths — suture  the  flexor 
and  extensor  tendons  into  the  wound — and  suture  the  convex  palmar  flap 
to  the  concave  dorsal  wound. 


DISARTICULATION     OF     FINGERS     AND     THUMB     AT     CARPO-META- 
CARPAL ARTICULATION 

BY  PALMAR  FLAP. 

Description. — Same,  in  principle,  as  the  disarticulation  of  the  hand  at 
the  wrist-joint  (page  352) — except  that  the  upper  limits  of  the  flap  extend 
only  to  the  ulnar  margin  of  the  unciform-metacarpal  articulation,  on  the 
one  side,  and  the  radial  margin  of  the  trapezio-metacarpal  articulation,  on 
the  other  side — the  lower  limit  crossing  the  necks  of  the  metacarpals. 


SURGICAL  ANATOMY  OF  THE  WRIST- JOINT. 

Bones. — Radius;  ulna;  first  row  of  carpal  bones  (scaphoid,  semilunar, 
cuneiform,  pisiform). 

Ligaments. — Anterior  radiocarpal;  posterior  radio-carpal;  external 
lateral;  internal  lateral;  and  synovial  membrane. 

Movements. — Flexion; — accomplished  by  flexor  carpi  radialis;  flexor 
carpi  ulnaris;  palmaris  longus.  Extension; — by  extensor  carpi  radialis 
longior;  extensor  carpi  radialis  brevior;  extensor  carpi  ulnaris.  Adduction; — 
by  flexor  carpi  ulnaris;  extensor  carpi  ulnaris.  Abduction; — by  extensor  ossis 
metacarpi  pollicis;  extensores  brevior  et  longior  pollicis;  extensores  carpi 
radialis  longior  et  brevior;  flexor  carpi  radialis. 

Muscles  and  Tendons  in  Neighborhood  of  Wrist-joint.— (a)  Ante- 
riorly;— flexor   carpi   radialis;   palmaris   longus;   flexor   carpi   ulnaris;   flexor 


SURFACE    FORM    AND    LANDMARKS    OF    THE    WRIST-JOINT.  349 

sublimis  digitorum;  tlcxor  profundus  digitorum;  flexor  longus  pollicis.  (b) 
Posteriorly; — extensores  carpi  radialis  longior  et  brevior;  extensor  communis 
digitorum;  extensor  indicis;  extensor  minimi  digiti;  extensor  carpi  ulnaris.  (c) 
Radial  Aspect; — supinator  longus;  extensor  ossis  metacarpi  pollicis;  extensor 
brevis  (primi  internodii)  pollicis;  extensor  longus  (secundi  internodii)  pollicis. 

Arteries  in  Neighborhood  of  Wrist-joint. — Radial,  with  its  anterior 
carpal,  superficialis  volae,  posterior  carpal  and  metacarpal  (first  dorsal  inter- 
osseous). Ulnar,  with  its  anterior  carpal,  posterior  carpal,  carpal  branch 
of  anterior  interosseous,  posterior  termination  of  anterior  interosseous.  Carpal 
recurrent  branch  from  deep  arch. 

Veins  in  Neighborhood  of  Wrist-joint. — Superficial — anterior  ulnar; 
posterior  ulnar;  radial;  median.  Deep — two  vena1  comites  accompany  each 
of  the  above  arteries. 

Nerves  in  Neighborhood  of  Wrist-joint. — Superficial — anterior  and 
posterior  branches  of  musculocutaneous;  anterior  and  posterior  branches 
of  internal  cutaneous;  palmar  cutaneous  branch  of  median;  palmar  cutaneous 
branch  of  ulnar;  cutaneous  branch  of  ulnar  communicating  with  anterior 
branch  of  internal  cutaneous  (frequently  absent) ;  dorsal  cutaneous  branch 
of  ulnar;  palmar  cutaneous  branch  of  radial;  dorsal  division  of  radial. 
Deep; — median;  ulnar;  termination  of  interosseous. 


SURFACE    FORM    AND    LANDMARKS    OF    THE    WRIST-JOINT. 

Articulation  of  the  wrist-joint  is  on  a  level  with  the  apex  of  the  styloid 
process  of  the  ulna,  which  is  the  key  to  the  joint.  To  find  the  joint-line  of 
the  wrist,  draw  a  straight  line  connecting  the  radial  and  ulnar  styloid  processes 
— then  draw  a  curved  line  between  the  same  points,  with  the  highest  part  of 
the  convexity  1.3  cm.  (J  inch)  above  the  straight  line — this  curved  line  will 
represent  the  dome-shaped  articular  line.  The  ulnar  styloid  process  is  more 
distinct  in  pronation — that  of  radial  in  supination. 

Two  or  three  skin-folds  generally  cross  the  palmar  surface  of  the  wrist 
transversely — the  lowest  fairly  represents  the  upper  border  of  the  anterior 
annular  ligament — and  is  about  1.3  to  2  cm.  (^  to  f  inch)  below  the  arch 
of  the  wrist-joint. 

All  the  muscles  mentioned  above  under  Surgical  Anatomy  can  generally 
be  felt  and  recognized  about  the  wrist-joint — except  the  flexor  profundus 
digitorum  and  flexor  longus  pollicis,  of  the  anterior  group;  the  extensor 
carpi  ulnaris,  of  the  posterior  group;  and  the  supinator  longus,  of  the  radial 
group. 

Bony  prominences  of  the  tubercle  of  the  scaphoid  and  ridge  of  the  trape- 
zium are  generally  to  be  felt  on  the  anterior  aspect  of  the  radial  side  of  the 
wrist — and  those  of  the  pisiform  and  unciform  process  of  the  unciform,  on 
the  ulnar  side. 

The  lower  end  of  the  diaphysis  of  the  ulna  just  comes  to  the  radio-ulnar 
joint.  The  lower  end  of  the  diaphysis  of  the  radius  comes  within  the  synovial 
membrane. 

The  tendon  of  the  extensor  longus  (secundi  internodii)  pollicis  marks 
the  center  of  the  lower  end  of  the  radius — and  indicates  the  interval  between 
the  scaphoid  and  semilunar. 

The  ulnar  artery,  with  the  ulnar  nerve  to  the  ulnar  side,  lies  on  the  anterior 
annular  ligament,  to  the  radial  side  of  the  pisiform  and  to  the  ulnar  side  of 
the  hook  of  the  unciform  (in  the  groove  between  them).  The  deep  branch 
of  the  ulnar  artery  arises  directly  below  the  pisiform. 


350  AMPUTATIONS. 

The  radial  artery  passes  under  the  extensor  tendons  of  the  thumb,  upon 
the  external  lateral  ligament,  winding  over  the  outer  side  of  the  carpus  from 
a  point  just  below  and  internal  to  the  styloid  process  of  the  radius  to  the 
base  of  the  first  interosseous  space. 

The  superficial  palmar  arch  is  on  a  line  with  the  lower  border  of  the 
outstretched  thumb — and  the  deep  arch  is  1.3  cm.  (h  inch)  higher. 


GENERAL  SURGICAL  CONSIDERATIONS  IN  DISARTICULATING  AT  THE 

WRIST-JOINT. 

Disarticulation  at  the  wrist-joint  is  preferable  to  amputation  through 
the  forearm,  as  pronation  and  supination  are  usually  retained,  and  the  stump 
is  better  adapted  to  an  artificial  limb. 

Avoid  injuring  the  radio-ulnar  articulation — which  is  adjacent  to,  but 
not  a  part  of,  the  wrist-joint. 

The  styloid  processes  of  the  radius  and  ulna  should  not  be  removed, 
especially  that  of  the  radius,  owing  to  the  attachment  of  the  supinator  longus. 

Disarticulation  of  the  joint  is  more  easily  done  from  the  dorsum. 

The  pisiform  bone  is  often  unconsciously  removed  with  the  flap,  and  it 
is  convenient  to  so  remove  it  and  subsequently  to  dissect  it  out. 

The  best  covering  for  the  joint  is  from  the  palm,  but  the  nature  of  the 
condition  for  which  the  operation  is  done  will  generally  determine  from 
which  aspect  the  covering  can  be  gotten.  Care  must  be  exercised  to  cover 
the  prominent  radial  styloid  process.  In  approximating  the  thick  palmar 
to  the  thin  dorsal  skin,  the  sutures  are  to  be  securely  tied  and  left  amply  long. 
Drainage  is  indicated  for  twenty-four  or  thirty-six  hours.  The  stump  should 
be  placed  upon  a  splint  which  will  steady  the  part  and  prevent  pronation 
and  supination,  in  a  position  midway  between  pronation  and  supination. 

The  lower  epiphyses  of  the  radius  and  ulna  join  the  bones  about  the 
twentieth  year. 


DISARTICULATION  AT  THE  WRIST- JOINT,  IN  GENERAL. 

Best  Methods. — Anterior  Ellipse;  Palmar  Flap;  External  lateral,  or 
radial,  Flap  (Dubrueil's  Method). 

Other  Methods. — Modified  Circular;  Circular;  Equal  Palmar  and 
Dorsal  Flaps;  Dorsal  Flap. 

Comment. — Anterior  ellipse  method  forms  the  best  covering,  and  amounts 
to  a  palmar  flap.  Palmar  flap — rather  bulky  and  unyielding  and  less  ad- 
justable. External  flap — a  good  substantial  covering,  and  especially  adapted 
to  cases  in  which  the  palmar  covering  is  not  available.  Circular  method — 
forms  a  scanty  covering.  Dorsal  flap — warrantable  when  the  palmar  and 
external  coverings  are  unavailable,  but  consists  only  of  skin  and  tendons. 

General  Indications. — Bad  crushes  of  hand;  malignant  disease;  chronic 
disease  of  bones  or  joints  of  hand 


DISARTICULATION    AT    THE    WRIST-JOINT. 


DISARTICULATION  AT  THE  WRIST- JOINT 

BY  ANTERIOR  ELLIPSE. 

Description. — The  covering  raised  is,  practically,  an  anterior  flap.  The 
idea  of  the  ellipse  is  appreciated  after  marking  the  outline,  as  given  below, 
and  then  viewing  it  from  the  radial  or  ulnar  aspect  of  the  hand. 


Fig.  324. — Disarticulation  ai  the  Wrist-joint  by  the  Anterior  Elliptical  Method. 

(Palmar  view.) 
Fig.  325.— Disarticulation  at  the  Wrist-joint  by  the  Palmar  Flap  Method.     (Palmar 

view.) 

Position. — Patient  on  back,  forearm  abducted  horizontally;  hand  pro- 
nated  or  supinated,  as  indicated  by  the  stage  of  the  operation.  Surgeon  sits 
or  stands,  facing  the  patient's  hand.  An  assistant  steadies  the  limb  from 
above,  and  holds  the  parts  out  of  the  way. 

Landmarks. — Line  of  the  wrist- joint;  pisiform;  base  of  fifth  metacarpal; 
carpo-metacarpal  joint  of  the  thumb. 

Incision. — Highest  point  of  the  ellipse  is  upon  the  dorsum,  1.3  cm.  (| 
inch)  below  the  line  of  the  wrist-joint,  and  on  a  line  with  the  middle  finger. 
Lowest  point  of  the  ellipse  is  upon  the  palm,  6.3  cm.  {t\  inches)  below  the 
line  of  the  wrist-joint,  and  on  a  line  with  the  middle  finger.  The  inner 
portion  of  the  ellipse  crosses  the  ulnar  border  of  the  hand  between  the  pisiform 
bone  and  base  of  the  fifth  metacarpal.     The  outer  portion  of  the  ellipse 


352  AMPUTATIONS. 

crosses  the  radial  border  of  the  hand  at  the  carpo-metacarpal  joint-line  of 
the  thumb.  The  entire  incision  has,  therefore,  a  downward  convexity  upon 
the  palm  and  an  upward  convexity  upon  the  dorsum,  and  passes  through 
the  four  above-mentioned  points  (Fig.  324,  A). 

Operation. — Supinating  the  hand  while  incising  the  palm,  and  pronating 
it  while  making  the  dorsal  incisions,  this  entire  ellipse,  which  has  been  made 
through  the  skin  and  fascia  at  first,  is  now  deepened  throughout.  The 
dorsal  integuments  are  first  dissected  to  the  joint-line.  The  hand  is  flexed 
and  the  extensor  tendons,  posterior  ligament,  and  lateral  ligaments  are  cut 
and  the  joint  opened — and  then  the  anterior  ligaments.  First  one  and  then 
the  other  lateral  border  of  the  hand  is  made  to  present  and  the  lateral  parts 
of  the  ellipse  carried  to  the  bones.  The  knife  is  then  carried  between  the 
flexor  tendons  and  the  carpus,  from  above  and  within,  and  made  to  clear 
out  the  hollow  of  the  carpus  in  the  act  of  cutting  its  way  obliquely  from  within 
downward  and  outward,  to  the  margin  of  the  palmar  incision  through  the 
skin — and  the  hand  thus  severed  from  the  arm.  All  loose  tendons  and 
nerves  are  to  be  cut.  The  following  arteries  are  to  be  tied;  radial,  ulnar 
(below  the  deep  branch),  deep  branch  of  the  ulnar,  superficialis  volae.  The 
deep  palmar  arch  and  part  of  the  superficial  palmar  arch  are  removed  with 
the  hand.  The  convex  palmar  flap  is  sutured  into  the  concave  wound  at 
the  back  of  the  wrist. 

Comment. — The  palmar  covering  can  be  entirely  freed  up  to  the  joint- 
line  before  disarticulating. 


DISARTICULATION  AT  THE  WRIST 

BY  PALMAR  FLAP. 

Description. — The  flap  is  U-shaped,  and  raised  entirely  from  the  palm. 

Position. — As  in  the  disarticulation  by  an  anterior  ellipse  (page  304). 

Landmarks. — Styloid  process  of  radius;  styloid  process  of  ulna;  middle 
of  metacarpus. 

Incision. — Palmar  incision — radial  limb  of  the  U  begins  1.3  cm.  (^  inch) 
below  the  radial  styloid  process  and  is  directed  downward  along  the  radial 
border  of  the  index.  Ulnar  limb  of  the  U  begins  1.3  cm.  (J?  inch)  below  the 
ulnar  styloid  process  and  is  directed  downward  along  the  ulnar  border  of 
the  little  finger.  These  limbs  are  bluntly  rounded  at  their  lower  ends  and 
pass  transversely  toward  each  other  so  as  to  meet  just  above  the  center  of 
the  metacarpus.  Dorsal  incision — crosses  the  carpus  in  a  straight  line,  or, 
better,  with  slightly  downward  convexity,  between  the  two  upper  ends  of  the 
palmar  incision  (Fig.  325). 

Operation. — With  the  hand  in  supination  and  extension,  the  palmar 
incision  is  deepened  to  the  flexor  tendons,  the  thenar  and  hypothenar  muscles 
being  cut  through  to  that  extent — and  the  palmar  flap  then  dissected  up  to 
the  joint-line,  raising  the  flap  from  the  bony  prominences  in  the  palm.  With 
the  hand  now  in  pronation  and  the  skin  of  the  wrist  drawn  upward,  the  dorsal 
incision  is  deepened  and  the  integuments  dissected  up  to  the  joint-line,  when 
the  extensor  tendons,  posterior  ligament,  and  lateral  ligaments  are  severed 
and  disarticulation  accomplished.  The  flexor  tendons  and  surrounding  tis- 
sues on  the  palmar  surface  are  now  severed,  while  on  the  stretch,  by  dividing 
the  anterior  ligament  from  within  the  disarticulated  joint  and  then  cutting 
the  flexor  tendons  from  the  dorsal  toward  the  palmar  aspect,  on  a  line  with 


SURGICAL    ANATOMY    OF    THE    FOREARM.  353 

the  retracted  palmar  (lap.  The  same  arteries  are  to  be  tied  as  in  the  ellip- 
tical method,  the  deep  arch  and  loops  of  the  superficial  arch  coming  away 
with  the  hand. 


DISARTICULATION  AT  THE  WRIST- JOINT 

BY  EXTERNAL  LATERAL,  OR  RADIAL  FLAP  —  DUBRUEIL'S  METHOD. 

Description. — A  saddle-shaped  flap  of  skin  and  muscles  is  raised  from 
the  metacarpal  region  of  the  thumb,  and  approximated  to  the  disarticulated 
ends  of  the  radius  and  ulna. 

Position. — As  in  disarticulation  by  the  elliptical  method  (page  351). 

Landmarks. — Wrist-joint;  first  metacarpal. 

Incision. — Flap-incision — begins  on  back  of  wrist,  about  6  mm.  (j  inch) 
below  the  wrist-joint  line,  and  at  the  junction  of  the  outer  and  middle  thirds 
of  that  line — passes  thence  downward  upon  the  dorsal  aspect  of  the  thumb — 
thence  rounds  outward  to  cross  the  first  metacarpal  transversely  about  its 
middle  (remaining,  up  to  the  point  of  rounding  outward,  as  far  from  the 
outer  border  of  the  hand  as  at  the  beginning).  The  incision  now  passes 
upward  correspondingly  on  the  inner  aspect  of  the  thumb,  following  the 
inner  part  of  the  thenar  eminence  to  a  point  about  6  mm.  (|  inch)  below  the 
wrist-joint  line,  at  the  junction  of  the  outer  and  middle  thirds  of  that  line 
on  the  palmar  surface.  Disarticulating-incision — the  two  upper  ends  of  this 
flap  are  connected  by  a  transverse  incision  passing  directly  around  the  inner 
aspect  of  the  wrist-joint  (Fig,  320,  P,  P). 

Operation. — The  thenar  incision,  forming  the  flap,  is  deepened — the 
soft  parts  are  dissected  from  the  metacarpal,  and  as  much  of  the  thenar 
muscles  as  possible  is  taken.  The  soft  parts  upon  the  inner  aspect  of  the 
wrist  are  divided  to  the  bone  by  the  circular  incision  on  a  level  with  the  base 
of  the  flap.  Disarticulation  is  accomplished  from  the  dorsal  and  inner 
aspect,  toward  the  palmar  and  outer.  The  following  arteries  are  to  be  tied: 
superficial  and  deep  palmar  arches,  dorsalis  and  radialis  indicis  and  ulnar. 
The  tendons  and  nerves  are  treated  as  in  the  preceding  operations  upon  the 
wrist.  The  external  or  thenar  flap  is  now  brought  transversely  across  the 
articular  ends  of  the  radius  and  ulna,  and  sutured  to  the  circularly  divided 
parts. 


SURGICAL  ANATOMY  OF  THE  FOREARM. 

Bones. — Radius;  ulna. 

Articulations  and  Ligaments. — (a)  Superior  Radio-ulnar  Articulation; 
— orbicular  ligament;  synovial  membrane,  (b)  Middle  Radio-ulnar  Articu- 
lation;— oblique  (round)  ligament;  interosseous  membrane.  (c)  Inferior 
Radio-ulnar  Articulation; — anterior  radio-ulnar  ligament;  posterior  radio- 
ulnar ligament;  interarticular  (triangular)  fibro-cartilage;  synovial  mem- 
brane,    (d)  Elbow-joint  (page  359).      (e)  Wrist-joint  (page  348). 

Muscles  of  the  Forearm. — (a)  Anterior  radio-ulnar  region  : — (i) 
More  Superficial  Muscles; — pronator  radii  teres;  flexor  carpi  radialis;  palmaris 
longus;  flexor  carpi  ulnaris;  flexor  sublimis  digitorum.  (2)  Deeper  Muscles; 
— flexor  profundus  digitorum;  flexor  longus  pollicis;  pronator  quadratus. 
(b)  Radial  region: — supinator  longus;  extensor  carpi  radialis  longior;  ex- 
tensor   carpi    radialis    brevior.     (c)   Posterior    radio-ulnar    region:— (1) 

23 


354  AMPUTATIONS. 

More  Superficial  Muscles; — extensor  communis  digitorum;  extensor  minimi 
digiti;  extensor  carpi  ulnaris;  anconeus.  (2)  Deeper  Muscles; — supinator 
brevis;  extensor  ossis  metacarpi  pollicis;  extensor  brevis  (primi  internodii) 
pollicis;  extensor  longus  (secundi  internodii)  pollicis;  extensor  indicis. 

Arteries  of  the  Forearm. — Radial,  with  radial  recurrent;  muscular; 
anterior  carpal;  superficialis  volar,  posterior  carpal  branches.  Ulnar,  with 
anterior  ulnar  recurrent;  posterior  ulnar  recurrent;  common  interosseous; 
anterior  interosseous;  posterior  interosseous;  muscular;  anterior  carpal; 
posterior  carpal  branches. 

Veins  of  Forearm. — Superficial — median;  median  cephalic;  median 
basilic;  deep  median;  radial  cephalic;  cephalic;  anterior  ulnar;  posterior 
ulnar;  common  ulnar;  basilic.  Deep — two  venae  comites  accompanying  each 
of  above  arteries. 

Nerves  of  Forearm. — Superficial; — musculocutaneous;  internal  cutane- 
ous; external  cutaneous  branch  of  musculospiral;  cutaneous  branch  of  ulnar; 
dorsal  cutaneous  branch  of  ulnar;  cutaneous  branches  of  radial.  Deep; — 
ulnar  and  its  muscular  branches;  median  and  its  muscular  branches;  muscular 
branches  of  musculospiral;  radial  branch  of  musculospiral;  posterior  inter- 
osseous branch  of  musculospiral.  The  cross-sections  of  the  forearm  are  shown 
in  Figs.  32,  34,  and  327. 


SURFACE  FORM  AND  LANDMARKS  OF  THE  FOREARM. 

Olecranon  and  posterior  border  of  upper  part  of  ulna  are  subcutaneous 
— and  the  entire  shaft  is  to  be  felt  down  to  the  styloid  process,  passing  from 
the  center  of  the  forearm  above  to  the  ulnar  side  of  the  wrist  below,  and  lying 
between  the  flexor  and  extensor  carpi  ulnaris.  The  ulnar  styloid  process  is 
best  felt  with  the  forearm  midway  between  flexion  and  extension,  being  con- 
tinuous with  the  posterior  subcutaneous  border  of  the  bone. 

Head  of  the  radius  is  felt  just  below  and  a  little  in  front  of  the  posterior 
surface  of  the  external  condyle,  revolving  in  the  orbicular  ligament  and  lesser 
sigmoid  cavity — marked  by  a  dimple  in  the  skin  posteriorly,  best  seen  when 
the  arm  is  extended.  The  lower  half  of  the  radius  can  be  outlined,  though 
not  subcutaneous — the  outer  aspect  of  the  lower  part  alone  being  subcutaneous, 
and  ending  in  the  radial  styloid  process.  The  radius  is  deeply  covered  above 
and  superficially  covered  below.  Opposite  a  point  in  the  forearm  where 
one  bone  is  most  slender,  the  opposite  bone  is  most  substantial — both  being 
about  equal  in  the  middle.  The  radius  and  ulna  are  everywhere  nearer  the 
posterior  than  anterior  aspect  of  the  forearm,  and  increasingly  so  above. 
They  are  nearest  each  other  in  complete  pronation  and  furthest  in  complete 
supination. 

Flexor  and  pronator  muscles  form  the  muscular  elevation  upon  the  inner 
side  of  the  elbow  and  forearm — the  extensor  and  supinator  muscles  forming 
a  corresponding  elevation  upon  the  outer  and  posterior  side  of  the  elbow 
and  forearm.  These  two  groups  diverge  above  toward  the  condyles  of  the 
humerus  and  converge  below  toward  the  center  of  the  forearm — the  supinator 
longus  forming  the  outer  boundary  and  the  pronator  radii  teres  the  inner 
boundary  of  the  triangular  space  at  the  bend  of  the  elbow.  Of  the  muscles 
of  the  internal  group,  the  pronator  radii  teres,  flexor  carpi  radialis,  palmaris 
longus,  flexor  carpi  ulnaris,  alone  influence  surface  form,  the  remainder  being 
unrecognizable.     The  external  group  of  muscles  divides  into  two  longitudinal 


SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT    FOREARM.    355 

eminences,  diverging  from  each  other,  with  a  triangular  interval  between 
them: — the  outer,  consisting  of  the  supinator  longus,  extensor  carpi  radialis 
longior  and  brevis,  descending  from  the  outer  condyloid  ridge  toward  the 
radial  styloid  process; — the  other,  more  posterior,  consisting  of  the  extensor 
communis  digitorum,  extensor  minimi  digiti,  extensor  carpi  ulnaris,  descend- 
ing from  the  external  condyle,  separated  above  from  the  anconeus  by  a  furrow, 
and  below  from  the  pronator-flexor  mass  by  the  ulnar  furrow.  In  the  tri- 
angular interval  between  these  two  groups  the  extensor  ossis  metacarpi 
pollicis,  extensor  brevis  pollicis,  extensor  longus  pollicis,  and  extensor  indicis 
pass  downward.  The  anconeus  forms  a  slight  prominence  external  to  the 
subcutaneous  posterior  surface  of  the  olecranon. 

In  the  muscular,  the  transverse  is  much  greater  than  the  antero-posterior 
diameter  of  the  forearm — and  the  downward  tapering  is  marked.  In  the 
non-muscular,  the  forearm  is  more  rounded  and  the  tapering  is  less.  Above, 
the  muscles  are  found  chiefly  at  the  sides  and  in  front; — below,  more  equally 
along  the  anterior  and  posterior  aspects — hence  flap  amputations  are 
more  adapted  to  the  upper  and  circular  amputations  to  the  lower  part  of 
the  forearm. 

The  three  chief  pronators  of  the  forearm  are,  the  pronator  radii  teres, 
pronator  quadratus,  and  flexor  carpi  radialis.  The  three  chief  supinators 
are,  the  supinator  longus,  supinator  brevis,  and  biceps. 


GENERAL     SURGICAL    CONSIDERATIONS     IN     AMPUTATIONS  ABOUT 

THE  FOREARM. 

For  the  purposes  of  amputation,  the  forearm  may  be  divided  into  two 
natural  regions,  a  lower  one-third  and  an  upper  two-thirds — the  former 
being  characterized  by  an  almost  even  contour  of  similar  dimensions  through- 
out— the  latter,  especially  in  the  muscular,  by  its  rapidly  increasing  measure- 
ments up  to  from  2.5  to  5  cm.  (1  to  2  inches)  below  the  elbow,  and  with  a 
slight  decrease  thence  to  the  elbow-joint.  Therefore,  on  this  account,  and 
because  of  the  grouping  of  the  muscles,  amputation-methods  are  described 
as  applicable  to  "the  lower  third"  and  "the  upper  two-thirds."  (In  this 
connection,  see  the  last  paragraph  from  the  bottom,  in  the  above  section.) 

The  general  type  of  amputation  most  suitable  for  the  lower  third  of  the 
forearm  is  the  circular  method — and  the  general  type  most  suitable  for  the 
upper  two-thirds  is  the  flap  method. 

Saving  of  the  smallest  part  of  the  forearm,  with  its  movement,  is  preferable 
to  disarticulation  at  the  elbow. 

If  possible,  the  bones  should  be  sawed  below  the  insertion  of  the  pronator 
radii  teres,  otherwise  the  radius  will  become  supinated  and  rotatory  move- 
ments lost. 

Owing  to  the  tendency  of  the  bones  to  project  through  the  angles  of  the 
flaps,  the  flaps  at  their  bases  and  their  lower  ends  should  be  made  fully  long. 

In  cutting  by  transfixion  the  interosseous  membrane  is  apt  to  be  pierced. 

A  terminal  cicatrix  is  here  desirable,  as  best  adapted  to  an  artificial  limb. 

The  stump  should  be  dressed  with  the  forearm  midway  between  pronation 
and  supination,  and  the  elbow  steadied  by  a  right-angled  splint. 


356 


AMPUTATIONS. 


AMPUTATION  OF  THE  FOREARM,   IN  GENERAL. 

Best  Methods. — Modified  Circular — 
for  the  lower  third.  Equal  Anterior  and 
Posterior  Flaps— for  the  upper  two-thirds 

Other  Methods. — Long  Anterior  Flap 
— where  the  posterior  tissues  are  defi- 
cient. Long  Posterior  Flap — where  the 
anterior  tissues  are  deficient.  Long  An- 
terior and  Short  Posterior  Flap.  Rec- 
tangular Flaps  (Teale's  method).  Ex- 
ternal Lateral  Flap — where  the  internal 
tissues  are  deficient.  Equilateral  Skin- 
flaps.     Circular  Skin-flap.     Circular. 

General  Indications. — Injury;  tuber- 
cular    disease  of     wrist;     malignancy. 

AMPUTATION   OF  LOWER  THIRD   OF 
FOREARM 

BY  MODIFIED  CIRCULAR  METHOD. 

Description. — Two  short  flaps  of 
skin  and  fascia  are  turned  back  and 
the  muscles  are  then  circularly  divided  at 
the  level  of  the  retracted  skin-and-fascia 
flaps. 

Position. — Patient  supine,  near  edge 
of  table,  with  upper  limb  abducted  to  a 
right  angle — and  held  by  an  assistant  in 
supination  during  anterior  incisions,  and 
in  pronation,  or  vertically,  during  pos- 
terior incisions.  Surgeon  to  outer  side  of 
right  limbs  and  inner  side  of  left. 
Landmarks. — Saw-line. 
Incision. — The  total  covering  is  to  be 
i^  diameters  of  the  forearm  at  the  saw- 
line.  The  anterior  and  posterior  aspects  will  each  furnish  three-fourths 
of  a  diameter.  One-half  of  this  three-fourths  diameter  length  will  be  of 
skin  and  fascia  alone,  on  each  side — the  remaining  half  of  skin,  fascia, 
and  muscle.  Therefore  a  point  below  the  saw-line  equal  to  three-fourths 
of  a  diameter  at  the  saw-line  will  mark  the  lowest  limit  from  which  the  covering 
is  to  be  provided.  Two  small  flaps  are  incised,  each  having  a  base  equal 
to  a  half-circumference,  and  a  length  equal  to  half  (the  lower  half)  of  the 
distance  between  the  saw-line  and  the  lowest  limit  of  the  skin  incision.  These 
flaps  will  be  bluntly  rounded  at  their  lower  ends  (Fig.  326,  A). 

Operation. — Dissect  up  the  integumentary  flaps  half-way  to  the  saw- 
line — retract  them,  and,  on  a  level  with  the  retracted  flaps,  circularly  divide 
the  muscles  to  the  bone.  This  circular  incision  also  divides  the  periosteum 
and  interosseous  membrane.  The  muscles  and  periosteum  are  then  retracted 
to  the  saw-line — and  the  bones  divided,  completing  the  section  of  the  more 
movable  radius  first.  Tie  the  radial,  ulnar,  anterior  and  posterior  inter- 
osseous arteries.       Stitch  the  musculo-periosteal  covering  over  the  bones. 


Fig.  326. — Amputations  through 
the  Forearm  and  at  the  Elbow: — ■ 
A,  Through  lower  part  of  forearm  by 
modified  circular;  B,  Through  upper 
forearm  by  equal  anterior  and  posterior 
flaps;  C,  Disarticulation  at  elbow-joint 
by  oblique  circular  method. 


AMPUTATION    OF    LOWER    THIRD    OF    FOREARM.  357 

Quilt  the  muscles  or  tendons  of  the  anterior  to  those  of  the  posterior  aspect 
of  the  forearm  if  possible.  Suture  the  integumentary  coverings  in  a  straight 
line  antero-posteriorly. 

Comment. — The  preponderance  of  tendinous  over  muscular  tissues  here 
makes  the  infundibular  variety  of  the  modified  circular  difficult  or  impossible. 


Fig.  327. — Cross-section  of  the  Middle  of  the  Right  Forearm: — A,  Flexor  carpi 
radialis;  B,  Median  nerve;  C,  Supinator  longus;  D,  Radial  artery,  veins,  and  nerve;  E,  Flexor 
longus  pollicis;  F,  Extensor  carpi  radialis;  G,  Extensor  ossis  metacarpi  pollicis;  H,  Flexor  sub- 
limis  digitorum;  I,  Flexor  carpi  ulnaris;  J,  Ulnar  artery,  veins,  and  nerve;  K,  Flexor  profundus 
digitorum;  L,  Anterior  interosseous  vessels;  M,  Extensor  indicis;  X,  Extensor  carpi  ulnaris; 
O,  Extensor  minimi  digiti;  P,  Extensor  communis  digitorum.  (The  crods-section  modified 
from  Braune.) 


AMPUTATION  OF  LOWER  THIRD  OF  FOREARM 

BY    CIRCULAR     METHOD     (CUFF    VARIETY). 

Description. — The  cuff  variety  of  the  circular  amputation  is  here  done 
(see  under  Comment).  A  cuff  of  skin,  circularly  cut,  is  turned  back — and 
the  muscles  circularly  divided  on  a  level  with  the  reflected  skin — the  ends 
of  the  bones  being  covered  by  skin  and  fascia  alone. 

Position. — As  in  the  last  operation. 

Landmarks. — Saw- line. 

Incision. — Circular  cut,  placed  three-fourths  of  a  diameter  (at  the  saw- 
line)  below  the  line  of  bone-section — thus  making  a  total  covering  of  i1 
diameters,  as  each  side  may  be  regarded  as  furnishing  one-half  of  the  cover- 
ing.     (For  principle,  see  Fig.  328,  A.) 

Operation. — This  circular  incision  divides  the  skin  and  fascia,  which 
are  then  dissected  up,  the  forearm  being  vertical  while  the  posterior  dissection 
is  done.  This  dissection  and  turning  back  of  the  flap  is  continued  up  to  a 
distance  below  the  saw-line  which  will  leave  space  to  provide  a  musculo- 
periosteal  covering.  Here,  after  well  retracting  the  integumentary  coverings, 
the  muscles  are  divided  circularlv  to  the  bone, — extending  the  hand  while 


35» 


AMPUTATIONS. 


c 


B 


the  flexors  are  cut  and  flexing  it  while  the  extensors  are  being  severed.  A 
circular  cut  is  made  through  the  periosteum,  around  each  bone,  on  a  level 
with  the  cut  muscles — the  interosseous  membrane  is  divided  transversely — 

and  a  musculo-periosteal  covering  is  freed 
up  to  the  saw-line,  with  a  periosteal 
elevator,  from  each  bone.  All  soft  parts 
are  now  retracted  and  the  bones  sawed, 
completing  the  section  of  the  more  mov- 
able radius  first.  Tie  the  radial,  ulnar, 
anterior  and  posterior  interosseous  arter- 
ies. Cut  the  tendons  (which  are  here 
especially  numerous)  and  the  nerves 
short.  Suture  the  musculo-periosteal 
covering  over  the  bones — and  stitch  the 
skin  and  fascia  in  a  vertical  antero-pos- 
terior  or  lateral  direction. 

Comment. — (i)  Owing  to  the  pre- 
dominance of  tendons  in  this  locality,  the 
infundibuliform  variety  of  the  circular 
method  is  impracticable.  (2)  The  above 
operation  is  very  similar  to  the  modified 
circular  method  just  described,  which  is 
generally  considered  better  than  the  pres- 
ent form,  in  this  locality.  The  cuff 
method,  indeed,  is  not  possible  if  the 
limb  tapers  very  decidedly  at  the  site  in- 
volved. (3)  A  musculo-periosteal  cover- 
ing is  specially  indicated  here,  as  being 
the  best  means  of  guarding  against  a 
fusion  of  the  cut  edges  of  the  bones  and 
consequent  loss  of  pronation  and  supina- 
tion. (4)  As  the  large  mass  of  tendons 
is  difficult  to  cut  squarely  by  a  circular 
incision,  a  long,  narrow  knife  may  be 
slipped  under  them,  and  they  may  then 
be  cut  directly  upward  from  within — or  they  may  be  divided  with  strong, 
sharp  scissors. 


P'ig.328.— Amutations  about  Fore- 
arm and  Elbow  : — A,  Through  middled 
forearm,  by  circular  method  ;  B,  At  elbow- 
joint,  by  single  external  flap  ;  C,  At  elbow, 
by  oblique  circular  method. 


AMPUTATION  OF  UPPER  TWO-THIRDS  OF  FOREARM 

BV  EQUAL  ANTERIOR  AND  POSTERIOR  FLAPS. 

Description. — The  anterior  and  posterior  aspects  of  the  forearm  furnish 
equal  U-shaped  flaps  of  skin  and  muscle — the  anteriorly  largely  composed 
of  supinator  longus  and  flexors, — the  posterior  largely  made  up  of  extensors. 

Position. — As  in  the  modified  circular  method  (page  356). 

Landmarks. — Saw-line. 

Incisions. — An  anterior  and  a  posterior  U-shaped  flap  are  incised  on 
the  respective  aspects  of  the  forearm,  the  base  of  each  flap  at  the  saw-line 
being  equal  to  a  half-circumference  of  the  limb  at  that  line,  and  the  length 
of  each  equal  to  three-fourths  of  the  diameter — the  hand  being  supinated 
in  making  the  anterior  flap,  and  the  forearm  vertical  in  making  the  posterior 
flap  (Fig.  326,  B). 


SURGICAL    ANATOMY    OF    THE    ELBOW-JOINT.  359 

Operation. — Having  cut  through  skin  and  fascia  in  outlining  the  flaps, 
these  incisions  are  now  deepened  upon  the  line  of  the  retracted  skin,  beginning 
at  the  ulnar  side  of  the  anterior  flap,  in  case  of  the  right  arm  (and  on  the 
radial  side  upon  the  opposite  arm).  The  vertical  ulnar  incision  will  involve 
the  flexor  carpi  ulnaris  and  flexor  profundus — the  vertical  radial  incision 
will  involve  the  two  radial  carpal  extensors — both  vertical  incisions  passing 
directly  to  the  bones.  The  muscles  on  the  anterior  and  posterior  aspects 
of  the  forearm,  at  the  lower  rounded  extremities  of  the  flaps,  are  cut  from 
without  inward  in  such  a  manner  as  to  bevel  them,  slightly.  The  entire  flaps 
are  now  raised  from  the  bones  up  to  a  point  sufficiently  below  the  saw-line 
to  furnish  a  musculo-periosteal  covering — at  which  level  the  periosteum  is 
circularly  divided  around  the  bones — the  interosseous  membrane  cut  trans- 
versely— and  the  musculo-periosteal  covering  freed  to  the  saw-line.  The 
soft  parts  are  then  retracted  and  the  bones  sawed.  The  radial,  ulnar,  anterior 
and  posterior  interosseous  arteries  are  tied.  The  median,  radial,  and  ulnar 
nerves  should  be  cut  short,  or  even  dissected  from  the  flap.  The  musculo- 
periosteal  covering  is  sutured  and  the  muscles  quilted — and  the  integuments 
sutured  in  a  lateral  line. 

Comment. — These  flaps  may  be  less  satisfactorily  cut  by  transfixion— 
in  which  method,  also,  the  interosseous  membrane  is  apt  to  be  pierced. 


SURGICAL  ANATOMY  OF  THE  ELBOW-JOINT. 

Bones. — Humerus,  radius,  and  ulna. 

Articulations  and  Ligaments. — (a)  Of  the  Elbow-joint; — anterior, 
posterior,  internal  lateral  and  external  lateral  ligaments,  and  synovial  mem- 
brane, (b)  Of  the  Superior  Radio-ulnar  Joint; — orbicular  ligament,  and 
synovial  membrane. 

Muscles  in  Neighborhood  of  Elbow. — (A)  Muscles  arising  a  greater 
or  lesser  distance  above  elbow  and  inserted  below  elbow: — (a)  On  anterior 
aspect; — biceps  and  brachialis  anticus.  (b)  On  posterior  aspect; — triceps 
and  subanconeus.  (c)  On  radial  aspect; — supinator  longus  and  extensor 
carpi  radialis  longior.  (B)  Muscles  arising  from  inner  condyle  of  humerus 
and  inserted  into  forearm  and  hand; — pronator  radii  teres,  flexor  carpi 
radialis,  palmaris  longus,  flexor  carpi  ulnaris,  flexor  sublimis  digitorum. 
(C)  Muscles  arising  from  outer  condyle  of  humerus  and  inserted  into  forearm 
and  hand; — extensor  carpi  radialis  brevior,  extensor  communis  digitorum, 
extensor  minimi  digiti,  extensor  carpi  ulnaris,  anconeus  and  supinator  brevis. 

Muscles  in  Direct  Relation  with  Elbow-joint. — Anteriorly;  brachialis 
anticus.  Posteriorly;  triceps  and  anconeus.  Externally;  supinator  brevis 
and  common  tendon  of  origin  of  extensor  muscles.  Internally;  common 
tendon  of  origin  of  flexor  muscles. 

Arteries  in  Neighborhood  of  Elbow. — Brachial,  with  superior  profunda, 
inferior  profunda,  and  anastomotica  magna  branches.  Radial,  with  radial 
recurrent  branch.  Ulnar,  with  anterior  ulnar  recurrent  and  posterior  ulnar 
recurrent  branches. 

Veins  in  Neighborhood  of  Elbow. — Superficial; — median,  median 
basilic,  median  cephalic,  deep  median,  radial,  cephalic,  anterior  ulnar,  poste- 
rior ulnar,  and  common  ulnar.  Deep; — Two  venae  comites  accompanying 
each  of  above  arteries. 

Nerves  in  Neighborhood  of  Elbow. — Superficial; — musculocutaneous, 
internal  cutaneous,  lesser  internal  cutaneous,  external  cutaneous,  and  branches 


360  AMPUTATIONS. 

of  triusculospiral.  Deep; — ulnar,  median,  radial  and  posterior  interosseous 
branches  of  rnusculospiral. 

Bicipital  Fascia. — A  broad  aponeurosis  given  off  from  inner  side  of 
tendon  of  biceps,  opposite  bend  of  elbow — and  passing  between  the  brachial 
artery  and  superficial  veins  and  nerves  of  elbow  obliquely  downward  and 
inward  to  become  continuous  with  the  deep  fascia  of  forearm,  fastening 
down  the  flexor  muscles. 

Bursae  in  Neighborhood  of  Elbow. — Between  olecranon  and  skin,  and 
between  olecranon  and  triceps. 

Epiphyses. — Portion  of  epiphysis  forming  radial  condyle  and  trochlea 
is  within  the  capsule  of  the  joint — that  forming  the  two  condyles  is  without. 
The  epiphyses  for  the  trochlea  and  external  condyle  blend  and  join  shaft 
about  sixteenth  or  seventeenth  year — that  for  internal  condyle,  about  eighteenth 
year.  The  upper  epiphysis  of  radius  forms  the  head — is  within  the  joint — 
and  joins  shaft  about  sixteenth  or  seventeenth  year.  The  olecranon  is  chiefly 
formed  by  diaphysis — an  epiphysis  occurs  in  its  summit  from  the  tenth  to 
twelfth  year— joins  shaft  about  sixteenth  or  seventeenth  year — anteriorly 
the  epiphysis  being  intersynovial,  and  posteriorly  subperiosteal. 

Movements  of  Elbow- joint. — (1)  Flexion — by  biceps,  brachialis  anticus, 
aided  by  muscles  having  origin  from  internal  condyle  of  humerus  and  by 
supinator  longus.  (2)  Extension — by  triceps,  anconeus,  aided  by  extensors 
of  wrist  and  by  extensor  communis  digitorum  and  extensor  minimi  digiti. 
The  cross-sections  at  and  just  below  the  elbow-joint  are  shown  in  Figs.  329 
and  29. 


SURFACE  FORM  AND  LANDMARKS  OF  THE  ELBOW. 

Position  of  radio-humeral  line,  and  hence  the  joint-line  of  the  elbow,  may 
be  found  by  feeling  for  the  depression  between  the  head  of  the  radius  and 
capitellum  of  the  humerus  at  the  back  of  the  elbow,  marked  by  a  dimple  in 
the  integument  in  the  interval  between  the  anconeus  to  the  ulnar  side,  and 
the  muscular  mass  of  supinator  longus  and  two  carpal  radial  extensors  to 
the  radial  side. 

The  humero-radial  articulation  is  horizontal — the  humero-ulnar  articu- 
lation slopes  slightly  downward. 

The  fold  of  the  elbow,  more  prominent  when  the  forearm  is  semi-flexed, 
is  a  little  above  the  level  of  the  joint,  and  forms  the  base  of  the  triangular 
fossa  below  the  elbow,  whose  sides  are  formed  by  the  supinator  longus  and 
pronator  radii  teres. 

The  inner  condyle  of  the  humerus  is  the  more  prominent  and  is  a  little 
more  than  2.5  cm.  (1  inch)  above  the  elbow-joint.  The  outer  condyle  is  2 
cm.  (f  inch)  above. 

When  the  forearm  is  fully  extended,  the  inner  condyle,  tip  of  olecranon, 
and  external  condyle  are  all  on  the  same  transverse  line  (in  extreme  extension, 
the  tip  of  the  olecranon  is  slightly  above); — when  the  forearm  is  flexed  to  a 
right  angle,  the  tip  of  the  olecranon  is  directly  below  the  condyles; — when 
the  forearm  is  completely  flexed,  the  tip  of  the  olecranon  is  below  and  in 
front  of  the  condyles. 

A  line  connecting  the  two  condyles  forms  a  right  angle  with  the  axis  of 
the  arm — and  an  angle  with  that  of  the  forearm. 


SURGICAL    CONSIDERATIONS    IN    DISARTICULATING    ELBOW-JOINT.      361 

The  upper  part  of  the  olecranon  is  covered  by  the  triceps — the  lower 
part  is  subcutaneous,  and  separated  from  the  skin  by  a  bursa. 

Three  eminences  are  present  upon  the  anterior  aspect  of  the  elbow  region; 
— the  biceps  above  and  in  the  center — the  supinator  longus  and  common 
extensor  group  on  the  outer — and  the  pronator  radii  teres  and  common 
flexor  group  upon  the  inner  side. 

The  ulnar  nerve  and  posterior  ulnar  recurrent  artery  lie  in  a  deep  groove 
between  the  olecranon  and  inner  condyle  of  the  humerus. 

The  anterior  integument  of  the  elbow  is  thin  and  retractile — the  posterior 
integument  loose  and  but  little  retractile. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    DISARTICULATING    AT 

THE  ELBOW- JOINT. 

The  stump  after  disarticulating  at  the  elbow-joint  is  better  for  the  adapta- 
tion of  an  artificial  limb  than  after  amputation  through  the  arm. 

To  find  the  elbow-joint — place  the  thumb  just  beneath  the  external 
condyle  of  the  humerus  and,  grasping  the  wrist  with  the  right  hand,  pronate 
and  supinate  the  forearm — when  the  upper  limit  of  the  radial  head  will  be 
found  about  1.3  cm.  (4  inch)  below  the  external  condyle. 

The  joint  is  entered  and  disarticulated  more  easily  from  the  outer  side. 


Fig.  329. — Transverse  Section  through  the  Condyloid  Expansion  of  the  Right 
Arm: — A,  Biceps  tendon;  B,  Supinator  longus;  C,  Musculospiral  nerve  and  superior  profundus 
artery;  D,  Brachialis  anticus;  E,  Extensor  carpi  radialis  longior;  F,  Olecranon;  G,  Anconeus; 
H,  Triceps;  I,  Brachial  artery,  vena;  comites,  and  median  basilic  vein;  J,  Pronator  radii  teres; 
K,  Median  nerve;  L,  Flexor  carpi  radialis;  M,  Condyloid  expansion  of  humerus;  N,  Ulnar 
nerve;  O,  Olecranon  bursa.     (Cross-section  modified  from  Braune.) 

The  muscles  on  the  outer  side  of  the  elbow  retract  more  powerfully  than 
those  upon  the  inner  side,  chiefly  owing  to  the  presence  of  the  supinator 
longus. 


3^2  AMPUTATIONS. 

The  lower  end  of  the  humerus  is  so  large  that  a  liberal  allowance  of  covering 
is  necessary.  And  a  more  liberal  covering  has  to  be  provided  for  the  inner 
than  for  the  outer  condyle  of  the  humerus — incisions,  therefore,  are  longer 
on  the  inner  aspect. 

The  skin  posteriorly  is  used  to  pressure — but  the  muscles  here  are  not 
so  available  for  padding  as  in  front. 

Temporary  drainage  should  be  used  after  disarticulation.  The  stump 
should  be  elevated  upon  a  splint. 


DISARTICULATIONS  AT  THE  ELBOW,  IN  GENERAL. 

Best  Methods. — Anterior  Ellipse — best,  where  ample  sound  tissue  exists; 
well  nourished  and  thick  enough  to  cover  bones  well;  cicatrix  well  placed; 
but  requires  considerable  tissue;  skin-pouch  over  the  olecranon  is  apt  to  be 
left.  Posterior  Ellipse — best  where  anterior  tissue  is  unavailable;  covering 
thin  and  uneven,  though  used  to  pressure.  Long  Antero-internal  and  Short 
Postero-external  Flaps — cover  disarticulated  end  of  humerus  well;  especially 
indicated  where  both  lateral  aspects  of  forearm  can  furnish  covering  and 
neither  anterior  nor  posterior  can  supply  the  large  amounts  of  tissue  neces- 
sary for  the  elliptical  methods. 

Other  Methods. — Circular.  Modified  Circular.  Anterior  Flap.  Poste- 
rior Flap.  Long  Anterior  and  Short  Posterior  Flaps.  Short  Anterior  and 
Long  Posterior  Flaps.  Single  External  Flap.  Equal  Lateral  Flaps.  Un- 
equal Lateral  Flaps.  Lateral  Skin  Flap.  Racket  Method.  Of  these 
methods,  the  circular  requires  the  least  sacrifice  of  parts,  but  the  resulting 
covering  is  not  so  satisfactory. 

General  Indications. — Tubercular  disease;  injury  or  disease  of  forearm. 


DISARTICULATION  OF  ELBOW- JOINT 

BY  ANTERIOR  ELLIPSE  — FARABEUF. 

Description. — The  covering  is,  essentially,  an  anterior  flap — the  idea 
of  the  ellipse  being  gotten  in  viewing  the  outlined  incision  laterally.  The 
lower  anterior  convexity  of  the  covering  is  sutured  into  the  upper  posterior 
concavity. 

Position. — Given  in  the  course  of  the  operation. 

Landmarks. — Joint-line;  prominence  of  olecranon;  eminence  of  supinator 
longus  on  anterior  aspect  of  forearm. 

Incision. — The  highest  point  of  the  ellipse  is  posterior,  over  the  prominence 
of  the  olecranon.  The  lowest  point  of  the  ellipse  is  anterior,  over  the  eminence 
of  the  supinator  longus,  just  above  the  middle  of  the  forearm.  Midway 
between  the  upper  and  lower  rounded  ends  of  the  ellipse  the  lateral  borders 
of  the  ellipse  pass  along  the  mid-lateral  aspects  of  the  forearm  (Fig. 330,  A). 

Operation. — The  surgeon  stands  on  the  left  of  either  right  or  left  elbow 
(which  will  place  the  patient's  elbow  on  his  right) — grasping  his  wrist  with 
his  left  hand,  and  flexing  the  elbow,  so  rotates  the  limb  as  to  make  the  entire 
elliptical  incision  without  relaxing  his  hold  of  the  wrist,  or  removing  the 
knife,  which  passes  from  olecranon  to  olecranon.  Taking  the  right  limb, 
for  instance,  turn  the  slightly  flexed  elbow  so  as  to  present  the  radial  aspect— 


DISARTICULATION  OF  ELBOW-JOINT. 


363 


enter  the  knife  at  the  apex  of  the  olecranon — pass  down  the  radial  lateral 
aspect — across  the  lower  end  of  the  ellipse,  on  the  anterior  aspect  of  the 
forearm  (with  the  forearm  extended  and  supine) — then  along  the  inner 
aspect  (with  elbow  again  flexed  and  the  inner  aspect  of  the  forearm  thereby 
made  to  present)  and  upward  to  the  olecranon.  The  skin  and  fascia 
upon  the  proximal  side  of  the  lower  end  of  this  incision  are  now  further 
retracted  by  hand.  On  the  line  of  the  retracted  integuments  the  muscles  are 
then  cut  obliquely  from  without  inward  and  upward  toward  the  joint,  in  such 
a  manner  as  to  bevel  the  anterior  covering  which  is  being  raised — and,  at  the 
same  time,  raise  as  much  of  a  capsulo-periosteal  covering  as  possible.  This 
anterior  flap  is  dissected  and  retracted  upward  to  the  joint-line.  The  anterior 
lateral  and  posterior  ligaments  of  the  joint  are  now  cut  in  order.  The  triceps 
and  any  remaining  posterior  tissues  are  sev- 
ered. The  radial,  ulnar,  interosseous,  mus- 
cular branches,  and,  possibly,  the  posterior 
ulnar  recurrent  and  terminations  of  the  su- 
perior and  inferior  profunda  are  ligated. 
Quilt  the  muscles  in  the  anterior  flap  to  the 
fascia  along  the  margins  of  the  upper  half  of 
the  ellipse.  Suture  the  integumentary  tis- 
sues of  the  convex  lower  end  of  the  flap  into 
those  of  the  upper  concavity.  Temporary 
drainage  is  indicated. 

Comment. — After  the  integuments  are 
incised,  the  muscles  are  sometimes,  though 
less  satisfactorily,  cut  by  thrusting  a  long 
knife  through  the  limb  opposite  the  anterior  g 
aspect  of  the  joint  and  cutting  from  within 
outward  on  a  line  with  the  retracted  skin. 


DISARTICULATION  OF  ELBOW- JOINT 

BV  POSTERIOR  ELLIPSE. 


A 


Fig.  330. — Disarticulations  at 
the  Elbow-joint: — A,  By  anterior 
ellipse;  B,  By  long  antero-internal 
and  short  postero-external  flaps. 


Description.  —  The  covering  is,  practi- 
cally, a  posterior  flap — the  idea  of  the  ellipse 
being  seen  in  a  lateral  view  of  the  incision. 

Position.  —  Given  in  the  course  of  the 
operation. 

Landmarks. — Joint-line;  tip  of  olecranon. 

Incision. — The  highest  point  of  the 
ellipse  is  anterior,  opposite  the  lower 
margin  of  the  joint-line.  The  lowest 
part    is    posterior,    between    8  and   10  cm. 

(3  and  4  inches)  below  the  joint-line.  Midway  between  the  upper  and  lower 
rounded  ends  of  the  ellipse,  the  lateral  borders  of  the  ellipse  pass  along  the 
mid-lateral  aspects  of  the  forearm.  \\  ith  the  elbow  flexed  to  an  angle  of 
135  degrees,  the  lateral  parts  of  the  incision  will  be  parallel  with  the  prolonged 
anterior  aspect  of  the  arm  (Fig.  331). 

Operation. — The  surgeon  stands  on  the  right  of  either  elbow,  grasping 
the  patient's  wrist  with  his  left  hand  (the  back  of  his  hand  uppermost  and 
his  thumb  toward  the  patient's  fingers),  and  manipulates  the  elbow  so  as 
to  complete  the  incision  at  one  sweep — beginning  the  incision  at  the  anterior 
joint-line  with  the  elbow  flexed  at  the  above  angle — passing  down  the  inner 


3°4 


AMPUTATIONS. 


aspect  (while  that  part  is  manipulated  so  as  to  render  it  prominent) — crossing 
the  dorsal  aspect  (while  the  forearm  is  held  vertical) — ascending  the  outer 
aspect  (while  that  aspect  is  made  prominent) — to  the  place  of  beginning. 
Upon  the  line  of  the  retracted  integuments,  the  deeper  parts  are  now  cut. 
Those  along  the  posterior  aspect  of  the  ellipse  are  divided,  together  with 
the  periosteum,  and  including  the  anconeus,  and  insertion  of  the  triceps  when 
reached,  and  are  dissected  up  to  just  above  the  tip  of  the  olecranon.  The 
deeper  parts  along  the  anterior  portion  of  the  ellipse  are  then  divided,  corre- 
sponding with  the  joint-line,  and  the  capsule  of  the  joint  divided  transversely, 
lollowed  by  division  of  the  lateral  ligaments  and  posterior  portion  of  the 
capsule  (unless  a  capsulo-periosteal  covering  can  be  raised).  Tie  the  brachial, 
posterior  interosseous,  muscular  branches  and  terminations  of  the  superior 

and  inferior  profunda.  Cut  the  ulnar  nerve 
especially  short.  Quilt  the  muscles  in  the 
posterior  flap  to  the  fascia  along  the  mar- 
gins of  the  upper  half  of  the  ellipse.  Drain 
temporarily.  Suture  the  integuments  of  the 
lower  portion  of  the  ellipse  (the  convexity)  of 
the  posterior  flap,  to  the  upper  concavity  of 
the  incision. 

Comment.  —  Transfixion  of  the  lower 
part  of  the  posterior  flap  is  even  less  advisable 
than  transfixion  in  the  anterior  ellipse — as,  in 
the  former  case,  the  bone  is  almost  subcu- 
taneous. 


DISARTICULATION  OF  ELBOW- JOINT 

BY  LONG   ANTERO-INTERNAL  AND  SHORT    POS- 
TERO-EXTERNAL  FLAPS. 

Description. — A  method  of  unequal  lat- 
eral flaps  of  skin  and  muscles — the  incisions 
themselves  are  lateral,  the  bulk  of  the  mus- 
cles being  antero-internal  and  postero-ex- 
ternal. 

Position. — The  forearm  is  held  in  supi- 
nation during  anterior  incisions — and  verti- 
cal during  posterior  incisions,  or  partly  flexed. 
Landmarks. — Elbow  joint-line;  tip  and 
base  of  olecranon. 
Incisions. — Antero-internal  incision — begins  at  center  of  anterior  aspect 
of  the  joint-line — passes  obliquely  downward  and  inward  over  the  forearm, 
in  such  a  way  as  to  meet  the  mid-lateral  aspect  of  the  forearm,  on  the  ulnar 
side,  at  a  distance  of  about  7.5  cm.  (3  inches)  below  the  joint-line — thence 
passes  upward  and  backward  along  a  corresponding  line  to  the  base  of  the 
olecranon.  Postero-external  incision — a  shorter  incision  but  very  similar  to 
the  longer,  passes  between  the  same  points,  crossing  the  mid-lateral  aspect 
of  the  forearm,  on  the  radial  side,  about  2.5  cm.  (1  inch)  below  the  joint- 
line  (Fig.  330,  B).     This  is  practically  an  internal  and  external  flap. 

Operation. — Along  the  line  of  these  retracted  integuments  the  muscles 
are  cut  obliquely  down  to  the  bone — when  they,  and  as  much  of  the  periosteum 


Fig.      331. — Disarticulation      of 
Elbow  by  Posterior  Ellipse? 


SURGICAL    ANATOMY    OF    THE    ARM. 


365 


as  possible,  are  dissected  up  to  the  joint-line  in  front,  and  to  the  tip  of  the 
olecranon  behind.  The  elbow  is  then  flexed — the  triceps  is  divided  at  its 
attachment  to  the  olecranon — and  disarticulation  completed  by  dividing  the 
posterior,  lateral  and  anterior  ligaments,  in  order.  Tie  the  brachial,  termina- 
tions of  the  superior  and  inferior  profunda,  and,  possibly,  some  small  muscular 
and  articular  branches.  The  large  antero-internal  flap  folds  over  the  articular 
end  of  the  humerus— its  muscles  are  to  be  quilted  to  those  of  the  smaller  flap 
— and  the  integuments  of  the  two  flaps  sutured — placing  the  cicatrix  upon 
the  externo-terminal  aspect  of  the  joint. 


Fig.  332. —  Disarticulation  at 
Elbow  : — By  long  anterior  and  short 
posterior  flaps. 


Fig.  333.  —  Disarticulation  at 
Elbow  : — By  long  posterior  and  short 
anterior  flaps. 


SURGICAL  ANATOMY  OF  THE  ARM. 

Bones. — Humerus. 

Muscles  of  the  Arm. — (A)  Anterior  Humeral  Region: — coracobrachial, 
biceps,  brachialis  anticus.  (B)  Posterior  Humeral  Region: — triceps,  sub- 
anconeus.  (C)  Muscles  having  their  insertions  in  upper  portion  of  humerus: 
— supraspinatus,  infraspinatus,  teres  minor,  subscapularis,  pectoralis  major, 
latissimus  dorsi,  deltoid,  teres  major.  (D)  Muscles  having  their  origin 
from  lower  portion  of  humerus: — (a)  From  internal  condyle  and  ridge: — 
pronator  radii  teres,  flexor  carpi  radialis,  palmaris  longus,  flexor  carpi  ulnaris, 
flexor  sublimis  digitorum — (b)  From  external  condyle  and  ridge: — supinator 
longus,  extensor  carpi  radialis  longior,  extensor  carpi  radialis  brevior,  ex- 
tensor communis  digitorum,  extensor  minimi  digiti,  extensor  carpi  ulnaris, 
anconeus,  supinator  brevis. 

Arteries  of  Humeral  Region. — From  Axillary: — acromial  and  humeral 
branches  of  acromial  thoracic,  subscapular,  anterior  circumflex,  posterior 
circumflex,  and  axillary  itself.     From  Brachial: — superior  profunda,  nutrient, 


366  AMPUTATIONS. 

inferior  profunda,  anastomotica  magna,  muscular,  and  brachial  itself.  From 
Radial: — radial  recurrent.  From  Ulnar: — anterior  ulnar  recurrent,  posterior 
ulnar  recurrent. 

Veins  of  Humeral  Region. — Superficial: — cephalic,  basilic,  Deep: — 
two  vente  comites  accompany  each  of  above  branches  of  main  arteries,  and 
also  brachial  artery.  Axillary  vein  is  formed  by  two  brachial  venae  comites 
and  basilic  vein. 

Nerves  of  Humeral  Region. — Anteriorly: — musculocutaneous,  median, 
internal  cutaneous,  ulnar,  lesser  internal  cutaneous,  intercosto-humeral. 
Posteriorly: — circumflex,  musculospiral.  The  cross-sections  of  the  arm  are 
shown  in  Figs.  25,  27,  and  335. 

SURFACE  FORM  AND  LANDMARKS  OF  THE  ARM. 

The  humerus  is  almost  entirely  covered  by  muscles,  being  subcutaneous 
only  at  the  internal  and  external  condyles.  The  greater  and  lesser  tuber- 
osities and  the  head  may  be  defined.  The  greater  tuberosity  lies  just  below 
the  antero-external  aspect  of  the  acromion.  The  lesser  tuberosity  lies  to  the 
inner  side  of  and  below  the  greater,  the  bicipital  groove  intervening.  To 
feel  the  head  of  the  bone,  abduct  the  arm,  when  the  head  will  project  promi- 
nently into  the  axilla. 

The  internal  condyle  and  internal  condyloid  ridge,  and  external  condyle 
and  external  condyloid  ridge,  can  be  felt  just  above  the  elbow-joint.  The 
latter  are  more  easily  felt  during  semiflexion,  as  a  depression  between  adjacent 
muscles. 

The  greater  tuberosity  and  external  condyle  are  in  the  same  straight  line 
and  face  in  the  same  direction.  The  head  of  the  humerus  and  the  internal 
condyle  are  also  in  the  same  straight  line  and  likewise  face  in  the  same  direc- 
tion. 

When  the  arm  hangs  by  the  side,  the  bicipital  groove  looks  directly  for- 
ward. 

The  rough  prominence  upon  the  outer  aspect  of  the  middle  of  the  humerus, 
into  which  the  deltoid  is  inserted,  also  marks  the  level  of  the  insertion  of  the 
coracobrachialis  and  the  origin  of  the  brachialis  anticus — and  also  the 
entrance  of  the  nutrient  artery  into  the  bone,  and  the  level  at  which  the 
musculospiral  nerve  and  superior  profunda  artery  cross  the  back  of  the  bone. 

The  upper  epiphysis  is  horizontal  and  placed  just  above  the  surgical 
neck,  joining  the  shaft  at  the  twentieth  year. 

The  coracobrachialis  and  biceps  above,  and  the  biceps  below,  form  the 
prominent  muscular  mass  of  the  front  of  the  arm.  The  brachialis  anticus  is 
discernible  at  the  lower  part  of  the  arm,  on  each  side  of  the  biceps. 

The  triceps  determines  the  form  of  the  back  of  the  arm.  The  inner  head 
is  least  distinct.  The  outer  head  forms  the  large  prominence  just  below  the 
posterior  border  of  the  deltoid.  The  long  head  emerges  from  between  the 
teres  major  and  minor  and  descends  along  the  back  of  the  arm. 

The  supinator  longus  and  extensor  carpi  radialis  longior  form  a  prom- 
inence on  the  outer  side  of  the  lower  portion  of  the  arm. 

Above  the  middle  of  the  arm,  the  biceps,  deltoid,  coracobrachialis,  and 
long  head  of  triceps  are  more  or  less  free  and  capable  of  retraction.  Below 
the  middle  of  the  arm,  the  biceps  is  the  only  free  muscle.  It  is  for  this  reason 
that  the  circular  method  of  amputation  is  suitable  only  to  the  lower  half  of 
the  arm. 

In  women  and  in  fat  persons  the  contour  of  the  arm  is  more  rounded 


SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT    ARM.       367 

and  more  nearly  of  one  size  throughout.  In  the  muscular,  it  is  less  regular 
and  more  flattened  laterally. 

On  the  inner  and  outer  sides  of  the  biceps  are  found  the  inner  and  outer 
bicipital  furrow,— the  cephalic  vein  occupying  the  latter — and  the  brachial 
artery  and  basi'ic  vein  the  former. 

The  superior  profunda  artery  arises  just  below  the  outlet  of  the  axilla — 
the  inferior  profunda  opposite  the  center  of  the  shaft — and  the  anastomotica 
magna  about  5  cm.  (2  inches)  above  the  bend  of  the  elbow. 

The  skin  is  most  retractile  over  the  inner  aspect  of  the  arm. 


Fig.  334. — Transverse  Section  through  the  Lower  Third  of  the  Right  Arm: — 
A,  Biceps;  B,  Brachialis  anticus;  C,  Musculospiral  nerve  and  superior  profunda  artery;  G, 
Supinator  longus;  D,  Brachial  artery,  vena;  comites,  basilic  vein,  and  median  nerve;  E,  Ulnar 
nerve  and  superior  profunda  artery;  F,  Triceps.     (The  cross-section  modified  from  Braune.) 


GENERAL    SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT 

THE  ARM. 

The  shortest  stump  of  an  arm,  even  an  amputation  at  the  surgical  neck, 
is  better  than  a  shoulder-joint  disarticulation — as  such  a  stump  will  ordinarily 
be  able  to  move  an  artificial  limb.  It  is,  therefore,  desirable  to  retain  as 
much  of  the  humerus  as  possible,  as  leverage  for  the  artificial  limb. 

From  the  standpoint  of  the  amputator,  the  arm  may  be  divided  into  two 
natural  regions — a  lower  third,  more  or  less  cylindrical,  and  where  the  muscles 
are  largely  attached  to  bone — and  an  upper  two-thirds,  more  or  less  conical, 
flattened  or  irregular,  and  where  the  muscles  are  largelv  free  and  capable 
of  retraction.  Therefore  a  circular  method  of  amputation  is  preferable  for 
the  lower  third,  and  a  flap  method  for  the  upper  two-thirds. 

The  surgical  neck  of  the  humerus  marks  the  height  at  which  a  useful 
stump  can  be  obtained,  as  the  capsule  extends  down  to  its  level  internally. 


368  AMPUTATIONS. 

In  amputating  at  the  surgical  neck,  the  bone  is  sawed  between  the  tuber- 
osities, and  insertions  of  the  pectoralis  major  and  teres  major.  The  supra- 
spinatus,  infraspinatus,  teres  minor,  and  subscapularis  are  left  attached  to 
the  head  of  the  humerus.  The  bone  is  sawed  below  the  epiphyseal  line. 
The  synovial  membrane  of  the  joint  (accompanying  the  biceps  tendon)  is  apt 
to  be  opened  on  the  inner  aspect,  where  it  is  lowest.  The  bursa  under  the 
subscapularis  tendon  generally  communicates  with  the  joint  and  may  be 
opened  during  the  operation.  As  much  of  the  attachment  of  the  pectoralis 
major,  teres  major,  and  latissimus  dorsi  as  possible  is  raised  with  the  peri- 
osteum, so  as  to  be  included  in  the  musculo-periosteal  covering  of  the  end 
of  the  bone  and  in  the  quilting  of  the  muscles,  in  order  to  retain  the  attach- 
ments of  these  muscles  upon  the  stump  and,  therefore,  their  action  upon 
the  artificial  limb. 

In  an  amputation  through  the  upper  two-thirds  by  an  anterior  flap  twice 
as  long  as  the  posterior,  the  scar  will  eventually  be  terminal,  owing  to  the 
much  greater  retraction  of  the  anterior  parts — the  biceps  contracting  most  of 
any  muscle.     A  terminal  cicatrix  is  sought  in  the  stumps  of  the  arm. 

The  stump  should  be  dressed  upon  a  splint. 

For  control  of  hemorrhage  in  amputating  at  the  shoulder  joint,  see  page  374. 


AMPUTATION  OF  THE  ARM,  IN  GENERAL. 

Best  Methods. — Modified  Circular — best  for  the  lower  third.  Long 
Anterior  and  Short  Posterior  Flaps — best  for  the  upper  two-thirds.  Single 
Externa]  Flap — best  at  the  surgical  neck. 

Other  Methods. — Simple  Circular  (infundibular  form).  Single  Anterior 
Flap  (Malgaigne's  method).  Anterior  Ellipse  (practically  an  anterior  flap). 
Posterior  Ellipse  (practically  a  posterior  flap).  Lateral  Flaps  (of  skin  and 
muscles).  Rectangular  Flap  (Teale's  method).  Oval  Method  (at  the  surgi- 
cal neck). 

General  Indications. — Extensive  crushes  of  upper  extremity;  tubercular 
osteo-arthritis;  sarcoma;  tumors  of  elbow. 

AMPUTATION  THROUGH  THE  LOWER  THIRD  OF  THE  ARM 

BY  MODIFIED   CIRCULAR  METHOD. 

Description. — Two  short  skin-flaps  are  cut  and  turned  back,  and  the 
muscles  divided  circularly  in  the  infundibular  manner. 

Position. — Patient  supine,  at  edge  of  table;  limb  horizontally  abducted 
over  the  edge  of  table  during  anterior  incisions,  and  held  vertically,  with 
bent  elbow,  or  drawn  over  the  chest,  in  dorsal  incisions.  Surgeon  on  outer 
side  of  right  and  inner  side  of  left  limbs.  Assistants  steady  the  limb  above 
and  below  the  site  of  amputation. 

Landmarks. — Saw-line. 

Incision. — The  lowest  limit  of  the  skin  incision  is  placed  at  a  distance 
below  the  saw-line  equal  to  three-fourths  of  the  diameter  of  the  limb  at 
the  saw-line  (thus  securing  a  covering  of  ij  diameters).  Of  this  total  dis- 
tance the  small  flaps  will  occupy,  approximately,  the  lower  one-third.  These 
flaps  are  generally  anterior  and  posterior  (but  may  be  lateral,  or  in  any 
intermediate  position,  as  the  local  conditions  may  demand).  Their  base  is 
one-half  the  circumference  of  the  limb — they  pass  down  the  lateral  aspects 
of  the  limb  to  nearly  their  lower  limit,  when  the}-  bluntly  round  transversely 


AMPUTATION    THROUGH    THE    LOWER   THIRD    OF    THE    ARM.       369 

across  the  limb  to  a  corresponding  point  on  the  opposite  side.    The  anterior 
and  posterior  daps  are  similar  (Fig.  335,  A). 

Operation. — These  flaps  of  skin  and  fascia  are  freed  up  to  their  base 
and  turned  back  as  cuffs.  Here  the  more  superficial  muscles  are  circularly 
divided,  and  retracted  in  turn.  Upon  the  line  of  these  retracted  superficial 
muscles,  the  deeper  muscles  are  cut  to  the  bone — at  a  level  still  beneath  the 
saw-line.     This  last   circular  division   also  divides  the  periosteum  around 


Fig.335.— Amputations  through  Arm  and  at  Shoulder  :— A,  Through  lower  part  of  arm, 
by  modified  circular  ;  B,  Through  upper  part  of  arm,  by  long  anterior  and  short  posterior  flaps  ;  C, 
At  shoulder-joint,  by  external  racket  method  (Larrey's  operation)  ;  D,  D,  At  shoulder,  by  external,  or 
deltoid,  flap  (Dupuytren's  operation). 


the  entire  bone.  All  the  soft  parts,  including  the  periosteum,  are  now  freed 
up  to  the  saw-line  and  the  bone  divided.  Tie  the  brachial,  superior  pro- 
funda, inferior  profunda,  muscular,  and  possibly  the  anastomotica  magna, 
branches.  See  that  the  musculospiral  nerve  is  cleanly  divided,  and  excise 
any  portion  of  it  apt  to  be  pressed  upon  in  bending  the  flap  over  the  end  of 
bone.  Suture  the  musculo-periosteal  covering.  Quilt  the  muscles.  Suture 
the  flaps  in  a  lateral  line. 


37°  AMPUTATIONS. 

Comment. — (i)  The  modified  circular  method  makes  it  easier  to  free 
the  bone  of  soft  parts  up  to  the  saw-line,  and  also  furnishes  a  more  sym- 
metrical terminal  covering.  If  necessary,  the  skin-flaps  may  represent  one- 
half  of  the  distance  between  the  saw-line  and  the  lowest  limit  of  the  skin- 
incision.  (2)  The  simple  circular  method  (the  infundibular  form)  mav  be 
done  here  in  small  limbs  with  flabby  coverings — but  would  be  difficult  in 
large  limbs  with  firm  coverings.  When  the  infundibular  circular  method  is 
used,  it  should  be  an  oblique  circular,  the  circle  dipping  lower  on  the  antero- 
internal  aspect  of  the  arm,  where,  owing  to  greater  retraction,  it  will  be  sub- 
sequently drawn  up  to  the  level  with  the  outer  part. 


AMPUTATION  OF  THE  UPPER  TWO-THIRDS  OF  THE  ARM 

BY  LONG  ANTERIOR  AND  SHORT  POSTERIOR  FLAPS. 

Description. — Two  U-shaped  flaps  of  skin  and  muscle  are  raised,  the 
posterior  being  one-half  the  length  of  the  anterior. 

Position. — As  in  the  last  operation. 

Landmarks. — Saw-line. 

Incisions. — The  base  of  each  flap  equals  one-half  circumference  at  the 
saw-line.  The  length  of  the  anterior  flap  is  equivalent  to  one  diameter  at 
the  saw-line.  And  the  length  of  the  posterior  flap  is  one-half  the  diameter. 
Both  are  U  -shaped  flaps.  Care  is  taken  to  place  these  flaps  so  that  the  brachial 
artery  will  not  be  apt  to  be  split — the  vessel  should  be  in  the  posterior  flap — 
and  the  points  of  junction  of  the  two  flaps  on  the  inner  and  outer  aspect  of 
the  arm  should  be  so  shifted  toward  the  outer  side  as  to  make  this  certain. 
The  arm  is  raised  vertically  while  the  posterior  flap  is  being  marked  out 
and  incised  (Fig.  335,  B). 

Operation.- — Having  incised  skin  and  fascia  along  the  above  lines,  the 
muscles  are  divided  along  the  retracted  integumentary  coverings — cutting 
to  the  bone  along  the  vertical  limbs  of  the  flaps,  and  cutting  obliquely  inward 
and  upward  along  the  rounded  transverse  endings  of  the  flaps,  in  a  bluntly 
beveled  fashion — coming  down  upon  the  bone  sufficiently  far  below  the  saw- 
line  to  provide  a  periosteal  covering,  which,  with  the  muscles,  is  freed  up  to 
the  saw  line — and  the  bone  divided.  Care  is  taken  to  divide  the  musculo- 
spiral  nerve  evenly  and  short — as  well  as  the  nerves  in  the  anterior  flap  which 
bend  over  the  end  of  the  bone,  partially  excising  them  if  necessary.  Tie  the 
brachial,  superior  profunda,  and  inferior  profunda,  and  muscular  branches. 
Quilt  the  muscles  of  the  anterior  to  those  of  the  posterior  flap — the  former 
chieflv  covering  the  end  of  the  bone.  Suture  the  skin  margins  of  the  flaps. 
The  limbs  should  be  steadied  by  a  splint  which  also  includes  the  shoulder. 


AMPUTATION  OF  ARM  AT  SURGICAL  NECK 

BY  SINGLE  EXTERNAL  FLAP. 

Description. — A  U-shaped  flap,  composed  chiefly  of  deltoid,  is  raised 
from  the  outer  aspect  of  the  arm,  while  the  parts  on  the  inner  aspect  are 
divided  transversely,  or  with  slight  downward  convexity,  on  a  level  with  the 
upper  limit  of  the  limbs  of  the  flap. 

Position. — As  in  the  above  operations — the  limb  being  drawn  well  away 
from  the  body,  which  will  give  access  to  both  outer  and  inner  aspects. 

Landmarks. — Surgical  neck  of  humerus  (just  below  the  tuberosities). 


AMPUTATION    OF    ARM    AT    SURGICAL    NECK. 


371 


Incisions. — Flap  incision — the  base  of  the  flap,  which  is  U-shaped,  is 
placed  about  2.5  cm.  (1  inch)  below  the  saw-line  through  the  surgical  neck — 
its  width  being  equal  to  half  the  circumference  of  the  limb  at  the  flap's  upper 
limit — its  length  being  that  of  the  diameter  at  the  saw-line.  The  anterior 
limb  of  the  flap  passes  down  the  mid-anterior  aspect  of  the  arm,  and  the 


Fig. 336.— Amputations  about  Arm  and  at  Shoulder: — A,  Through  lower  part  of  arm,  by 
equal  lateral  flaps;  B,  Through  surgical  neck  of  humerus,  by  single  external  flap;  C,  At  shoulder- 
joint,  by  Furneaux  Jordan's  method. 

posterior  limb  down  the  mid-posterior  aspect.  Inner  incision — crosses  the 
inner  aspect  of  the  arm,  with  a  slight  downward  convexity,  connecting  the 
upper  limits  of  the  vertical  limbs  of  the  flap  (Fig.  336,  B). 

Operation. — The  above  incisions  pass,  at  first,  through  skin  and  fascia 
only.  After  the  integuments  have  retracted,  the  external  flap  is  cut  from 
without  inward,  upon  the  line  of  the  retracted  tissues,  beveling  obliquely 
upward  and  inward  toward  the  upper  limit  of  the  flap.  The  bleeding  vessels 
in  this  external  wound  are  clamped  as  met.  The  inner  incision  is  now  deep- 
ened— and  the  axillary  vessels  tied  as  encountered  and  before  being  cut — 


372  AMPUTATIONS. 

and  the  nerves  cut  short.  The  tendon  of  the  pectoralis  major  is  preserved, 
the  periosteum  being  divided  below  the  bicipital  groove  and  stripped  up, 
including  this  tendon.  Avoid  opening  the  synovial  sheath  of  the  biceps 
tendon,  dividing  it  low  down,  together  with  the  coracobrachialis.  Detach 
the  tendons  of  the  latissimus  dorsi  and  teres  major  as  subperiosteal^  as 
possible.  Retract  the  outer  flap  and  the  parts  on  the  inner  aspect  of  the  arm 
up  to  the  saw-line — and  divide  the  bone  through  the  lowest  part  of  the  surgical 
neck  possible.  Avoid  the  circumflex  nerve  and  the  posterior  circumflex 
artery.  The  brachial  artery  will  have  been  tied  in  the  course  of  operation — 
branches  of  the  anterior  and  posterior  circumflex  and  muscular  branches 
which  have  not  been  previously  tied  are  now  taken  up.  Bring  the  outer 
flap  across  the  end  of  the  bone — quilt  the  muscles  of  the  flap  to  those  divided 
in  the  inner  incision — and  suture  the  integumentary  portion  of  the  flap  trans- 
versely to  corresponding  tissues  of  the  inner  wound.  Dress  the  arm  against 
a  full  pad  in  the  axilla. 

Comment. — ( i)  The  chief  advantages  of  amputation  through  the  surgical 
neck,  over  disarticulation  at  the  shoulder,  are,  that  the  mortality  is  less; 
that  a  stump  for  an  artificial  limb  is  secured;  and  that  there  is  not  so  much 
muscular  atrophy.  The  chief  disadvantages  are,  that  the  remaining  epiph- 
ysis is  apt  to  produce  bone;  and  that  the  stump  may  be  strongly  abducted. 
(2)  The  outer  flap  may  be  less  satisfactorily  cut  by  transfixion. 


SURGICAL  ANATOMY  OF  SHOULDER- JOINT. 

Bones. — Scapula;  clavicle;  humerus. 

Articulations  and  Ligaments. — (a)  Acromio-clavicular  Articulation: — 
superior  acromio-clavicular,  inferior  acromio-clavicular  ligaments;  inter- 
articular  fibro-cartilage;  synovial  membrane,  (b)  Coraco-clavicular  Union: — 
trapezoid  and  conoid  ligaments,  (c)  Shoulder-joint: — capsular,  gleno- 
humeral  bands  of  capsular,  coraco-humeral,  glenoid  and  transverse  humeral 
ligaments,  and  synovial  membrane. 

Muscles  Reinforcing  Shoulder-joint. — Above: — supraspinatus.  Be- 
low:— long  head  of  triceps;  an  upward  extension  of  pectoralis  major.  In- 
ternally:— subscapularis.  Externally: — infraspinatus;  teres  minor.  Within 
Joint: — long  head  of  biceps.     Surrounding  Joint: — deltoid. 

Muscles  in  More  or  Less  Direct  Relation  with  Shoulder-joint. — (a) 
Anterior  Thoracic  Region: — pectoralis  major,  pectoralis  minor,  subclavius. 
(b)  Lateral  Thoracic  Region: — serratus  magnus.  (c)  Acromial  Region: — 
deltoid,  (d)  Anterior  Scapular  Region: — subscapularis.  (e)  Posterior  Scapu- 
lar Region: — supraspinatus,  infraspinatus,  teres  minor,  teres  major,  (f) 
Muscles  Passing  from  Shoulder  to  Arm  Anteriorly: — biceps,  coracobrachialis. 
(g)  Muscles  Passing  from  Shoulder  to  Arm  Posteriorly: — triceps. 

Movements  of  Shoulder-joint. — Forward: — pectoralis  major,  anterior 
fibers  of  deltoid,  coracobrachialis,  biceps  (when  elbow  is  flexed).  Backward: 
— latissimus  dorsi,  teres  major,  posterior  fibers  of  deltoid,  triceps  (when 
elbow  is  extended).  Abduction: — deltoid,  supraspinatus.  Adduction: — 
subscapularis,  pectoralis  major,  latissimus  dorsi,  teres  major.  Outward 
Rotation: — infraspinatus,  teres  minor.  Inward  Rotation: — subscapularis, 
latissimus  dorsi,  teres  major,  pectoralis  major. 

Bursa?  in  Neighborhood  of  Joint. — Beneath  tendon  of  subscapularis 
— communicating  with  joint  by  opening  on  anterior  side  of  capsule.  Beneath 
tendon  of  infraspinatus  (sometimes  present) — communicating  with  joint  by 


SURFACE    FORM    AND    LANDMARKS    OF    SHOULDER- JOINT.  373 

opening  on  posterior  aspect  of  capsule.  Between  under  surface  of  deltoid 
and  outer  surface  of  capsule — not  communicating  with  joint.  Biceps  tendon 
passes  through  the  joint  and  is  surrounded  by  tubular  sheath  continuous 
with  synovial  membrane. 

Arteries  in  Neighborhood  of  Shoulder-joint. — Suprascapular,  trans- 
versalis  colli,  superior  thoracic,  acromial  thoracic,  long  thoracic,  alar  thoracic. 
subscapular,  anterior  circumflex,  posterior  circumflex. 

Veins  in  Neighborhood  of  Shoulder-joint. — Two  suprascapular,  two 
transversalis  colli,  superior  thoracic,  acromial  thoracic,  long  thoracic,  alar 
thoracic,  subscapular,  anterior  circumflex,  posterior  circumflex,  cephalic 

Nerves  in  Neighborhood  of  Shoulder-joint. — Acromial  branch  of 
cervical  plexus,  posterior  thoracic,  suprascapular,  external  anterior  thoracic, 
internal  anterior  thoracic,  upper  subscapular,  lower  subscapular,  middle 
subscapular,  circumflex, — and  following  passing  through  axilla  to  arm  and 
forearm;  musculocutaneous,  internal  cutaneous,  lesser  internal  cutaneous, 
median,  ulnar,  musculospiral. 


SURFACE  FORM  AND  LANDMARKS  OF  SHOULDER- JOINT. 

To  find  the  direction  and  position  of  the  shoulder-joint — having  fully 
abducted  the  arm,  draw  a  slightly  curved  line  from  the  middle  of  the  coraco- 
acromial  ligament,  with  convexity  inward,  to  the  innermost  part  of  the  head 
of  the  humerus  felt  in  the  axilla. 

The  coracoid  process  is  not  actually  within  the  infraclavicular  fossa,  but 
lies  near  the  pectoro-deltoid  groove,  covered  by  the  anterior  fibers  of  the 
deltoid,  and  a  little  below  the  clavicle. 

The  center  of  the  coraco-acromial  ligament  lies  over  the  superior  aspect 
of  the  shoulder-joint. 

The  greater  tuberosity  of  the  humerus  is  felt  externally — the  lesser  ante- 
riorly. To  the  former  are  attached  the  supraspinatus,  infraspinatus,  and 
teres  minor,  in  order,  from  above  downward.    To  the  lesser — the  subscapularis. 

With  the  arm  by  the  side  and  the  hand  supine,  the  bicipital  groove  looks 
directly  forward — the  head  of  the  humerus  lying  entirely  to  the  outer  side 
of  the  vertical  line  from  the  coracoid  process.  The  head  of  the  humerus 
faces,  practicallv,  in  the  direction  of  the  inner  condyle — and  the  greater 
tuberosity  in  the  direction  of  the  outer  condyle. 

The  upper  epiphysis  of  the  humerus  unites  with  the  bone  about  the 
twentieth  year — the  inner  part  of  the  cartilage  is  within  the  capsule  of  the 
joint — the  outer,  anterior  and  posterior  parts  are  subperiosteal. 

The  surgical  neck  lies  between  the  bases  of  the  tuberosities  and  the  inser- 
tions of  the  latissimus  dorsi,  teres  major,  and  pectoralis  major. 

The  deltoid  gives  the  rounded  outline  to  the  shoulder — and  its  insertion 
is  marked  by  a  depression  on  the  outer  aspect  of  the  middle  of  the  arm. 

The  groove  between  the  pectoralis  major  and  deltoid  contains  the  cephalic 
vein  and  the  humeral  branch  of  the  acromio-thoracic  artery. 

The  acromio-thoracic  artery  emerges  from  the  upper  border  of  the  pec- 
toralis minor  in  the  course  of  the  brachial  artery,  where  a  line  from  near  the 
junction  of  the  third  rib  and  its  cartilage  to  the  coracoid  process  crosses  that 
vessel. 

The  posterior  circumflex  artery  and  circumflex  nerve  cross  the  surgical 
neck  of  the  humerus  transversely  about  1.3  cm.  (h  inch)  above  the  center 
of  the  vertical  axis  of  the  deltoid. 


374 


AMPUTATIONS. 


The  skin  over  the  deltoid  is  thick,  adherent,  and  little  retractile — that 
over  the  pectoralis  major  is  fine  and  retractile. 

The  dorsalis  scapulae  artery  crosses  the  axillary  border  of  the  scapula 
opposite  the  center  of  the  vertical  axis  of  the  deltoid. 


GENERAL  SURGICAL  CONSIDERATIONS   IN  DISARTICULATING   AT 

SHOULDER- JOINT. 

Methods  of  Hemorrhage-control  during  operations  near  the  Shoulder- 
joint — (a)  Wyeth's  Shoulder  Transfixion  Pins,  with  tubular  rubber  Tourni- 
quet placed  above  them; — The  anterior  pin  (Fig.  337,  A)  enters  the  middle 
of  the  anterior  axillary  fold,  slightly  to  the  inner  side  of  the  center  of  the  fold — 

D  A 

u  A 


tig.  337. — Wyeth's  Pins  Controlling  Hemorrhage  in  Disarticulation  at  the 
Shoulder-joint: — A  Anterior  pin;  B,  Posterior  pin.  The  rubber  tubing  is  then  wound  about 
the  limb  proximally  to  the  pins  and  knotted. 


Fig.  337- 


and  emerges  2.5  cm.  (1  inch)  within  the  tip  of  the  acromion  process.  The 
posterior  pin  (Fig.  337,  B)  enters  the  posterior  axillary  fold,  at  a  point  corre- 
sponding with  the  entrance  of  the  anterior  pin — and  similarly  emerges  poster- 
iorly 2.5  cm.  (1  inch)  within  the  tip  of  the  acromial  process.  Care  is  neces- 
sary to  avoid  striking  the  spine  of  the  scapula  with  the  posterior  pin.  Rubber 
tubing  of  1.3  cm.  (£  inch)  diameter  is  wound  several  times  around  the  axilla, 
above  the  pins,  and  tied  (Fig.  268,  right  shoulder),  (b)  Where  the  special 
pins  are  not  at  hand,  the  tube  has  been  held  in  place  by  several  sutures  passed 
through  the  true  skin  and  temporarily  tied  over  the  tubing,  after  it  has  been 
knotted.  The  tubing  is  thus  prevented  from  slipping  when  the  soft  parts 
recede,  or  sink  in,  after  the  head  of  the  humerus  is  removed.  The  method, 
however,  is  less  satisfactory  than  the  use  of  the  pins  (Fig.  338).  (c)  J.  Lynn 
Cardiff  has  devised  a  clever  forceps-tourniquet  for  controlling  hemorrhage 
during  operations  upon  the  extremities.     It  consists  of  a  clamp,  one  blade  of 


SURGICAL    CONSIDERATIONS    IN    SHOULDER    DISARTICULATIONS.    375 

which  is  probe-pointed,  the  other  serrated.  In  the  interscapulo-thoracic 
amputation  a  limited  incision  is  made,  exposing  the  lower  edge  of  the  pectoral 
muscle  in  the  mid-axilla — through  this  the  probe-pointed  blade  of  the  clamp 
is  thrust  and  carried  onward  and  upward  beneath  the  pectoral  muscles  and 
the  axillary  vessels  and  nerves — to  emerge  through  the  wound  previously  made 
for  the  purpose  of  dividing  the  clavicle  (Fig.  339).     The  instrument  is  then 


Fig.  338.— Illustrating  the  Use  of  Sutures  Passed  through  the  True  Skin  and 
Temporarily  tied  over  Rubber  Tubing  to  hold  it  in  Place: — Used  in  order  to  control 
the  vessels  in  disarticulating  at  the  shoulder-joint  in  the  absence  of  the  Wyeth  pins. 


clamped — thus  compressing  the  muscles  and  axillary  structures  between  the 
probe-pointed  and  serrated  blades.  The  soft  parts  are  then  divided  distally 
to  the  clamp — the  vessels  are  brought  within  easy  reach — and  the  ligatures 
are  placed  (Fig.  340).  The  points  of  entrance  and  exit  of  the  probe-pointed 
blade  are  made  to  correspond  with  some  part  of  the  incision  for  the  interscapulo- 
thoracic  amputation,  (d)  Preliminary  exposure  and  double  ligation  of  the 
axillary  artery,  with  division  between  the  two  ligatures  (as  in  Larrey's  oper- 
ation, page  381).  (e)  Digital  compression  of  the  main  artery  in  the  flap  by 
an  assistant,  who  grasps  the  part  just  prior  to  division  of  the  artery  (as  in 
Spence's  operation,  page  378).  (f)  By  Tourniquet  and  Pad; — A  firm  pad 
is  placed  in  the  axilla — over  tins  are  placed  several  turns  of  rubber  tubing 
passing  around  the  axilla — the  ends  are  then  carried  in  a  single  figure-of-eight 
fashion  over  the  clavicle  of  the  same  side,  and  thence  across  the  chest  and  are 
tied  beneath  the  opposite  axilla.  Two  strips  of  sterile  gauze  run  beneath 
the  tubing  anteriorly  and  posteriorly  (or  placed  in  position  prior  to  applying 
the  tubing)  will  enable  the  tubing  to  be  further  and  more  securely  drawn 
inward  and  thus  make  less  the  chances  of  slipping  when  the  head  of  the  humerus 
is  removed  (Fig.  268,  left  shoulder),  (g)  Compression  (digital  or  instru- 
mental) of  subclavian  artery  against  the  first  rib,  either  with  or  without  pre- 
liminary incision  over  the  third  part  of  the  artery,  through  the  superficial 
tissues,     (h)   Securing  of  the  main  vessels  at  the  lower  end  of  the  incision,  as 


376 


AMPUTATIONS. 


met  in  the  course  of  the  operation — an  ordinary  tourniquet  having  been  first 
applied — (as  in  the  Fourneaux  Jordan  method) . 

Comparison  of  methods  of  hemorrhage-control:— The  control  of  hemor- 
rhage in  disarticulating  at  the  shoulder-joint,  or  in  amputating  very  near 
the  shoulder  articulation,  is  the  most  serious  consideration  connected  with 
these  operations.  Wyeth's  method,  where  the  pins  do  not  interfere  with  the 
operation  as  planned,  may  be  regarded  as  the  best  means  against  hemorrhage. 
Preliminary  exposure  and  ligation  of  the  artery — and  compression  of  the 
artery  in  the  flap— may  be  regarded  as  the  next  best  methods. 


Fig.  339. — Thomas'  Forceps-tourniquet  for  Controlling  Hemorrhage  during 
Operations  itpon  the  Extremities: — The  probe- pointed  blade  passes  under  the  pectoral 
muscles  and  axillary  vessels  and  nerves,  and  the  serrated  blade  over  these  structures — the  former 
coming  out  above  the  region  of  the  previously  divided  clavicle.     (Modified  from  Thomas.) 


The  axillary  vessels  should  be  as  cleanly  cut  as  possible — and  so  approached 
as  to  be  secured  before  being  cut,  where  the  method  of  preliminary  ligation 
is  adopted. 

The  branches  of  the  brachial  plexus  are  to  be  divided  high  up. 

The  acromial  process  should  always  be  preserved — as  it  furnishes  a 
support  for  the  artificial  limb. 

A  capsulo-periosteally  covered  stump  should  be  sought — as  furnishing 
the  best  support  for  an  artificial  limb — therefore  one  should  endeavor  to 


DISARTICULATION    AT    SHOULDER-JOINT,    IN    GENERAL. 


377 


detach  the  insertions  of  the  pectoralis  major,  latissimus  dorsi,  teres  major, 
subscapularis,  supraspinatus,  infraspinatus,  and  teres  minor  along  with  the 
periosteum  and  capsule,  in  so  far  as  this  is  possible. 

A  vertical  wound,  in  closing  the  site  of  operation,  affords  the  best  drainage. 
Sometimes  drainage  is  made  through  a  secondary  opening.  Temporary 
drainage  is  always  indicated — owing  to  the  extensive  synovial  surfaces. 

The  stump  should  be  dressed  so  as  to  compress  dead  spaces — and  steadied 
against  the  thorax  as  a  splint  by  the  surrounding  bandaging. 


Fig.  340. — Thomas'  Forceps-tourniquet: — The  pectoral  muscles  and  axillary  structures 
have  been  divided  distally  to  the  clamp  and  turned  forward.  Note: — the  probe-pointed  blade 
is  here  erroneously  shown  to  be  where  the  serrated  blade  should  be,  and  vice  versa.  The  correct 
position  of  the  blades  is  shown  in  the  preceding  illustration.     (Modified  from  Thomas.) 


DISARTICULATION  AT  SHOULDER- JOINT,  IN  GENERAL. 

Best  Methods. — Anterior  Racket  Method  (Spence's  operation).  Ex- 
ternal Racket  Method  (Larrey's  operation).  External  or  Deltoid  Flap 
(Dupuytren's  operation). 

Other  Methods. — Anterior  and  Posterior  Flaps.  Circular.  Elliptical. 
Lateral  Flaps.     Fourneaux  Jordan's  Method. 

Comparison  of  Methods. — The  racket  methods  are  the  best.  The 
features  of  the  anterior  racket  method  are: — excision  of  the  shoulder-joint 


378  AMPUTATIONS. 

may  be  done,  instead  of  an  amputation,  through  the  vertical  portion  of  the 
incision,  which  may  be  alone  made  at  first,  until  it  be  found  whether  ampu- 
tation be  necessary;  there  is  the  smallest  division  of  muscle;  the  posterior 
circumflex  artery  and  circumflex  nerve  are  not  cut;  the  main  vessels  are 
easily  controlled.  The  features  of  the  external  racket  method  are: — the 
vertical  portion  of  the  incision  also  allows  of  an  excision,  the  incision  at  first 
being  exploratory,  through  which  an  excision  of  the  joint  may  be  made,  or 
the  operation  may  be  converted  into  an  amputation;  there  is  considerable 
division  of  muscle  and  the  joint  is  more  deeply  placed  than  in  the  anterior 
racket;  the  posterior  circumflex  artery  and  circumflex  nerve  are  apt  to  be  cut. 
The  disadvantages  of  the  external  or  deltoid  flap,  which  may  be  regarded 
as  probably  the  third  best  form  of  disarticulation,  are,  that  the  circumflex 
nerve  and  posterior  circumflex  artery  are  cut — and  that  preliminary  exami- 
nation of  the  joint  is  impossible. 

General  Indications. — Tumors  of  arm;  extensive  injury  of  arm;  com- 
pound comminuted  fractures;  gunshot  injuries;  chronic  disease  of  shoulder- 
joint;  gangrene  of  upper  limb;  extensive  osteomyelitis;  extensive  tumor  masses 
of  shoulder  and  scapula. 


DISARTICULATION  AT  SHOULDER- JOINT 

BV  ANTERIOR  RACKET  METHOD  — SPENCE'S  OPERATION. 

Description. — The  queue  of  the  incision  is  placed  over  the  anterior 
aspect  of  the  upper  end  of  the  humerus — the  diverging  limbs  of  the  racket, 
or  oval,  encircling  the  inner  and  outer  aspects  of  the  arm  and  meeting  behind. 

Position. — Patient  near  edge  of  table;  shoulders  elevated;  head  to  oppo- 
site side;  limb  partly  abducted.  Surgeon  on  outer  side  of  both  shoulders, 
or  may  stand  on  inner  side  of  left.  First  assistant  stands  between  shoulder 
and  patient's  head,  controls  hemorrhage  and  retracts  flaps.  Second  assistant 
stands  near  elbow  and  manipulates  limb. 

Landmarks. — Coracoid  process;  pectoro-deltoid  groove. 

Incision. — Abduct  the  arm  and  rotate  the  head  of  the  humerus  outward. 
Begin  the  incision  just  to  the  outer  side  of  the  coracoid  process — pass  down 
through  the  clavicular  fibers  of  the  deltoid  and  pectoralis  major,  until  the 
humeral  attachment  of  the  pectoralis  major  is  reached,  which  is  divided. 
From  this  point,  the  outer  limb  of  the  racket  curves  gently  outward  through 
the  lowest  part  of  the  deltoid  to  the  posterior  border  of  the  axilla.  From 
the  point  of  division  of  the  humeral  attachment*  of  the  pectoralis  major,  the 
inner  limb  of  the  racket  curves  downward  across  the  inner  aspect  of  the  arm — 
until  it  coincides  with  the  opposite  limb  of  the  racket  (Fig.  341,  B). 

Operation. — (I)  The  vertical  portion  of  the  incision  is  carried  directly 
to  the  bone.  The  outer  limb  of  the  racket  at  first  passes  through  skin  and 
fascia,  and  is  then  deepened  to  the  bone  and  through  the  periosteum,  along 
the  line  of  the  incised  integuments.  The  inner  limb  of  the  racket  merely 
passes  through  skin  and  fascia,  and  especial  care  is  taken  that  it  goes  no 
deeper  at  this  stage.  (2)  Returning  to  the  outer  lip  of  the  wound,  the  anterior 
fibers  of  the  deltoid  will  be  found  divided,  and  this  lip  of  the  wound  is  now 
freed  from  the  bone  and  joint,  as  nearly  subperiosteally  as  possible,  thereby 
securing  the  retention  of  some  of  the  attachments  of  the  pectoralis  major,  * 
latissimus  dorsi,  and  teres  major  to  the  fibrous  tissue — the  freeing  being 
accomplished  by  means  of  the  thumb,  periosteal  elevator  and  knife,  and 
continuing  up  to  the  great  tuberosity — carefully  avoiding  (by  hugging  the 


DISARTICULATION    AT    SHOULDER-JOINT. 


379 


bone)  injury  to  the  circumflex  nerve  and  posterior  circumflex  artery,  which 
are  raised  from  the  bone  in  this  outer  flap.  (3)  The  inner  lip  is  similarly, 
though  less  extensively,  freed  up  to  the  lesser  tuberosity,  carefully  guarding 


Fig. 341.— Amputations  through  Arm  and  at  Shoulder  :— A,  Through  lower  arm,  by  oblique 
circular  method  ;  B,  At  shoulder,  by  anterior  racket  method  (Spence's  operation)  ;  C,  Of  upper  limb, 
together  with  scapula  and  part  of  clavicle,  by  antero-inferior  (pectoro-axillary)  and  postero-superior 
(cervico-scapular)  flaps  (Berger's  operation). 


the  axillary  vessels.  (4)  By  manipulating  the  limb  from  the  elbow,  flexed 
at  a  right  angle,  the  head  of  the  bone  and  its  tuberosities  are  made  to  present 
themselves  in  the  wound.  By  rotating  inward,  the  great  tuberosity  presents, 
and  the  supraspinatus,  infraspinatus,  and  teres  minor  are  severed  very  close 


380  AMPUTATIONS. 

to  the  bone.  By  rotating  outward,  the  lesser  tuberosity  presents,  and  the 
subscapularis  is  severed.  (5)  The  long  head  of  the  biceps  is  next  cut,  and 
the  capsule  opened  by  dividing  it  transversely  against  the  head  of  the  bone. 
The  capsule  being  cut  and  the  muscles  attached  to  the  tuberosities  severed, 
the  head  of  the  bone  is  now  disarticulated  and  thrust  upward  above  the 
glenoid  cavity,  by  abducting  and  rotating  the  head  of  the  humerus  outward — 
the  connection  of  the  limb  being  maintained  by  the  still  unsevered  tissues 
upon  the  inner  aspect.  (6)  The  surgeon  grasps  the  disarticulated  head  with 
the  left  hand  and  draws  it  outward  from  the  trunk.  As  he  does  so,  the  first 
assistant,  standing  behind  the  shoulder,  places  the  palm  of  the  fingers  of 
both  hands  against  the  axillary  aspect  of  the  still  uncut  inner  tissues,  and  his 
thumbs,  one  from  each  side,  between  the  neck  of  the  bone  and  the  tissues 
of  the  inner  side,  compressing  the  axillary  vessels  between  the  thumbs  in  the 
wound  and  the  outspread  fingers  in  the  axilla — until  he  feels  all  circulation 
controlled.  The  surgeon  now  passes  a  long  knife  between  the  neck  of  the 
bone  and  the  thumb-nails  of  his  assistant,  and,  by  a  steady,  sawing  move- 
ment, cuts  his  way  from  within  downward  and  outward,  aiming  to  come  out 
on  a  line  with  the  retracted  integuments  along  the  original  incision,  along 
me  inner  limb  of  the  racket.  As  the  knife  cuts  its  way  out,  the  fingers  of 
the  assistant  follow  the  blade  closely,  with  the  artery  under  his  grasp.  Just 
prior  to  the  final  passage  of  the  knife,  the  tissues  are  tightly  grasped  and 
steadilv  held,  until  the  knife  emerges — when  he  presents  to  the  surgeon  the 
cut  margin  of  the  inner  flap,  with  the  vessels  in  easy  evidence.  (7)  Tie  the 
brachial  artery  at  once,  and  the  two  brachial  venae  comites  and  the  basilic 
vein.  In  the  vertical  and  external  limb  of  the  racket,  in  incising  and  deepen- 
ing the  wound,  branches  of  the  acromial  thoracic,  the  anterior  circumflex, 
and  muscular  branches  are  at  first  clamped  and  subsequently  tied.  (8)  The 
posterior  circumflex  nerve  should  not  be  injured.  The  nerves  which  are 
severed  are  cut  short.  (9)  The  margins  of  the  capsulo-periosteal  wound, 
where  any  appreciable  periosteum  has  been  saved,  are  sutured.  The  muscles 
are  quilted  by  deep  and  superficial  tiers  of  buried  catgut  (chromic)  sutures. 
Temporary  drainage  is  provided.  The  integumentary  edges  of  the  wound 
are  sutured  in  one  vertical  line.  The  stump  should  be  snugly  compressed 
against  the  thorax  by  the  bandage. 

Comment. — (1)  This  operation  is  an  illustration  of  the  control  of  hemor- 
rhage by  digital  compression  in  the  flap.  (2)  By  saving  as  much  of  the 
attachment  of  the  pectoralis  major,  latissimus  dorsi  and  teres  major,  in  the 
subperiosteal  freeing  of  the  humerus,  connections  in  the  stump  are  formed 
by  these  tendons  and  considerable  range  of  movement  is  thereby  added  to 
an  artificial  limb.  (3)  The  axillary  vessels  have  been  exposed  where  the 
inner  limb  of  the  racket  crosses  their  course  and  ligated  prior  to  disarticula- 
tion. (4)  Where  the  deltoid  tissues  are  very  thick,  this  flap  may  be  ad- 
vantageously thinned  a  little  by  making  the  incision  of  the  outer  limb  of  the 
racket  in  a  beveling  manner.  (5)  The  more  nearly  the  operation  is  done 
subperiosteallv,  where  no  contraindication  to  the  preservation  of  the  peri- 
osteum exists,  the  greater  the  safety  to  the  important  tissues,  especially  the 
circumflex  nerve  and  posterior  circumflex  artery. 


DISARTICULATION    AT    SHOULDER-JOINT.  381 

DISARTICULATION  AT  SHOULDER- JOINT 

BY  EXTERNAL  RACKET  METHOD  —  LARREY'S  OPERATION. 

Description. — The  queue  of  the  incision  is  placed  oYer  the  external 
aspect  of  the  upper  end  of  the  humerus — from  the  center  of  this  incision 
(which  may  first  haYe  been  made  for  exploration  of  the  joint  alone)  the  two 
limbs  of  the  racket  diverge — encircling  the  anterior  and  posterior  aspects 
of  the  arm  and  meeting  on  the  inner  side. 

Position. — As  in  Spence's  operation  (page  378). 

Landmarks. — Prominence  of  acromion. 

Incisions. — d)  Vertical  incision — (arm  being  slightly  abducted)  begins 
immediately  below  the  anterior  aspect  of  the  prominence  of  the  acromion 
and  passes  thence  vertically  down  the  external  aspect  of  the  arm  for  10  cm. 
(4  inches).  (2)  Oval  incision — from  the  center  of  the  vertical  incision  the 
two  limbs  of  the  oval,  or  racket,  begin  and  pass  obliquely  downward  over 
the  anterior  and  posterior  aspects  of  the  limb,  meeting  upon  its  inner  border 
on  a  level  with  the  lowest  part  of  the  vertical  incision  (Fig.  335,  C). 

Operation. — (i)  The  vertical  incision  passes  at  once  through  the  deltoid 
directly  to  the  bone  and  into  the  joint.  The  operation,  which  may  have 
been  begun  as  an  exploratory  one,  may  end  with  an  investigation  of  the  joint 
— or  may  proceed  to  an  excision  of  the  joint  structures — or  may  end  as  an 
amputation.  If  the  latter,  the  oval,  or  racket,  incision,  as  above  described, 
is  added  to  the  vertical  incision.  (2)  The  limbs  of  the  racket  are  at  first 
incised  through  skin  and  fascia  only,  and  may  be  made  at  one  stroke,  or, 
better,  by  two.  (3)  The  anterior  limb  of  the  racket  is  now  deepened,  while 
the  arm  is  rotated  outward — the  incision  passing  through  the  anterior  portion 
of  the  deltoid — the  tendon  of  the  pectoralis  major  is  severed  as  near  the 
bone  as  possible — the  coracobrachialis  and  biceps  are  divided — and,  next  to 
these,  the  axillary  vessels  are  encountered,  carefully  exposed  and  doubly 
ligated,  beyond  the  posterior  circumflex  branch.  This  flap  is  then  freed 
up  to  the  joint.  For  the  same  reasons  mentioned  under  the  last  operation, 
the  freeing  of  these  flaps  should  be  done  as  subperiosteally  as  possible.  (4) 
The  posterior  limb  of  the  racket  is  similarly  deepened,  the  arm  being  rotated 
inward — the  incision  passing  through  the  posterior  portion  of  the  deltoid — 
and  meeting  the  anterior  limb  upon  the  inner  side  of  the  arm.  This  flap 
is  then  also  freed  up  to  the  joint  as  subperiosteally  as  possible.  (5)  Dis- 
articulation is  accomplished  (after  severing  close  to  the  bone  in  the  above 
freeing  of  the  anterior  and  posterior  flaps,  the  attachments  of  the  supra- 
spinatus,  infraspinatus,  and  teres  minor  to  the  great  tuberosity,  and  the 
subscapularis  to  the  lesser)  by  cutting  the  capsule  and  the  long  head  of  the 
biceps  against  the  head  of  the  bone  transversely.  The  head  of  the  bone  is 
now  disarticulated  and  thrust  upward.  (6)  To  sever  the  remaining  soft 
parts,  the  surgeon  grasps  the  disarticulated  head  of  the  humerus  with  his 
left  hand  and  draws  it  outward — then  inserts  a  long  knife  between  the  neck 
of  the  bone  and  the  remaining  undivided  parts,  and,  by  a  sawing  movement, 
cuts  his  way  downward  and  outward  between  the  severed  axillary  vessels 
and  the  bone,  coming  out  on  a  line  with  the  retracted  inner  limb  of  the  racket 
incision  (just  as  in  the  disarticulation  by  the  anterior  racket).  (7)  Besides 
the  above-named  vessels,  the  anterior  and  posterior  circumflex  are  both  apt 
to  be  divided,  as  well  as  some  muscular  branches.  The  circumflex  nerve  is 
likely  to  be  severed.  All  nerves  are  cut  short.  (8)  The  capsule  is  to  be 
trimmed,  if  hanging  in  tags.     Temporary  drainage  is  used.     The  capsulo- 


382  AMPUTATIONS. 

periosteal,    or   capsulo-muscular  covering   is   sutured — the  muscles   quilted 
deeply  and  superficially — and  the  skin  sutured  in  a  vertical  line. 

Comment. — This  operation  is  an  illustration  of  the  control  of  hemor- 
rhage by  the  ligation  of  the  main  vessels  in  the  line  of  incision,  prior  to  dis- 
articulation. 

DISARTICULATION  AT  SHOULDER- JOINT 

PA'   EXTERNAL  OR  DELTOID  FLAP. 

Description. — A  U-shaped  flap,  consisting  practically  of  the  deltoid 
muscle,  is  raised  from  the  outer  side  of  the  shoulder — its  upper  limits  being 
connected  by  a  transversely  curved  incision  across  the  inner  aspect  of  the 
arm. 

Position.— As  in  Spence's  operation  (page  378). 

Landmarks. — Coracoid  process  of  scapula;  spine  of  scapula. 

Incision. — The  base  of  this  U-shaped  flap  extends  from  the  coracoid 
process,  anteriorly,  to  the  spine  of  the  scapula  at  the  root  of  the  acromion 
posteriorly.  In  length,  the  flap  extends  nearly  to  the  insertion  of  the  deltoid. 
The  upper  extremities  of  the  limbs  of  the  flap  are  joined  by  a  transversely 
curved  incision  (with  slight  downward  convexity)  crossing  the  inner  side 
of  the  arm  about  5  cm.  (2  inches)  below  the  lower  limit  of  the  axilla.  On 
the  right  side,  the  incision  begins  at  the  root  of  the  acromion  and  ends  at  the 
coracoid,  the  arm  having  been  placed  across  the  chest.  On  the  left  side, 
the  incision  begins  at  the  coracoid,  with  the  arm  abducted — and  ends  at  the 
root  of  the  acromion,  with  the  arm  across  the  chest.  In  both,  the  surgeon 
manipulates  the  limb  with  his  left  hand.  This  flap  consists  of  the  entire 
thickness  of  the  deltoid  at  the  base,  while  its  margins  are  beveled.  (Fig.  335, 
D,  D.) 

Operation. — The  entire  length  of  the  superficial  incision  outlining  the 
flap  is  now  deepened  to  the  bone  along  the  line  of  the  retracted  skin — cutting 
in  a  beveling  fashion  obliquely  from  without  inward  and  from  below  upward. 
This  mass  of  soft  tissues  is  then  raised  from  the  bone,  severing  the  attach- 
ments of  the  muscles  of  the  great  and  less  tuberosities.  The  joint  is  now 
opened  by  cutting  directly  down  upon  the  capsule  and  long  head  of  the  biceps 
transversely  against  the  head  of  the  bone.  The  head  of  the  bone  is  dis- 
articulated and  thrust  upward,  and  the  operation  completed  as  in  Spence's 
method  of  disarticulating — that  is,  the  head  of  the  bone  is  grasped  and  drawn 
outward — an  assistant  guarding  the  tissues  of  the  inner  flap  as  in  the  opera- 
tion just  mentioned,  a  long  knife  is  inserted  between  the  neck  of  the  bone 
and  the  still  undivided  tissues  upon  the  inner  aspect  and  made  to  cut  its  way 
downward  and  outward  on  a  line  with  the  transversely  curved  portion  of  the 
incision  connecting  the  upper  limbs  of  the  flap,  thus  severing  the  pectoralis 
major,  latissimus  dorsi,  and  teres  major.  Having  ligated  the  vessels  and 
cut  the  nerves  short — the  muscles  are  quilted — and  the  integumentary  margin 
of  the  deltoid  flap  is  sutured  to  the  border  of  the  short  internal  flap. 

Comment. — (1)  This  is  the  least  desirable  of  the  three  methods  of  dis- 
articulation described.  (2)  Hemorrhage  may  be  controlled  by  some  form 
of  tourniquet,  or  by  the  early  ligation  of  the  artery  in  the  axilla.  (3)  An 
attempt  may  be  made  to  save  the  circumflex  nerve  and  the  posterior  circumflex 
artery — either  by  isolating  and  retracting  them  while  incising  from  the  skin 
downward  in  the  posterior  limb  of  the  flap — or  by  approaching  them  from 
the  anterior  portion  of  the  flap,  working  under  the  periosteum  and  then 
retracting  them. 


INTERSCAPULO-THORACIC    AMPUTATION.  383 


AMPUTATION    OF    UPPER    LIMB,    TOGETHER    WITH    SCAPULA    AND 
PART  OF  CLAVICLE, 

BY    ANTEROINFERIOR    (OR    PECTORO-AXILLARY)    AND     POSTERO-SITERIOR    (OR 
CERVICO-SCAPULAR)  FLAPS— BERGER'S  OPERATION. 

Description. — Consists  in  the  removal  of  the  upper  limb,  together  with 
the  scapula  and  the  outer  two-thirds  of  the  clavicle,  en  masse,  without  dis- 
articulation at  the  shoulder-joint. 

Position. — Given  in  the  steps  of  the  operation. 

Landmarks. — Outline  of  clavicle;  outline  of  scapula;  line  of  shoulder- 
joint  articulation. 

Operation.— (1)  Subperiosteal  Excision  of  middle  third  of  Clavicle  and 
double  ligature  and  division  of  Subclavian  Artery  and  Vein: — Patient  on 
back,  at  edge  of  table;  shoulders  raised;  arm  by  side.  Make  an  incision 
through  the  periosteum  to  bone,  over  the  upper  surface  of  the  clavicle,  from 
outer  border  of  sternomastoid  to  just  beyond  the  acromioclavicular  articu- 
lation (Fig.  341,  C,  C,  C).  The  vein  from  the  cephalic  to  the  external  jugular 
is  hereby  cut  and  is  doubly  ligated.  The  periosteum  is  raised,  with  curved 
periosteal  elevator,  from  around  the  entire  circumference  of  the  middle  third 
of  the  clavicle.  A  chain  or  Gigli  saw  is  passed  between  bone  and  periosteum 
and  the  clavicle  is  divided  at  the  junction  of  its  inner  and  middle  thirds. 
The  outer  two-thirds  of  the  clavicle  is  now  grasped  with  lion-jaw  forceps 
and  drawn  outward,  during  which  outward  traction  whatever  periosteum 
may  remain  is  now  detached  from  its  middle  third.  The  clavicle  is  then 
sawed  at  the  junction  of  the  middle  and  outer  thirds,  by  a  chain,  Gigli,  or 
small  saw.  The  middle  third  of  the  clavicle  is  thereby  removed.  The 
periosteum  over  the  subclavius  muscle  and  the  subclavius  muscle  are 
now  divided  transversely,  opposite  the  inner  section  of  the  clavicle,  and 
are  dissected  up  and  turned  outward,  thereby  exposing  the  subclavian 
vessels,  surrounded  by  more  or  less  fascia.  Having  divided  the  over- 
lying fascia,  the  subclavian  vein  and  then  the  artery  are  exposed.  Both 
artery  and  vein  are  doubly  ligated  and  divided  opposite  the  lower 
border  of  the  first  rib — the  former  being  secured  first  (to  lessen  the 
amount  of  blood  left  in  the  limb).  (2)  Formation  of  Anteroinferior  (or 
Pectoro-axillary)  Flap: — Patient  on  back,  with  shoulder  over  edge  of  table; 
arm  abducted;  head  to  opposite  side.  Surgeon  between  arm  and  trunk. 
The  incision  begins  at  the  middle  of  the  clavicular  incision — curves  down- 
ward and  outward,  passing  close  to  the  outer  side  of  the  coracoid  process — 
thence  along  the  anterior  portion  of  the  deltoid,  just  external  to  the  pectoro- 
deltoid  groove,  to  the  junction  of  the  anterior  axillary  wall  with  the  arm — 
thence  across  the  lower  border  of  the  pectoralis  major — thence  transversely 
across  the  inner  or  axillary  surface  of  the  arm — to  the  lower  borders  of  the 
tendons  of  the  latissimus  dorsi  and  teres  major.  Here  the  limb  is  elevated — 
and  the  incision  is  earned  downward  and  inward  in  the  groove  between 
the  vertical  border  of  the  scapula  and  the  muscular  elevation  formed  by 
the  teres  major  and  latissimus  dorsi,  to  end  over  the  posterior  surface  of  the 
inferior  angle  of  the  scapula.  This  incision  passes,  at  first,  through  skin 
and  fascia,  and  is  then  deepened  through  the  pectoral  and  axillary  tissues 
— the  pectoralis  major  being  cut  where  its  tendinous  portion  commences — 
the  pectoralis  minor  near  the  coracoid  process — the  brachial  plexus  near  the 
first  rib — the  latissimus  dorsi  in  the  more  posterior  part  of  the  line  of  incision 
— and  whatever  remaining  axillary  tissues  bind  the  limb  are  cut  as  encoun- 
tered.    The  shoulder  is  thus  freed  from  the  trunk  anteriorly — and  tends  to 


384  AMPUTATIONS. 

fall  outward  and  backward.  (3)  Formation  of  the  Postero-superior  (or 
Cervico-scapular)  Flap: — The  patient  is  still  supine,  with  shoulder  over 
edge  of  table;  the  arm  is  now  drawn  across  the  chest  to  emphasize  the  scapular 
region.  The  surgeon  stands  to  the  outer  side.  The  incision  begins  at  the 
outer  end  of  the  clavicular  incision,  just  external  to  the  acromio-clavicular 
joint — passing  thence  backward  over  the  spine  of  the  scapula  by  the  shortest 
route,  to  join  the  lower  end  of  the  antero-inferior  flap  incision  over  the  inferior 
angle  of  the  scapula.  This  incision  at  first  involves  only  the  skin  and  fascia, 
which  are  then  well  retracted  along  their  upper  part,  thus  exposing  the  trape- 
zius, which  is  now  divided  near  its  attachment  to  the  clavicle  and  scapula, 
and  thus  severed  from  the  whole  limb.  (4)  Severing  of  Connections  of 
Scapula  to  Trunk: — The  patient  lies  as  in  the  last  step — and  the  surgeon 
stands  to  the  inner  side  of  the  right  and  outer  side  of  left  limb.  The  anterior 
and  posterior  flaps  are  well  retracted  and  the  limb  permitted  to  hang  away 
from  the  side.  The  superior  and  vertical  borders  of  the  scapula  are  rendered 
prominent  and  are  now  freed  by  cutting  the  following  muscles  close  to  the 
bone,  in  order  from  above  downward:  omohyoid,  levator  anguli  scapula1, 
rhomboideus  minor,  rhomboideus  major,  and  serratus  magnus.  The  upper 
extremity  is  now  free  from  the  trunk — the  muscles  arising  from  the  scapula 
and  inserted  into  the  humerus  (teres  major  and  minor,  subscapulars,  supra- 
spinatus,  and  infraspinatus)  are  removed  untouched  with  the  limb.  (5)  Con- 
trol of  Hemorrhage: — Preliminary  ligation  of  the  subclavian  artery  and  vein 
control  the  chief  hemorrhage.  In  forming  the  anterior  flap,  branches  of 
the  acromio-thoracic,  long  thoracic  and  subscapular  are  encountered.  In 
forming  the  posterior  flap,  the  muscular  branches  in  the  trapezius  are  met. 
In  severing  the  scapula  the  chief  bleeding  occurs — the  suprascapular  artery 
is  to  be  tied  near  the  omohyoid  as  it  is  about  to  enter  the  supraspinous  fossa 
— and  the  posterior  scapular  is  to  be  tied  near  the  upper  angle  of  the  scapula 
just  after  dividing  the  levator  anguli  scapulae.  (6)  Closure  of  the  Wound: — 
All  the  nerves  are  divided  short.  Generally  no  sufficient  redundancy  of  mus- 
cles is  present  to  admit  of  quilting,  it  usually  being  difficult  to  approximate 
the  edges  of  the  wound — but,  if  it  be  possible,  quilting  of  the  muscles  together 
with  buried  gut  sutures  should  be  done — to  make  a  thicker  stump-padding 
and  to  take  the  strain  off  the  cutaneous  sutures.  The  anterior  and  posterior 
flaps  are  brought  together  and  sutured  in  one  oblique  line,  extending  from 
above,  downward,  outward,  and  backward.  To  obliterate  the  dead  spaces 
which  tend  to  form  in  so  extensive  a  wound,  considerable  even  pressure  is 
applied  in  the  dressings  which  bind  the  parts  to  the  thorax.  No  drainage 
is  indicated  in  simple  cases. 

Comment. — (1)  Sometimes  the  outer  two-thirds  of  the  clavicle  is  drawn 
outward  and  disarticulated  at  the  acromion.  (2)  If  the  suprascapular  and 
posterior  scapular  arteries  are  ligated  through  such  a  wound  as  is  made 
in  exposing  the  clavicle,  at  this  stage,  the  chief  bleeding  of  the  whole  operation 
will  be  avoided.  The  former  is  easily  found.  (3)  One  is  apt  to  find  too 
scanty  an  allowance  of  flap  covering,  which  is  caused  by  not  extending  the 
oval  parts  of  the  incisions  far  enough  out  over  the  shoulder. 


SURFACE    FORM    AND    LANDMARKS    OF    TOES.  385 

AMPUTATIONS  AND   DISARTICULATIONS  OF  THE  LOWER 

EXTREMITY. 

SURGICAL  ANATOMY  OF  THE  TOES. 

Bones. — Third,  second,  and  first  Phalanges. 

Articulations  and  Ligaments. — (a)  Second  and  Third  Interphalangeal 
Joint: — Plantar;  dorsal  and  two  lateral  ligaments.  Extensor  tendon  rein- 
forces dorsal  aspect  of  joint,  (b)  First  and  Second  Interphalangeal  Joint: — 
Same  as  last,  (c)  Metatarsophalangeal  Joints: — Plantar  (glenoid),  dorsal, 
and  two  lateral  ligaments.     Extensor  tendon  reinforces  dorsal  aspect. 

Muscles. — See  under  Foot  (page  397). 

Sheaths  of  Flexor  Tendons. — Tendons  of  flexor  longus  digitorum  and 
flexor  brevis  digitorum,  in  their  passage  along  the  phalanges,  are  bound 
against  the  bones  by  fibrous  sheaths  attached  to  margins  of  phalanges  and 
forming  osseo-aponeurotic  canals  lined  by  synovial  membrane.  They  are 
strongest  opposite  the  first  and  second  phalanges,  and  weakest  opposite 
the  interphalangeal  joints. 

Arteries. — Two  dorsal  digital,  from  dorsal  interosseous  and  from  dorsalis 
hallucis;  two  plantar  from  plantar  digital  and  from  princeps  hallucis. 

Veins. — Superficial: — branches  from  the  superficies  of  each  toe.  Deep: 
— accompany  the  digital  arteries.  Note — From  the  foot  to  the  knee,  two 
veins  accompany  each  artery;  from  knee  upward,  one  vein  accompanies 
each  artery,  except  at  back  of  thigh  and  gluteal  region,  where  there  are  gener- 
ally two. 

Nerves. — External  saphenous;  internal  and  external  branches  of  musculo- 
cutaneous; internal  branch  of  anterior  tibial;  digital  branches  of  internal 
plantar;  digital  branches  of  external  plantar. 


SURFACE  FORM  AND  LANDMARKS  OF  TOES. 

Extensor  tendons  of  four  outer  toes — the  four  tendons  of  the  extensor 
longus  digitorum,  having  been  joined  by  the  tendons  of  the  extensor  brevis 
digitorum  (except  that  the  latter  muscle  furnishes  no  tendon  to  the  little 
toe)  and  by  fibrous  expansions  from  the  interossei  and  lumbricales — all 
spread  out  into  a  broad  aponeurosis,  which  covers  the  dorsum  of  the  first 
phalanx  and  divides  into  three  slips — the  middle  slip  being  inserted  into 
the  bases  of  the  second  phalanges  of  the  four  lesser  toes — the  two  lateral 
slips,  having  united  on  the  dorsum  of  the  second  phalanx,  are  inserted  into 
the  bases  of  the  third  phalanges  of  the  four  lesser  toes. 

Extensor  tendon  of  great  toe — the  innermost  tendon  of  the  extensor 
brevis  digitorum  is  inserted  into  the  dorsal  surface  of  the  base  of  the  first 
phalanx — blending  with  the  tendon  of  the  extensor  proprius  hallucis,  which 
is  inserted  into  the  dorsal  surface  of  the  base  of  the  last  phalanx. 

Flexor  tendons  of  four  outer  toes — the  four  tendons  of  the  flexor  brevis 
digitorum  divide  opposite  the  base  of  the  first  phalanges  (for  the  passage  of 
the  tendon  of  the  flexor  longus  digitorum)  and  then  unite  opposite  the  first 
phalanges  to  form  a  channel  for  the  flexor  longus  digitorum — then  divide — 
and  are  finally  inserted  into  the  sides  of  the  middle  of  the  second  phalanges. 
The  four  tendons  of  the  flexor  longus  digitorum  are  inserted  into  the  bases 
of  the  plantar  surfaces  of  the  last  phalanges  of  the  four  lesser  toes. 

25 


386  AMPUTATIONS. 

Flexor  tendons  of  great  toe — the  flexor  brevis  hallucis  is  inserted  into 
the  inner  and  outer  sides  of  the  plantar  surface  of  the  base  of  the  first  phalanx, 
a  sesamoid  bone  being  present  in  each  of  its  two  heads  of  insertion.  The 
tendon  of  the  flexor  longus  hallucis  is  inserted  into  the  plantar  surface  of  the 
base  of  the  last  phalanx. 

The  flexor  sheaths,  which  are  not  so  distinct  as  in  the  fingers,  have  been 
given  under  Surgical  Anatomy  (page  385). 

The  first  interphalangeal  joint  of  each  toe  is  about  opposite  its  middle. 

The  knuckle  of  each  phalangeal  joint  is  formed  by  the  head  of  the  proximal 
bone — as  in  the  hand. 

The  joint-line  of  the  interphalangeal  and  metatarso-phalangeal  articula- 
tions is  found  by  flexing  the  distal  bone  at  a  right  angle  to  the  proximal  and 
extending  the  mid-lateral  axis  of  the  proximal  bone — which  will  pass  over 
the  joint-line. 

The  metatarso-phalangeal  joints  follow,  approximately,  the  curve  of  the 
toes  and  are  about  2.5  cm.  (1  inch)  behind  the  webs.  The  metatarso-phalangeal 
articulation  of  the  first  and  fifth  toes  is  detectable  by  manipulation,  and  the 
line  of  the  other  joints  then  found  by  making  a  curve  between  them  about 
parallel  with  the  interdigital  webs. 

The  anterior,  or  glenoid,  ligament  occupies  the  plantar  surface  of  the 
metatarso-phalangeal  and  the  interphalangeal  joints  and  is  more  firmly 
adherent  to  the  base  of  the  distal  than  to  the  head  of  the  proximal  bone. 
It  is  cut  against  the  base  of  the  former. 

The  nail  largely  overlies  the  last  phalanx. 

Each  metatarsal  has  one  epiphysis  at  its  head,  uniting  from  the  eighteenth 
to  twentieth  year — that  of  the  great  toe  having  it  at  its  base,  and  uniting 
at  the  same  time.  Each  phalanx  has  one  epiphysis  at  its  base — uniting 
from  the  seventeenth  to  eighteenth  year. 

GENERAL  SURGICAL  CONSIDERATIONS  IN  AMPUTATIONS  AND 
DISARTICULATIONS  ABOUT  THE  TOES. 

Many  of  the  observations  made  concerning  amputations  and  disarticula- 
tions about  the  fingers  apply  to  corresponding  regions  of  the  toes.  But 
operations  here,  except  about  the  great  toe,  are  apt  to  be  very  irregular  pro- 
ceedings, largely  determined  by  circumstances. 

Minimum  sacrifice  of  parts  is  indicated,  often  amounting  to  mere  trim- 
mings— but  this  principle  is  not  as  absolutely  necessary  as  in  the  fingers. 

Preservation  of  the  heads  of  the  metatarsals  increases  the  strength  of 
the  foot. 

If  the  base  of  the  last  phalanx  be  saved,  all  of  the  extensor  and  the  deep 
flexor  tendon  (flexor  longus  digitorum)  will  be  preserved.  If  the  proximal 
half  of  the  second  phalanx  be  saved,  part  of  the  extensor  and  the  superficial 
flexor  (flexor  brevis  digitorum)  tendon  will  be  saved. 

Preservation  of  parts  of  the  great  toe  is  much  more  important  than  preser- 
vation of  the  four  lesser  toes. 

As  the  foot  rests  on  the  heel,  heads  of  the  metatarsals  and  inner  margin 
of  the  sole,  as  much  as  possible  of  the  anterior  part  of  the  foot  and  phalanges 
of  the  great  toe  is  to  be  saved. 

It  is  important  to  save  the  base  of  the  first  phalanx  of  the  great  toe,  owing 
to  the  number  of  muscles  which  are  there  inserted.  If  the  base  of  the  first 
phalanx  cannot  be  saved,  its  many  attached  tendons  should  be  removed  as 
nearly  subperiosteally  as  possible  and  be  sutured  into  the  tissues  of  the  stump. 


SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT    TOES.     387 

Except  in  the  case  of  the  great  toe,  a  portion  of  a  toe  is  of  little  or  no  use; 
and,  in  the  case  of  the  four  outer  toes,  a  retained  portion  of  a  toe  may  be 
drawn  permanently  upward  and  thus  be  pressed  against.  Therefore  some 
surgeons  remove  the  four  outer  toes  at  the  metatarso-phalangeal  joint,  if 
removed  at  all. 

The  flexor  sheaths  should  be  closed  as  in  the  finger  operations  (page  339). 

The  flexor  tendons  should  be  so  sutured  as  to  secure  their  union  to  the 
stump,  if  it  be  wished  to  retain  their  action.  But,  except  in  the  case  of  the 
great  toe,  this  is  much  less  important  than  in  the  fingers. 

Musculo-periosteal  coverings  and  capsulo-periosteal  coverings  in  these 
small  amputations  and  disarticulations  are,  theoretically,  desirable,  but, 
practically,  difficult  or  impossible. 

Cicatrices  should  be  planned  not  to  fall  in  the  sole,  where  they  would 
be  constantly  exposed  to  pressure.  The  plantar  flap,  therefore,  is  the  best 
general  type  of  amputation  or  disarticulation  for  the  toes,  bringing,  as  it 
does,  the  cicatrix  upon  the  dorsum. 

In  amputating  by  the  plantar  flap  a  slight  downward  convexity  given  to 
the  transverse  dorsal  incision  makes  a  better  fit. 

In  making  all  plantar  incisions  the  part  should  be  extended — and  flexed 
while  making  dorsal  incisions — whereby  a  fuller  covering  will  be  obtained. 

Flaps  are  generally  formed  (in  the  palmar  flap  method)  by  cutting  directly 
downward  in  the  mid-lateral  aspects  of  the  toes,  but  if  the  vertical  limbs  of 
the  incisions  be  a  little  nearer  the  dorsal  than  the  plantar  surface,  a  more 
liberal  covering  will  be  secured. 

All  flaps  should  be  cut  from  without  inward. 

Bones  should  be  divided  by  a  fine,  rigid  saw,  or  a  chain  or  Gigli  saw — 
and  never  by  bone-cutting  forceps. 

Disarticulation  of  the  interphalangeal  joints  may  be  made  from  the 
dorsal  or  plantar  aspect.  In  the  former,  the  extensor  tendon  is  cut  from 
without,  and  then  the  lateral  and  glenoid  ligaments  are  cut  from  within 
outward.  In  the  latter,  the  glenoid  ligament  is  cut  against  the  base  of  the 
distal  bone,  and  the  joint  opened,  and  then  the  lateral  ligaments  and  the 
extensor  tendon  are  cut  from  within  outward.  The  dorsal  disarticulation 
is  preferable. 

In  disarticulating  at  the  metatarso-phalangeal  joints,  the  following  points 
are  to  be  observed: — The  joint  is  to  be  disarticulated  from  the  dorsum. 
The  sesamoid  bones  are  to  be  left  in  with  the  head  of  the  metatarsal.  Ample 
covering  is  necessary  for  the  disproportionately  large  head  of  the  metatarsal. 
The  cicatrix  should  be  away  from  the  plantar  surface  (where  it  would  be 
exposed  to  pressure).  Owing  to  the  distance  of  the  joint-line  above  the 
web,  it  would  be  difficult  to  disarticulate  from  the  plantar  aspect.  The 
heads  of  the  metatarsals  should  not  be  removed. 

Great  care  is  necessary  to  hug  the  bone  in  freeing  up  flaps,  in  order  to 
avoid  the  digital  arteries,  which  run  near  the  bone  and  are  the  sole  supply 
to  the  coverings.     These  vessels  should  run  to  the  end  of  the  flaps. 

Ligatures  should  be  catgut — and  sutures  silk,  or  silkworm-gut  for  the 
skin.  Sutures  for  quilting  muscles  or  tendons,  or  for  closing  sheaths,  should 
be  of  catgut. 

Drainage  is  generally  unnecessary. 

In  all  amputations  or  disarticulations,  the  stump  should  be  snugly  dressed 
and  bandaged  against  an  adjoining  toe  as  a  splint. 

The  stump  should  be  kept  out  from  under  the  bed-clothes  while  healing 


388  AMPUTATIONS. 

—and  the  patient  frequently  lie  upon  the  side  to  favor  drainage,  where  in- 
dicated. 

Note. — The  indications  for  amputations  through  the  various  parts  of  the 
lower  extremity  correspond,  in  a  general  way,  with  those  for  amputating 
through  the  corresponding  parts  of  the  upper  extremity. 

AMPUTATION  THROUGH  LAST  PHALANX  OF  TOES,  IN  GENERAL. 

Best  Method. ■■ -Plantar  Flap. 
Other  Method.— Oblique   Circular. 


V  jtO 


Fig.   342. — Dorsal  View  of  the  Bones  or  the  Foot,  Showing  the  Intertarsal,  Tarso- 
metatarsal, AND  INTERMETATARSAL  ARTICULATIONS. 
Fig-  343- — Plantar  View  of  the  Bones  of  the  Foot,  Showing  the  Intertarsal,  Tarso- 
metatarsal, AND  INTERMETATARSAL  ARTICULATIONS. 


AMPUTATION  THROUGH  LAST  PHALANX  OF  TOES 

BV  PLANTAR  FLAP. 

Description. — Hardly  feasible  as  a  definite  operation — amounting, 
generallv,  to  trimming  of  the  parts — except  in  the  case  of  the  great  toe,  which 
is  the  operation  here  described. 

Position.— (For  all   amputations   about  the   toes) : —Patient  supine, 


DISARTICULATION    AT    SECOND    INTERPHALAXGEAL    JOINT.         389 

with  foot  bevond  end  of  table;  toes  extended  during  plantar  incisions,  and 
flexed  during  dorsal  incisions.  Assistant  stands  in  front  of  surgeon,  steadying 
foot  with  both  hands,  the  fingers  of  which,  at  the  same  time,  draw  aside 
and  out  of  the  way,  the  adjacent  toes.  Surgeon  grasps  toe  to  be  removed 
with  thumb  and  forefinger  of  left  hand — with  his  thumb  on  the  dorsum 
of  the  toe  during  dorsal  incisions;  and  on  the  plantar  surface  of  toe  during 
plantar  incisions — the  index-finger  occupying  the  opposite  aspect  in  each 
case.  His  hand  will  be  supinated  during  dorsal,  and  pronated  during  plantar 
incisions. 

Landmarks. — Saw-line,  which  will  lie  between  base  of  nail  and  inter- 
phalangeal  joint  above. 

Incision. — The  vertical  portion  begins  opposite  the  saw-line,  in  the 
mid-lateral  aspect  of  the  toe,  or  a  little  nearer  the  dorsum  (which  furnishes 
a  fuller  plantar  flap) — passes  straight  down  that  aspect  and  around  the 
pulp  of  the  toe  to  the  corresponding  point  on  the  opposite  side.  The  trans- 
verse dorsal  incision  connects  the  upper  ends  of  the  limbs,  with  slight  down- 
ward convexity  (Fig.  349,  A,  for  principle). 

Operation. — Having  incised  skin  and  fascia,  these  incisions  are  deepened 
to  the  bone — the  soft  parts  are  separated  up  to  the  saw-line  and  retracted. 
The  tip  of  the  phalanx  is  grasped  with  bone-holding  forceps  and  steadied, 
while  the  bone  is  sawed.  If  the  base  of  the  last  phalanges  be  left,  the  inser- 
tion of  the  flexor  and  extensor  tendons  will  be  preserved.  Arteries  rarely 
have  to  be  tied — except  in  the  case  of  the  great  toe. 


DISARTICULATION     AT     SECOND     INTERPHALANGEAL     JOINT,     IN 

GENERAL. 


Best  Method.— Plantar  Flap. 
Other  Method. — Oblique  Circular. 


DISARTICULATION  AT  SECOND  INTERPHALANGEAL  JOINT  OF  TOES 

BV  PLANTAR  FLAP. 

Description. — A  U-shaped  flap  is  raised  from  the  plantar  aspect  of  the 
toe  and  approximated  to  the  dorsal  wound. 

Position. — As  for  the  last  phalanx  (page  388). 

Landmarks. — Second  interphalangeal  joint-line. 

Incisions. — The  vertical  portion  of  the  incision  begins  opposite  the 
joint-line,  in  the  mid-lateral  aspect,  or  a  little  nearer  the  dorsum — passes 
directly  down  this  aspect  of  the  toe  a  distance  sufficient  to  furnish  a  covering 
of  ii  diameters  of  the  toe  at  the  saw-line — then  rounds  bluntly  across  the 
plantar  surface  and  is  continued  up  to  a  corresponding  point  on  the  opposite 
side.  The  transverse  incision  connects  the  upper  limbs  of  the  flap  by  a 
slight! v  rounded  convex  line  (Fig.  349,  A). 

Operation. — Deepen  the  vertical  portion  and  the  rounded  end  of  the 
flap  to  the  bone — dissect  up  the  soft  parts  to  the  joint-line,  cutting  the  glenoid 
ligament  and  flexor  tendon  against  the  base  of  the  last  phalanx,  thus  opening 
the  joint.  Forcibly  hex  the  joint  and  deepen  the  transverse  incision  to  and 
into  the  joint,  entering  from  the  dorsum  and  cutting  the  lateral  ligaments 


39°  AMPUTATIONS. 

from  within  outward.  Two  dorsal  and  two  plantar  digital  arteries  may 
require  ligation.  Close  the  flexor  sheath  with  catgut — and,  in  the  great 
toe,  include  the  flexor  tendon.  Suture  the  plantar  flap  to  the  transverse 
dorsal  wound. 


AMPUTATION  THROUGH  SECOND  PHALANX  OF  TOES,  IN  GENERAL. 

Best  Method.— Plantar  Flap. 
Other  Method. — Oblique  Circular. 


AMPUTATION  THROUGH  SECOND  PHALANX  OF  TOES 

BY  PLANTAR  FLAP. 

Description. — The  manner  of  performing  this  operation  is  sufficiently 
described  in  the  amputation  through  the  last  phalanx  (page  388),  and  the 
dimensions  of  the  flap,  under  the  disarticulation  at  the  second  interphalangeal 
joint  (page  389). 

DISARTICULATION  AT  FIRST  INTERPHALANGEAL  JOINTS  OF  TOES, 

IN  GENERAL. 
Best  Method.— Oval  Method. 
Other  Methods. — Oblique  Circular.     Plantar  Flap. 


DISARTICULATION  AT  FIRST   INTERPHALANGEAL   JOINTS  OF  TOES 

BY  OVAL  METHOD. 

Description. — Queue  of  incision  over  dorsal  aspect  of  joint — the  limbs 
of  the  oval  encircling  the  toe  beyond  the  first  interphalangeal  jointdine. 

Position. — As  in  amputating  through  the  last  phalanx. 

Landmarks. — First  Interphalangeal  joint. 

Incision. — The  queue  of  the  oval  begins  just  above  the  head  of  the 
first  phalanx,  on  its  mid-dorsal  aspect — passes  vertically  downward  over 
the  head  of  the  phalanx,  and  continues  down  to  near  the  middle  of  the  first 
phalanx — where  the  two  corresponding  limbs  diverge  to  encircle  the  second 
phalanx  and  meet  in  the  middle  of  its  plantar  aspect  (Fig.  344,  C). 

Operation. — Deepen  the  dorsal  incision  to  the  extensor  tendon.  Extend 
the  toe  and  deepen  the  oval  to  the  bone,  cutting  the  flexor  tendons  trans- 
versely. Dissect  up  the  soft  parts  upon  the  plantar  and  lateral  aspects. 
Divide  the  glenoid  (anterior)  ligament  by  cutting  against  the  base  of  the 
second  phalanx  and  opening  the  joint.  Divide  the  lateral  ligaments  from 
wdthin  outward.  Draw  upon  the  toe  and  cut  the  extensor  tendon  high  up. 
Two  plantar  and  two  dorsal  digital  arteries  are  cut — the  former  may  require 
ligation.  Close  the  flexor  sheath.  Suture  the  wound  vertically.  The 
cicatrix  will  be  vertical  and  dorso-terminal. 

Comment. — The  head  of  the  first  phalanx  may  be  removed,  especially 
of  the  second  and  third  toes — as  it  is  large  and  mav  be  in  the  way. 


AMPUTATION    THROUGH    FIRST    PHALANGES    OF    TOES. 


391 


Fig.  344.— Amputations  about  the  Toes  and  Foot  :— A.  At  interphalangeal  joint  of  great  toe, 
by  a  single  internal  flap:  B,  At  first  phalangeal  joint,  by  equal  lateral  flaps  ;  C,  At  first  phalangeal 
joint,  by  oval  method  ;  D,  Through  second  phalanx,  by  oblique  circular  ;  E,  At  first  phalangeal  joint 
of  little  toe,  by  single  external  flap  ;  F,  At  metatarso-phalangeal  joint  of  little  toe,  by  externo-dorsal 
flap;  G,  At  metatarso-phalangeal  joint,  by  oval  method ;  H.  At  metatarso-phalangeal  joint  of  great 
toe,  by  interno-plantar  flap  ;  I,  Of  two  inner  toes  at  tarso-metatarsal  joints,  by  racket  method  ;  J,  Of 
toe,  with  its  entire  metatarsal  at  tarso-metatarsal  joint,  by  racket  method. 


AMPUTATION  THROUGH  FIRST  PHALANGES  OF  TOES,  IN  GENERAL. 

Best  Methods. — Oval  Method.     Circular  Method. 

Other  Methods. — Oblique  Circular.  Equal  Lateral.  Single  External 
Flap. 

Comparison. — The  oval  method  allows  readier  access  to  the  saw-line 
and  the  freeing  of  the  soft  parts  to  that  line.     The  scar  is  dorso-terminal. 


392  AMPUTATIONS. 

The   circular   furnishes   less   easy  approach,   but  leaves  a  smaller  cicatrix, 
which,  however,  is  terminal. 


AMPUTATION  THROUGH  FIRST  PHALANX  OF  TOES 

BY  OVAL   METHOD. 

Description. — The  operation  is  exactly  similar  to  that  for  disarticulation 
at  the  first  interphalangeal  joint  just  described — except  that  the  queue 
begins  just  above  the  future  saw-line,  and  the  oval  extends  down  the  toe 
a  distance  that  will  make  the  covering  furnished  by  the  two  lateral  aspects 
of  the  oval  about  equal  to  i^  diameters  of  the  toe  at  the  saw-line. 


AMPUTATION  THROUGH  FIRST  PHALANX  OF  TOES 

BY  CIRCULAR  METHOD. 

Description. — The  covering  is  furnished  by  a  circular  division  of  all 
the  soft  parts  down  to  the  bone,  with  a  vertical  suturing  of  the  covering. 

Position — Landmarks. — As  for  the  toes  in  general. 

Incision. — A  circular  incision  is  made  through  skin  and  fascia  around 
the  toe  at  a  distance  below  the  saw-line  equal  to  three-fourths  of  the  diameter 
of  the  toe  at  the  saw-line  (to  furnish  a  covering  of  i|  diameters)  (Fig.  350,  A, 
for  principle,  disregarding  obliquity  of  incision). 

Operation. — Upon  the  level  of  the  retracted  integuments,  the  remaining 
soft  parts  are  circularly  divided  to  the  bone — flexing  the  toe  while  cutting 
the  dorsal,  and  extending  it  while  cutting  the  plantar  aspect.  These  are  now 
retracted  to  the  saw-line  and  the  bone  severed.  The  arteries  divided  are  the 
same  as  in  the  last  operation — and  the  flexor  sheath  is  treated  in  the  same 
manner.     The  cicatrix  will  be  vertical  and  terminal. 


DISARTICULATION   AT   METATARSO-PHALANGEAL   JOINTS   OF   TOES. 

IN  GENERAL. 

Best  Methods. — Oval  Method — best  for  the  inside  toes  (second,  third, 
and  fourth).  Interno-Plantar  Flap — best  for  great  toe.  Externo-Dorsal 
Flap — best  for  little  toe.  Short  Dorsal  and  Plantar  Flaps — best  for  toes 
en  masse  at  the  metatarso-phalangeal  joints. 

Other  Methods. — Lateral  Flaps.  Internal  Flap — for  great  toe.  Ex- 
ternal Flap — for  little  toe.  Oval  Flap — for  great  or  little  toe.  Irregular 
Circular,  with  U-shaped  flap  for  Great  Toe  (Dubrueil's  method) — for  toes 
en  masse  at  the  metatarso-phalangeal  joints. 


DISARTICULATION  OF  SECOND,  THIRD,  OR  FOURTH  TOES  AT  META- 
TARSO-PHALANGEAL JOINT 

BY  OVAL  METHOD. 

Description. — Same,  in  principle,  as  disarticulation  at  first  interphalangeal 
joint  by  the  oval  method. 

Position. — As  for  the  toes  in  general  (page  388). 


METATARSOPHALANGEAL    DISARTICULATION    OF    GREAT    TOE.        393 

Landmarks. — Metatarsophalangeal  joint. 

Incision. — The  queue  of  the  incision  begins  just  above  the  head  of  the 
metatarsal,  over  its  mid-dorsal  aspect — passes  downward  in  the  median 
line  until  past  the  base  of  the  first  phalanx — the  limbs  of  the  oval  now  gradu- 
ally diverge  to  pass  obliquely  downward  over  the  lateral  aspects  of  the  toes 
and  cross  the  plantar  surface  transversely,  meeting  just  in  front  of  the  line 
of  the  webs  (Fig.  344,  G). 

Operation. — The  vertical  portion  of  the  incision  is  deepened  to  the 
extensor  tendon — the  lateral  portions  are  cut  to  the  bone — the  toe  is  extended 
and  the  plantar  aspect  cut  transversely  to  the  bone,  thereby  severing  the 
flexor  tendons  high  up.  The  soft  parts  are  freed,  partly  by  retraction  and 
partly  by  disseccion,  from  the  upper  portion  of  the  first  phalanx  to  the  joint- 
line,  which  lies  about  2.5  cm.  (1  inch)  above  the  web.  The  glenoid  ligament 
is  cut  transversely  against  the  base  of  the  first  phalanx  and  the  joint  opened. 
Disarticulation  may  be  completed  from  below,  but  more  conveniently  by 
severing  the  extensor  tendon  and  disarticulating  from  the  dorsum,  cutting 
the  lateral  ligaments  from  within  outward,  as  the  toe  is  rotated  from  side 
to  side  and  disarticulation  completed.  Two  dorsal  and  two  plantar  digital 
arteries  are  cut.  The  flexor  sheath  should  be  closed.  The  wound  is  sutured 
vertically — the  scar  becoming  dorso-terminal. 


DISARTICULATION    OF    GREAT    TOE    AT    METATARSOPHALANGEAL 

JOINT 

BY  IXTERXO-FLAXTAR  FLAP  —  FARABEUF. 

Description. — A  modification  of  the  oval  method,  whereby  the  covering 
is  gotten  from  the  internal  and  plantar  aspects  of  the  great  toe,  and  the  cica- 
trix is  brought  well  over  to  lie  obliquely  from  the  upper  angle  of  the  inter- 
digital  web  to  the  head  of  the  metatarsal,  and  thus  well  removed  from  internal 
and  terminal  pressure. 

Position. — As  for  the  toes  in  general  (page  388). 

Landmarks. — Metatarso-phalangeal  joint-line;  interdigital  web. 

Incision. — Begins  over  the  metatarso-phalangeal  joint,  at  the  junction 
of  the  dorsal  and  internal  surfaces — passes  vertically  down  the  toe,  in  the 
line  represented  by  the  junction  of  these  two  surfaces  (parallel  with  the 
extensor  tendon),  nearly  to  the  head  of  the  first  phalanx — curves  thence 
downward  over  the  inner  surface  to  the  junction  of  the  internal  and  plantar 
surfaces — passes  thence  obliquely  across  the  plantar  surface  to  the  angle  of 
the  interdigital  web — thence  runs  directly  over  the  external  and  dorsal  surfaces 
of  the  toe  to  the  point  of  beginning,  by  the  shortest  route  (Fig.  344,  H). 

Operation. — This  incision  is  now  deepened  to  the  bone  in  the  same 
order  as  made,  extending  the  toe  while  cutting  the  plantar  and  flexing  while 
cutting  the  dorsal  tissues.  Free  the  soft  parts  up  to  the  joint-line.  Sever 
the  glenoid  ligament  against  the  base  of  the  first  phalanx,  thus  opening  the 
joint,  and  leaving  the  glenoid  ligament  and  sesamoid  bones  in  the  stump. 
Divide  the  lateral  ligaments  and  the  extensor  tendon.  Two  plantar  and 
two  dorsal  digital  arteries  are  cut  and  will  probably  require  ligation.  Close 
the  flexor  sheath.  Include  the  cut  flexor  and  extensor  tendons  in  the  tissues 
of  the  stump.  Suture  the  internal  and  plantar  portions  of  the  oval  to  the 
straight  incision  from  the  interdigital  web  to  the  head  of  the  metatarsal, 
which  will  represent  the  line  of  the  cicatrix. 


394 


AMPUTATIONS. 


Comment. — If  the  vertical  portion  of  the  oval  be  placed  directly  over 
the  mid-dorsal  aspect  (as  in  the  corresponding  operation  upon  the  index- 
finger,  page  336)  a  fuller  covering  will  be  gotten  and  the  cicatrix  will  be 
more  certainly  protected. 


DISARTICULATION    OF    LITTLE    TOE    AT    METATARSOPHALANGEAL 

JOINT 

BV  EXTERNO-DORSAL  FLAP— FARABEUF. 

Description. — This  is  the  reverse  of  the  last  operation — a  modification 
of  the  oval  method,  whereby  the  covering  is  gotten  from  the  external  and 
dorsal  aspects  of  the  little  toe — and  the  cicatrix  brought  well  over  to  lie  obliquely 


Fig-  345- — Amputations  about  the  Foot: — A,  Disarticulation  of  the  great  toe  at  the 
tarsometatarsal  joint  by  a  curvilinear  racket  incision;  B,  Disarticulation  of  the  little  toe  at  the 
tarsometatarsal  joint  by  a  curvilinear  racket  incision;  C,  Amputation  of  a  toe  with  part  of  its 
metatarsal   by  a  racket  incision. 


from  the  upper  angle  of  the  interdigital  web  to  the  head  of  the  metatarsal — 
and  thus  well  removed  from  external  and  terminal  pressure. 

Position — Landmarks. — As  in  the  last  operation. 

Incision. — Begins  over  dorsal  aspect  of  metatarso-phalangeal  joint,  just 


METATARSOPHALANGEAL    DISARTICULATION    EN    MASSE.  395 

to  inner  side  of  extensor  tendon — passes  vertically  down  the  inner  margin 
of  the  tendon  to  the  end  of  the  first  phalanx — curves  thence  downward  and 
outward  over  the  external  aspect  of  the  toe — thence  obliquely  across  the 
plantar  surface  to  the  angle  of  the  interdigital  web — thence  along  the  internal 
aspect  of  the  toe  to  the  point  of  beginning,  by  the  shortest  route  (Fig.  344,  F). 
Operation. — The  steps  of  the  operation  are  exactly  similar  to  those  of 
the  disarticulation  of  the  metatarso-phalangeal  joint  of  the  great  toe.  The 
dorsal,  external  and  part  of  the  plantar  portion  of  the  oval  are  sutured  to  the 
straight  incision  from  the  metatarso-phalangeal  joint  to  the  interdigital  web, 
which  will  represent  the  line  of  cicatrix  and  be  out  of  the  way  of  pressure. 


DISARTICULATION     OF     TWO     ADJOINING     TOES     AT     METATARSO- 
PHALANGEAL JOINT 

BV  OVAL  METHOD. 

Description. — Same  as  the  disarticulation  of  a  single  toe  at  the  meta- 
tarso-phalangeal joint  (page  392) — except  that  the  queue  of  the  oval  is  placed 
between  the  two  toes,  beginning  a  little  higher  above  the  metatarso-phalangeal 
joint-line — the  two  limbs  of  the  oval  diverging  to  encircle  the  outer  and 
inner  toes  and  meet  at  the  margin  of  the  web  between  the  toes.  Each  toe 
is  then  freed  up  to  the  metatarso-phalangeal  joint  and  disarticulated.  The 
wound  is  sutured  as  a  vertical  cicatrix. 


DISARTICULATION    OF    ALL    TOES    EN    MASSE    AT    METATARSO- 
PHALANGEAL JOINT 

BY  EQUAL  SHORT  DORSAL  AND  PLANTAR  FLAPS. 

Description. — The  covering  is  gotten  equally  from  the  dorsal  and  plantar 
surfaces  and  the  scar  is  terminal. 

Position. — Patient  supine;  foot  over  edge  of  table.  Surgeon  grasps 
toes  with  left  hand,  with  thumb  on  dorsum  and  fingers  on  plantar  surface 
for  dorsal  incisions — and  thumb  on  plantar  and  fingers  on  dorsum  for  plantar 
incisions — manipulating  the  foot  as  indicated.  After  the  incisions  are  made, 
an  assistant  takes  the  toes  and  the  surgeon  manipulates  the  flaps.  The 
surgeon  stands  for  the  dorsal  and  sits  for  the  plantar  incisions. 

Incisions. — (Supposing  the  left  foot  to  be  operated  upon) — the  dorsal 
incision  (with  foot  extended  and  toes  flexed)  begins  at  the  mid-lateral  aspect 
of  the  metatarso-phalangeal  joint  of  the  great  toe — passes  vertically  down 
the  inner  margin  of  the  foot  to  the  middle  of  the  first  phalanx — thence  rounds 
broadly  on  to  the  dorsum  of  the  foot  and  follows  the  line  of  the  web,  dipping 
in  between  the  toes  as  they  are  separated,  until  the  little  toe  is  reached,  when 
the  incision  again  rounds  broadly  into  the  outer  aspect  of  the  foot  and  passes 
vertically  up  in  the  mid-lateral  aspect  to  the  metatarso-phalangeal  joint. 
The  plantar  incision  (with  foot  flexed  and  toes  extended)  passes  transversely 
across  the  plantar  surface  of  the  foot,  connecting  the  distal  ends  of  the  vertical 
limbs  of  the  dorsal  incision — beginning  at  a  point  where  the  vertical  limb 
begins  to  round  onto  the  dorsum,  the  plantar  incision  rounds  onto  the  plantar 
surface  at  the  middle  of  the  first  phalanx  of  the  great  toe,  and  thence  follows 
the  line  of  the  web  and  creases  of  the  toes,  dipping  in  between  the  toes  as  they 


396 


AMPUTATIONS. 


are  separated,  until  the  little  toe  is  reached,  when  the  incision  rounds  into 
the  outer  aspect  and  joins  the  dorsal  incision  at  a  point  where  the  outer 
vertical  limb  began  to  round  onto  the  dorsum  (Fig.  346,  A,  A). 

Operation. — The  dorsal  incision  is  deepened   to  the  extensor  tendons 


Fig.  346.— Disarticulations  about  the  Foot:— A,  A.  Of  all  the  toes  at  metatarsophalangeal 
joints,  by  equal  short  dorsal  and  plantar  flaps  :  B.  B,  Of  all  the  toes  at  tarso-metatarsal  joints,  by 
short  dorsal  and  long  plantar  flaps  (Lisfranc"s  operation). 


and  freed  half-way  back  to  the  joint-line,  when  the  extensor  tendons  are  cut 
transversely,  each  toe  being  previously  forcibly  flexed  in  turn.  The  flap  of 
entire  soft  parts  is  then  dissected  back  to  the  metatarso-phalangeal  joint-line. 
The  plantar  incision  is  now  deepened  to  the  flexor  tendons  and  freed  half-way 
back  to  the  joint-line,  when  the  flexor  tendons  are  cut  transversely,  each 
toe  being  previously  forcibly  extended  in  turn.  The  flap  of  entire  soft  parts 
is  then  dissected  back  to  the  metatarso-phalangeal  joint-line.  Both  flaps 
are  well  retracted  to  the  general  joint-line — the  toes  are  flexed  and  the  joints 
are  opened  from  the  dorsum  and  the  lateral  ligaments  cut  from  within  out- 
ward. The  toes  are  then  extended  and  the  plantar  ligaments  are  cut  from 
the  plantar  surface,  preserving  the  glenoid  ligaments.     The  disarticulation 


SURGICAL    ANATOMY    OF    THE    FOOT.  397 

of  each  toe  is  thus  completed  in  turn.  The  flexor  sheaths  are  closed.  Two 
plantar  and  two  dorsal  digital  arteries  for  each  toe  are  cut — the  latter  may 
not  require  ligature.  The  dorsal  and  plantar  flaps  are  sutured  in  one  lateral, 
terminal  line. 

Comment. — It  is  difficult  to  get  covering  for  the  large  head  of  the  first 
metatarsal — special  care  is,  therefore,  given  to  procuring  this  covering  by 
keeping  well  in  the  mid-lateral  aspect  of  the  inner  surface  of  the  great  toe 
until  quite  to,  or  beyond,  the  middle  of  the  first  phalanx,  before  rounding 
into  the  dorsal  and  plantar  surfaces. 


SURGICAL  ANATOMY  OF  THE  FOOT. 

Bones. — Five  metatarsals;  seven  tarsals  (astragalus;  os  calcis;  scaphoid; 
internal  cuneiform;  middle  cuneiform;  external  cuneiform;  cuboid). 

Articulations  and  Ligaments. — (A)  Metatarsophalangeal  Articula- 
tions:— See  Surgical  Anatomy  of  Toes,  page  333.  (B)  Articulation  of  Meta- 
tarsals with  each  other: — Dorsal,  plantar,  transverse  metatarsal,  interosseous 
ligaments,  and  synovial  membrane.  (C)  Articulations  of  Metatarsals  with 
Tarsals: — dorsal,  plantar,  and  interosseous  ligaments,  and  synovial  mem- 
brane. (D)  Articulation  of  External  Cuneiform  and  Cuboid: — dorsal, 
plantar,  and  interosseous  ligaments,  and  synovial  membrane.  (E)  Articu- 
lations of  Internal,  Middle,  External  Cuneiform  bones  with  each  other: — 
dorsal,  plantar,  and  interosseous  ligaments,  and  synovial  membrane.  (F) 
Articulation  of  Scaphoid  and  Cuboid: — dorsal,  plantar,  and  interosseous 
ligaments,  and  synovial  membrane.  (G)  Articulation  of  Scaphoid  and 
three  Cuneiform  Bones: — dorsal  and  plantar  ligaments,  and  synovial  mem- 
brane. (H)  Articulation  of  Astragalus  and  Scaphoid: — Superior  astragalo- 
scaphoid  ligament,  and  synovial  membrane.  (I)  Articulation  of  Os  Calcis 
and  Scaphoid: — superior  (or  external)  and  inferior  (or  internal)  calcaneo- 
scaphoid  ligaments,  and  synovial  membrane.  (J)  Articulation  of  Os  Calcis 
and  Cuboid: — (a)  Dorsal — superior  and  internal  (interosseous)  ligaments; 
(b)  Palmar — long  calcaneocuboid  (long  plantar)  and  short  calcaneocuboid 
(short  plantar)  ligaments.  And  synovial  membrane.  (K)  Articulation  ot 
Os  Calcis  and  Astragalus : — external,  internal,  and  posterior  calcaneo-astraga- 
loid,  and  interosseous  ligaments,  and  synovial  membrane.  (L)  Articulation 
of  Tarsus  with  Bones  of  Leg: — See  Surgical  Anatomy  of  the  Ankle,  page  358. 

Anterior  Annular  Ligament. — Consists  of  two  portions: — (a)  Vertical 
(Superior)  Portion: — Binds  down  extensor  tendons  to  tibia  and  fibula.  Con- 
tinuous with  fascia  of  leg  above,  and  extending  from  anterior  border  of  tibia 
to  anterior  border  of  subcutaneous  surface  of  fibula.  Contains  synovial 
sheath  for  tendon  of  tibialis  anticus.  Following  structures  pass  under  it- 
extensor  proprius  hallucis,  extensor  longus  digitorum,  peroneus  tertius, 
anterior  tibial  vessels  and  nerve,  (b)  Horizontal  (Inferior,  or  Y-shaped) 
Portion: — Binds  down  extensor  tendons  to  tarsus.  Is  connected  with  vertical 
portion.  Attached,  externally,  to  superior  surface  of  os  calcis, — anteriorly, 
to  depression  for  interosseous  ligament.  It  passes  upward  and  inward  in  a 
superficial  band  (which  runs  in  front  of  the  peroneus  tertius.  extensor  longus 
digitorum,  and  part  of  origin  of  extensor  brevis  digitorum),  and  a  deep  band 
(which  runs  behind  these  muscles).  Having  formed  this  loop  containing 
the   above   muscles,    surrounded   by   synovial   membrane,    these   two   bands 


398  AMPUTATIONS. 

unite  and  redivide  into  two  limbs.  The  Upper  Limb  passes  upward  and 
inward  tu  the  internal  malleolus — containing  tibialis  amicus  muscle  and  its 
synovial  sheath  in  its  structure,  but  passing  over  extensor  proprius  hallucis 
and  anterior  tibial  vessels  and  nerve.  The  Lower  Limb  passes  downward 
and  inward  to  the  scaphoid  and  internal  cuneiform — running  over  extensor 
proprius  pollicis,  tibialis  anticus,  and  anterior  tibial  vessels  and  nerve. 

Internal  Annular  Ligament. — Extends  from  inner  malleolus  above, 
to  internal  border  of  os  calcis  below,  converting  the  grooves  of  this  region 
into  four  canals,  each  lined  by  separated  synovial  membrane.  The  canals 
transmit,  from  within  outward — tibialis  posticus — flexor  longus  digitorum — 
posterior  tibial  vessels  and  nerve — flexor  longus  hallucis.  It  is  continuous, 
above,  with  deep  fascia  of  leg,  and,  below,  with  plantar  fascia  and  origin  of 
abductor  hallucis. 

External  Annular  Ligament. — Extends  from  extremity  of  external 
malleolus  to  outer  surface  of  os  calcis.  Binds  down  and  transmits  tendons 
of  peroneus  longus  and  brevis  beneath  the  outer  ankle,  in  one  synovial  sheath. 

Plantar  Fascia. — (a)  Central  Portion: — Arises  from  internal  tubercle 
of  os  calcis,  posterior  to  origin  of  flexor  brevis  digitorum — divides,  near 
heads  of  metatarsals,  into  processes  for  each  of  five  toes — which  again  sub- 
divide, opposite  metatarso-phalangeal  joints,  into  superficial  and  deep  por- 
tions. The  superficial  part  is  inserted  into  the  transverse  sulcus  between 
sole  and  toes.  The  deep  part  redivides  into  two  slips — which  blend  with 
flexor  tendons  and  sheaths  and  transverse  metatarsal  ligament.  Two  vertical 
intermuscular  septa  are  sent  up  by  central  portion — separating  middle  from 
external  and  from  internal  plantar  groups  of  muscles,  (b)  Outer  Lateral 
Portion : — From  os  calcis  to  base  of  fifth  metatarsal — covering  inferior  surface 
of  abductor  minimi  digiti — and  continuous  with  central  and  dorsal  fascia, 
(c)  Inner  Lateral  Portion: — From  internal  annular  ligament — covering 
abductor  hallucis — and  continuous  with  central  and  dorsal  fascia. 

Muscles. — (a)  Dorsal  Region: — Extensor  brevis  digitorum;  and  muscles 
from  leg  (page  416).  (b)  Plantar  Region: — First  Layer — abductor  hallucis, 
flexor  brevis  digitorum,  abductor  minimi  digiti; — Second  Layer — flexor  ac- 
cessorius,  four  lumbricales; — Third  Layer — flexor  brevis  hallucis,  abductor 
obliquus  hallucis,  abductor  transversus  hallucis,  flexor  brevis  minimi  digiti; — 
Fourth  Layer — four  dorsal  interossei,  three  plantar  interossei.  And  muscles 
from  leg  (page  416). 

Synovial  Membranes  of  Tarsal  and  Metatarsal  Joints. — Synovial 
membranes  exist  for  following  joints; — posterior  calcaneo-astragaloid  joint; — 
anterior  calcaneo-astragaloid  and  astragalo-navicular  joints; — calcaneo- 
cuboid joint; — articulation  of  navicular  with  three  cuneiforms,  three  cunei- 
forms with  each  other,  external  cuneiform  with  cuboid,  middle  and  external 
cuneiform  with  bases  of  second  and  third  metatarsals,  lateral  surfaces  of 
second,  third,  and  fourth  metatarsals  with  each  other; — internal  cuneiform 
with  metatarsal  of  great  toe; — articulation  of  cuboid  with  fourth  and  fifth 
metatarsals; — (and  sometimes  the  articulation  of  navicular  with  cuboid). 

Arteries. — Dorsalis  pedis  branch  of  anterior  tibial,  and  following  branches 
— external  tarsal;  internal  tarsal;  metatarsal  and  its  three  dorsal  interosseous 
branches,  with  the  latter's  three  posterior  and  three  anterior  perforating 
branches;  dorsalis  hallucis  (or  first  dorsal  interosseous);  communicating  (or 
plantar  digital).  Posterior  tibial  and  following  branches — anterior  peroneal, 
posterior  peroneal  and  external  calcaneal  branches  of  peroneal;  internal 
calcaneal   branch   of  posterior  tibial;   internal   plantar   branch   of  posterioi 


SURGICAL    ANATOMY    OF    THE    FOOT.  399 

tibial;  external  plantar  branch  of  posterior  tibial  and  following  branches, 
three  posterior  perforating  (between  plantar  arch  and  interosseous),  four 
plantar  digital,  three  anterior  perforating  (between  digital  and  interosseous), 
princeps  hallucis  (fifth  plantar  digital). 

Veins. — Superficial — tributaries  of  internal  (long)  saphenous;  tributaries 
of  external  (short)  saphenous.     Deep — two  venae  comites  for  each  artery. 

Nerves. — (a)  From  Lumbar  Plexus — internal  saphenous,  (b)  From 
Sacral  Plexus — following  from  great  sciatic; — external  (short)  saphenous — 
posterior  tibial  and  plantar  cutaneous  branch — internal  plantar  with  cutane- 
ous, muscular,  articular,  and  four  digital  branches — external  plantar,  with 
superficial  and  deep  (or  muscular)  branches — anterior  tibial,  with  external 
(or  tarsal)  branch  and  its  three  interosseous;  internal  branch  (continuation 
of  anterior  tibial)  and  its  interosseous  branch ;— and  internal  and  external 
branches  of  musculocutaneous. 

Bursae  About  Foot. — These  are  variable — the  following  are  generally 
present — (a)  Above,  or  beneath,  tendon  of  extensor  proprius  hallucis,  over 
instep, — (b)  Between  tendon  of  extensor  longus  digitorum  and  projecting 
end  of  astragalus  (sometimes  communicating  with  joint  of  head  of  astragalus), 
— (c)  Between  tendo  Achillis  and  calcaneum, — And  others  may  occur  over 
any  bony  prominence. 


SURFACE  FORM  AND  LANDMARKS  OF  FOOT. 

Bony  landmarks  of  dorsum — head  of  astragalus  is  felt  on  extension  of 
foot,  in  front  of  ankle-joint. 

Bony  landmarks  of  inner  aspect  of  foot — internal  tuberosity  of  os  calcis; 
sustentaculum  tali  (lesser  process  of  os  calcis),  2.5  cm.,  or  1  inch,  below 
internal  malleolus;  tuberosity  of  scaphoid  (2.5  to  3  cm.,  or  1  to  i|  inches,  in 
front  of  internal  malleolus) ;  internal  cuneiform  (but  slightly) ;  base  of  first 
metatarsal  (obscurely);  shaft  of  first  metatarsal;  head  of  first  metatarsal; 
base  of  first  phalanx  of  great  toe;  internal  sesamoid  bone. 

Bony  landmarks  of  outer  aspect  of  foot — outer  tuberosity  of  os  calcis; 
greater  part  of  outer  surface  and  anterior  end  of  os  calcis;  peroneal  tubercle 
(when  present)  2.5  cm.,  or  1  inch,  below  external  malleolus;  base  of  fifth 
metatarsal;  shaft  of  fifth  metatarsal;  head  of  fifth  metatarsal;  base  of  first 
phalanx  of  little  toe. 

Bony  landmarks  of  plantar  aspect  of  foot — inferior  surface  of  os  calcis; 
heads  of  metatarsals. 

Landmarks  of  medio-tarsal  articulation — the  joint-line  runs  transversely 
across  the  foot  from  the  astragalo-scaphoid  articulation  on  the  inner  side, 
to  the  calcaneo-cuboid  articulation  on  the  outer  side.  The  astragalo-scaphoid 
joint  lies  just  posterior  to  the  prominent  tuberosity  of  the  scaphoid  (forcibly 
extend  the  foot,  when  the  interval  between  the  tuberosity  of  the  scaphoid 
and  head  of  the  astragalus  will  be  evident).  The  calcaneo-cuboid  joint  lies 
midway  between  the  external  malleolus  and  the  prominent  base  of  the  fifth 
metatarsal. 

Landmarks  of  the  tarso-metatarsal  articulation — the  cubo-metatarsal 
joint  (on  the  outer  side)  is  found  on  a  line  with  the  base  of  the  prominent 
fifth  metatarsal,  and  this  serves  as  a  guide  to  the  remaining  joints — the  line 
of  which  runs  obliquely  forward  toward  the  inner  side  of  the  foot,  to  a  point 
about  2.5  cm.,  or  1  inch  (extremes  3.8  to  4.5  cm.,  or  1^  to  if  inches),  below 


400 


AMPUTATIONS. 


the  posterior  margin  of  the  tuberosity  of  the  scaphoid.  Practically,  the 
articulations  of  the  fifth,  fourth,  third,  and  first  metatarsals  are  in  one  line, 
while  the  line  of  the  articulation  of  the  second  metatarsal  with  the  middle 


Fig.  347. — Lines  of  Disarticulations  about  the  Foot: — A,  A,  Metatarsophalangeal 
disarticulation;  B,  B,  Tarsometatarsal  disarticulation  (Lisfranc's  operation);  C,  C,  Anterior 
intertarsal  amputation  (between  the  cuneiforms  and  scaphoid,  with  transverse  section  of  the 
cuboid — the  Jaeger-Bona,  or  Forbes'  operation);  D,  D,  Posterior  intertarsal  or  mediotarsal 
disarticulation  (Chopart's  operation);  E,  E,  Disarticulation  at  the  ankle-joint.  Note: — Pirogoff's 
intercalcaneal  osteoplastic  amputation,  with  section  of  the  tibia  and  fibula,  and  also  the  sub- 
astragaloid  disarticulation  are  not  shown  here. 


cuneiform  is  from  7  mm.  to  1.3  cm.  (J  to  ^  inch)   above  this   oblique  line. 
The  tarso-metatarsal  articulation  of  the  great  toe  can  sometimes  be  felt  as  a 


SURGICAL  CONSIDERATIONS  IN  FOOT  AMPUTATIONS.  401 

depression  3.8  to  4.5  cm.  (i£  to  if  inches)  anterior  to  the  posterior  margin 
of  the  tuberosity  of  the  scaphoid,  by  pressure  here  while  manipulating  the 
toe — which  would  give  an  inner  landmark  to  be  used  with  the  base  of  the 
fifth  metatarsal  on  the  outer  aspect. 

Landmarks  of  the  metatarso-phalangeal  articulations — about  2.5  cm.  (1 
inch)  behind  the  webs  of  the  corresponding  toes. 

Muscles  and  tendons  more  or  less  influencing  surface  form  upon  the 
dorsum  of  the  foot,  from  within  outward — tibialis  anticus,  extensor  proprius 
hallucis,  extensor  longus  digitorum,  peroneus  tertius — and,  beneath  these, 
extensor  brevis  digitorum  and  dorsal  interossei. 

Muscles  on  sole  of  foot  influencing  surface  form — abductor  minimi  digiti, 
abductor  hallucis,  flexor  brevis  digitorum. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT 

THE  FOOT. 

Remove  as  little  as  possible  of  the  metatarsals  of  the  great  and  little  toes 
as  they  largely  support  the  weight  of  the  body. 

Amputation  of  the  toe,  except  the  great  toe,  with  part  or  all  of  its  meta- 
tarsal, is  of  very  little  practical  applicability. 

'    Scars  should  be  kept  from  the  plantar,  internal,  and  external  aspects  of 
the  foot.     They  should  be  at  the  end  of  the  stump  or  dorsal. 

Plantar  covering  is  the  best  form  to  provide. 

In  removing  the  metatarsal  bones  entirely,  or  in  part,  it  is  well  to  adopt 
the  subperiosteal  method  as  far  as  possible. 

There  is  an  increasing  tendency  to  regard  the  foot  as  a  whole  and  to 
amputate  regardless  of  joints. 

Sutures  should  remain  in  the  thick,  hard  skin  of  the  sole  extra  long. 

Temporary  drainage  is  indicated  when  large  joint-surfaces  are  opened  up. 

Stumps  should  remain  out  from  under  the  bed-covering  when  dressed. 

Patients  should  lie  part  of  the  time  on  their  side,  or  flex  the  knee,  to  allow 
of  drainage  from  the  angles  of  wounds,  if  any  fluid  accumulate. 

If  drainage  be  necessary,  drain  with  two  short  tubes  in  either  end  of  the 
wound. 

Amputation  through  the  metatarsus  is  preferable  to  tarso-metatarsal 
disarticulation,  for,  in  the  former,  attachment  of  all  the  important  muscles 
of  the  foot  and  all  its  movements  are  retained. 

Disarticulation  at  the  tarso-metatarsal  joints  (Lisfranc's  operation)  gives 
an  excellent  stump.  Disarticulation  at  the  medio-tarsal  joints  (Chopart's 
operation)  gives  a  not  altogether  satisfactory  result. 

Subastragaloid  disarticulation  gives  a  very  good  result,  furnishing  a 
long  limb  with  ankle-movement. 

Syme's  amputation  (disarticulation  at  the  ankle-joint)  is  generally  con- 
sidered preferable  to  either  Chopart's  or  Pirogoff's  operation. 

In  Lisfranc's  and  Chopart's  operations  the  unopposed  action  of  the  calf 
muscles  may  permanently  raise  the  heel. 


AMPUTATION  OF  TOES  WITH  PART  OF  THEIR  METATARSALS. 

The  amputation  of  the  toes  with  part  of  their  metatarsals  is  so  similar, 
in  all  essential  details,  to  disarticulation  of  the  toes  with  their  entire  meta- 
26 


402  AMPUTATIONS. 

tarsals  that  the  former  will  not  be  separately  given  (as  was  done  in  the  case 
of  the  fingers).  The  best  method  of  removing  any  of  the  toes  with  part  of 
their  metatarsal,  whether  an  inside  toe  or  the  great  or  little  toe,  is  by  the 
racket  method  (see  pages  404-406).  The  best  method  for  the  removal  of 
two  or  three  contiguous  toes  with  parts  of  their  metatarsals  is  by  the  oval 
operation  (see  page  407).  The  best  methods,  as  well  as  other  methods 
for  these  partial  operations,  are  the  same  as  for  the  entire  operations — and 
will  be  given  at  the  above  references. 

The  practical  differences  between  the  partial  and  complete  operations 
are — that  the  incision  begins,  in  the  former,  just  above  the  saw-line,  instead 
of  just  above  the  tarso-metatarsal  joint-line — and,  instead  of  disarticulating 
the  proximal  end  of  the  bone,  it  is  sawed  with  a  Gigli  or  chain  saw. 

The  amputation  of  all  the  toes  with  parts  of  their  metatarsals  will  be 
given. 


AMPUTATION  OF  ALL  THE  TOES  THROUGH  THE  METATARSUS 

BY  SHORT  DORSAL  AND  LONG  PLANTAR  FLAPS  (METATARSAL  AMPUTATION). 

Description. — The  height  at  which  the  amputation  will  be  done  will 
depend  upon  the  nature  of  the  cause  and  condition  of  the  parts.  The  opera- 
tion resembles  Lisfranc's  disarticulation  at  the  tarso-metatarsal  joint. 

Position. — Patient  supine;  foot  over  edge  of  table.  Surgeon  opposite 
foot,  standing  while  operating  on  dorsum,  sitting  while  working  upon  plantar 
aspect — steadying  the  toes  with  his  left  fingers  during  the  incisions,  while 
assistant  holds  ankle; — and,  as  soon  as  incisions  are  made,  assistant  takes 
the  toes,  while  the  surgeon  grasps  the  flaps  with  his  left  hand. 

Landmarks. — Saw-line  (which  is  oblique,  to  be  parallel  with  the  ends 
of  the  metatarsals — its  inner  end  being  more  anteriorly  placed  than  its  outer 
— the  line  running  about  parallel  with  the  webs) ;  interdigital  webs. 

Incisions. — Plantar  incision  (supposing  the  metatarsals  to  be  divided 
at  their  middle,  in  the  case  of  the  left  foot)  begins  at  the  mid-lateral  aspect 
of  the  inner  side  of  the  foot  and  just  behind  the  saw-line — passes  vertically 
down  this  side  of  the  foot  to  the  level  of  the  crease  between  the  sole  and 
plantar  surface  of  the  great  toe — thence  rounds  broadly  into  the  sole  and 
sweeps  across  the  plantar  aspect  just  behind  and  parallel  with  the  web,  to 
the  crease  between  the  sole  and  little  toe — whence  it  rounds  broadly  into  the 
mid-lateral  aspect  of  the  outer  side  of  the  foot  and  passes  straight  upward 
to  just  beyond  the  saw  line.  Dorsal  incision  is  made  parallel  with  the  plantar 
incision,  and  joins  the  vertical  portion  of  that  incision  about  2.5  cm.  (1  inch) 
from  their  upper  ends,  rounding  onto  the  dorsum  (that  is,  the  dorsal  flap  is 
about  2.5  cm.,  1  inch  long).  The  foot  is  flexed  on  the  leg  while  the  plantar 
incision  is  made  and  extended  while  the  dorsal  incision  is  made  (Fig.  348, 
A,  A). 

Operation. — The  plantar  incision  is  first  deepened  to  the  flexor  tendons, 
is  then  dissected  up  a  short  distance  and  the  flexor  tendons  divided  trans- 
verselv  while  the  foot  is  forcibly  flexed  on  the  leg  and  toes  extended  on  foot — 
thence  upward  to  the  saw-line,  all  soft  parts  down  to  the  bone  being  raised 
in  the  plantar  flap.  The  dorsal  incision  is  now  deepened  to  the  extensor 
tendons,  and  dissected  up  a  short  way,  when  these  tendons  are  divided  trans- 
verselv  while  the  foot  is  forcibly  extended  on  the  leg  and  the  toes  flexed  on 
the  foot — thence  upward  to  saw-line,  all  soft  parts  down  to  the  bone  being 
raised  in  the  dorsal  flap.     Both  flaps  are  now   retracted — the   bones   freed 


TARSOMETATARSAL  DISARTICULATIONS. 


403 


of  their  interossei  muscles — and  each  bone  separately  sawed  with  a  fine  saw. 
The  following  arteries  are  tied — six  plantar  digital  (upon  contiguous  sides 
of  the  toes,  and  outer  side  of  the  little  and  inner  side  of  the  great  toes),  second, 
third,  and  fourth  dorsal  interossei,  and  first  dorsal  interosseous,  or  its  three 
dorsal  digital  branches.  The  muscles  are  quilted,  those  of  the  dorsal  to 
those  of  the  plantar  aspect — and  the  integumentary  margins  of  the  dorsal 


Fig.  348.— Amputations  about  the  Foot  : — A,  A.  Amputation  of  all  the  toes  through  the  meta- 
tarsus, by  short  dorsal  and  long  plantar  flaps  (metatarsal  amputation)  ;  B,  B,  Disarticulation  of  an- 
terior part  of  foot  at  medio-tarsal  joints,  by  short  dorsal  and  long  plantar  flaps  (Chopart's  operation). 

and  plantar  flaps  united  in  a  transverse  line.     The  stump  is  supported  upon 
a  splint. 

Comment. — If  the  division  of  the  metatarsus  is  made  nearer  its  base, 
the  flaps  will  be  proportionately  shorter.  The  flaps  may  also  be  made  of 
equal  length,  or  otherwise  planned — according  to  available  tissue. 


DISARTICULATION    OF    TOES    WITH    THEIR  ENTIRE    METATARSALS. 

Best  Methods. — Racket — toes  in  general.     Racket,  with  or  without  an 
additional  transverse  incision  at  upper  end  of  queue — for  great  or  little  toe. 


404  AMPUTATIONS. 

Short  Dorsal  and  Long  Plantar  Flaps  (Lisfranc's  Operation) — for  the  toes 
en  masse.  Short  Dorsal  and  Long  Plantar  Flaps,  with  sawing  off  the  end 
of  the  internal  cuneiform  (Hey's  Operation) — for  the  toes  en  masse. 

Other  Methods. — Internal  Flap — for  great  toe.  External  Flap — for 
little  toe.  Equal  Plantar  and  Dorsal  Flaps — for  the  toes  en  masse.  Long 
Plantar  Flap — for  the  toes  en  masse. 


DISARTICULATION  OF  TOE  WITH  ITS  ENTIRE    METATARSAL 

BY  RACKET  METHOD. 

Description. — The  coverings  are  gotten  from  the  lateral  and  plantar 
aspects,  and  the  cicatrix  is  vertical  and  dorso-terminal. 

Position. — As  in  the  metatarsal  amputation,  page  402. 

Landmarks. — Tarso-metatarsal  joint;  interdigital  web. 

Incision. — Begins  just  above  the  tarso-metatarsal  joint,  in  the  mid- 
dorsal  aspect — passes  vertically  down  in  the  median  line  to  the  head  of  the 
metatarsal — thence  the  two  limbs  of  the  oval  diverge — the  outer  limb  running 
downward  across  the  outer  aspect  of  the  toe  to  the  web — the  inner  limb 
across  the  inner  aspect  to  the  web — the  two  meeting  in  the  digito-plantar 
crease  (which  about  corresponds  to  the  center  of  the  first  phalanx)   (Fig. 

344,  J)- 

Operation. — Deepen  the  vertical  incision,  dividing  the  extensor  tendons 
as  high  up  as  encountered,  while  the  toe  is  flexed.  Deepen  the  oval  incision 
to  the  bone,  upon  the  lateral  and  plantar  aspects,  extending  the  toe  while 
severing  the  flexor  tendons  transversely.  Free  the  soft  parts  along  the  dorsum 
and  lateral  surfaces,  with  a  periosteal  elevator,  hugging  the  bone  closely. 
Forcibly  extend  the  toe  and  its  metatarsal  and  free  the  plantar  surface  as 
far  as  possible.  Sever,  from  the  dorsum,  the  ligaments  binding  the  metatarsal 
to  the  tarsus  and  to  the  adjacent  metatarsals,  while  the  toe  is  being  manipu- 
lated and  the  ligaments  are  put  upon  the  stretch — thus  completing  the  dis- 
articulation. Divide  the  flexor  tendons  high  up  and  close  the  sheaths.  Two 
dorsal  and  two  plantar  digital  arteries  are  cut  and  are  to  be  tied.  Suture 
the  wound  in  one  vertical  line. 

Comment. — (1)  By  hugging  the  bone  very  closely  and  guarding  the  point 
of  the  knife  while  disarticulating,  minimum  damage  is  done  to  the  tissues 
of  the  sole  of  the  foot.  (2)  Disarticulation  of  the  second  toe  from  the  tarsus 
and  adjacent  metatarsals  is  somewhat  difficult  (see  Lisfranc's  operation). 

DISARTICULATION  OF  GREAT  TOE  WITH  ITS  ENTIRE  METATARSAL 

BY  RACKET  METHOD. 

Description — Landmarks. — As  in  the  last  operation. 

Incision. — Begins  just  above  the  tarso-metatarsal  joint,  at  its  dorso- 
internal  aspect — passes  vertically  downward  along  the  outer  margin  of  the 
extensor  tendon  to  just  beyond  the  center  of  the  metatarsal — thence  the  two 
limbs  of  the  oval  diverge — the  outer  limb  passing  across  the  dorso-external 
aspect  of  the  toe  to  the  web — the  inner  limb  passing  across  the  dorso-internal 
aspect  to  the  plantar  surface  at  a  point  opposite  the  web — the  two  limbs 
meeting  in  the  digito-plantar  crease.  If  needed  for  purpose  of  exposing  the 
joint  more  readily,  an  additional  transverse  incision  may  be  added  to  the 
upper  end  of  the  vertical  incision,  running  as  far  as  thought  necessary  directly 
inward  parallel  to  the  tarso-metatarsal  joint  (Fig.  349,  B). 

Operation. — Deepen   the   vertical   incision,   exposing   and   dividing   the 


TARSOMETATARSAL  DISARTICULATION  OF  GREAT  TOE. 


405 


tendons  of  the  extensor  proprius  and  brevis  hallucis  near  the  tarso-metatarsal 
joint.  Deepen  the  limbs  of  the  oval,  cutting  to  the  bone  along  the  lateral 
and  plantar  surfaces.  Free,  up  to  the  tarso-metatarsal  joint,  the  soft  parts 
from  the  external,  internal,  and  plantar  surfaces  of  the  metatarsal  and  phalanx 
by  closely  hugging  the  bones  with  periosteal  elevator,  rotating  the  toe  as 
indicated.  The  sesamoid  bones  are  left  behind,  and  the  structures  about 
the  metatarso-phalangeal  joint  are  removed  as  nearly  subcapsulo-periosteally 
as  possible,  in  order  to  retain  the  attachment  of  the  severed  tendons  there 
inserted.  Open  the  tarso-metatarsal  joint  from  the  dorsum,  completing  the 
disarticulation    by    severing    the   remaining    ligaments    while   under   tension 


Fig.  349.— Amputations  about  the  Toes  and  Foot — Inner  view  : — A,  At  interphalangeal  joint 
of  great  toe,  by  plantar  flap  ;  B.  Of  great  toe  and  its  metatarsal,  at  tarso-metatarsal  joint,  by  racket 
method,  with  transverse  incision  added  to  upper  end  ;  C.  Inner  aspect  of  plantar  and  dorsal  incisions 
in  Syme's  disarticulation  of  foot  at  ankle,  by  heel-flap ;  C,  Line  of  tibial  and  fibular  section  ;  D.  Inner 
aspect  of  plantar  and  dorsal  incisions,  in  PirogofT s  disarticulation  at  ankle,  by  heel-flap  ;  D',  Line  of 
section  of  bones  of  leg,  in  same  ;  I )".  Line  of  section  of  os  calcis.  in  same  ;  E,  Inner  aspect  of  plantar 
and  dorsal  incisions  in  subastragaloid  disarticulation  of  foot,  by  heel-flap. 


during  the  manipulation  of  the  toe.  Divide  the  tendons  of  the  peroneus 
longus  and  tibialis  anticus.  Cut  the  flexor  tendons  short  and  close  their 
sheaths.  The  following  arteries  are  divided — two  dorsal  digital,  two  plantar 
digital,  and  termination  of  internal  plantar.  Guard  against  wounding  the 
communicating  branch  of  the  dorsalis  pedis  in  the  first  interosseous  space. 
The  suture  line  will  be  vertical  and  fall  over  the  dorso-external  aspect  of  the 
toe,  out  of  the  way  of  pressure. 

Comment. — When  the  upper  transverse  incision  is  added,  the  vertical 
incision  generallv  begins  just  below  the  tarso-metatarsal  joint  and  the  trans- 
verse incision  is  then  parallel  with  the  tarso-metatarsal  joint.  When  the 
vertical  incision  alone  is  used,  it  begins  over  the  internal  cuneiform. 


406 


AMPUTATIONS. 


DISARTICULATION  OF  LITTLE  TOE  WITH  ITS  ENTIRE  METATARSAL 

PA'  RACKET  METHOD. 

Description — Landmarks. — As  in  the  last  operation. 

Incision. — Begins  just  above  the  tarsometatarsal  joint  at  its  dorso- 
external  aspect — passes  vertically  downward  along  the  outer  margin  of  the 
extensor  tendon  to  just  beyond  the  center  of  the  metatarsal — thence  the  two 
limbs  of  the  oval  diverge — the  inner  limb  passing  across  the  dorso-internal 
aspect  of  the  toe  to  the  web — the  outer  limb  passing  across  the  dorso-external 
aspect  of  the  plantar  surface  at  a  point  opposite  the  web — the  two  limbs 


Fig. 350. —  Amputations  about  the  Toes  and  Foot — Outer  view: — A,  Through  first  interpha- 
langeal  joint  of  little  toe,  by  oblique  circular  method  ;  B,  Of  little  toe  and  its  metatarsal,  by  racket 
method,  with  added  curved  incision  at  upper  end  ;  C,  Outer  aspect  of  plantar  and  dorsal  incisions,  in 
Syme's  disarticulation  of  foot  at  ankle,  by  a  heel-flap  ;  C,  Line  of  section  through  tibia  and  fibula,  in 
same  ;  D,  Outer  aspect  of  plantar  and  dorsal  incisions,  in  Pirogoff's  disarticulation'at  ankle  ;  D',  Line 
of  section  of  tibia  and  fibula  in  same  ;  D",  Line  of  section  of  os  calcis,  in  same;  E,  Supramalleolar 
amputation  of  leg,  by  oblique  elliptical  incision;  E',  Tibial  and  fibular  section  in  same;  F,  Outer 
aspect  of  dorsal  and  plantar  incisions  in  Subastragaloid  Disarticulation  of  foot  by  heel-flap. 


meeting  in  the  digito-plantar  groove.  If  needed  for  purpose  of  more  readily 
exposing  the  joint,  an  additional  transverse,  or  oblique,  incision  may  be 
added  to  the  upper  end  of  the  vertical  incision,  by  prolonging  the  latter  a 
short  wav  directly  outward  parallel  with  the  tarso-metatarsal  joint  (Fig. 
35o,  B).  ' 

Operation. — The  steps  of  the  operation  are  practically  the  same  as  in 
the  corresponding  operation  upon  the  great  toe  (page  404).  The  metatarsal 
is  disarticulated  from  the  cuboid  and  from  the  fourth  metatarsal.  Two 
dorsal  and  two  plantar  digital  arteries  are  cut. 


TARSOMETATARSAL  DISARTICULATION  OF  THE  TOES.  407 


DISARTICULATION    OF    TWO    OR    THREE  CONTIGUOUS    TOES   WITH 
THEIR  ENTIRE  METATARSALS 

BY  OVAL  OR  RACKET  METHOD. 

Description. — Same,  in  principle,  as  the  operation  for  the  removal  of 
a  single  toe  and  its  metatarsal  (page  402).  Where  two  contiguous  toes  are 
removed,  the  vertical  portion  of  the  incision  is  placed  between  the  two  toes, 
beginning  just  above  the  saw-line  and  diverging  to  include  both  toes — meeting 
on  the  plantar  surface  of  the  web  between  them.  Where  three  contiguous 
toes  are  removed,  the  vertical  portion  of  the  incision  is  placed  over  the  middle 
metatarsal,  beginning  at  the  disarticulation  line,  or  just  above,  and  diverging 
to  include  all  three  toes,  meeting  at  the  center  of  the  plantar  surface  of  the 
middle  toe,  in  the  digito-plantar  crease  (Fig.  344,  I) . 


DISARTICULATION     OF     ALL     THE     TOES     AT     TARSO-METATARSAL 

JOINTS 

BY  SHORT  DORSAL  AND  LONG  PLANTAR  FLAPS  — LISFRANC'S  OPERATION. 

Description. — Disarticulation  of  the  anterior  portion  of  the  foot  at  the 
tarso-metatarsal  line — the  stump  being  formed  of  plantar  and  dorsal  tissues. 

Position. — As  for  the  metatarsal  amputation  (page  402). 

Landmarks. — Tarso-metatarsal  joint-line;  heads  of  metatarsals. 

Incision. — (Supposing  the  foot  of  the  right  side  to  be  operated  upon) 
— (1)  Dorsal  Flap — The  surgeon's  left  hand  grasps  the  foot  with  his  thumb 
on  the  base  of  the  fifth  metatarsal  and  forefinger  on  the  base  of  the  first, 
his  palm  to  the  sole — the  foot  being  extended.  The  incision  begins  just 
behind  the  base  of  the  fifth  metatarsal,  nearer  the  plantar  than  dorsal  surface 
— passes  straight  down  the  outer  aspect  of  the  foot  for  2.5  cm.  (1  inch) — 
thence  rounds  onto  the  dorsum  and  crosses  the  foot  with  slight  downward 
convexity,  parallel  with  and  about  1.3  cm.  (J  inch)  below  the  tarso-metatarsal 
joints,  reaching  the  inner  border  of  the  foot  1.3  cm.  (J  inch)  below  the  tarso- 
metatarsal joint — thence  rounds  into  the  inner  aspect  of  the  foot  and  passes 
straight  upward  and  ends  2  cm.  (f  inch)  above  the  cuneiform-metatarsal  articu- 
lation of  the  great  toe,  somewhat  nearer  the  plantar  than  the  dorsal  aspect.  (2) 
Plantar  Flap — the  surgeon  holds  the  toes  between  the  fingers  on  the  dorsum 
and  thumb  on  the  plantar  surfaces — the  foot  being  flexed.  The  incision  is  con- 
tinuous with  the  horizontal  portion  of  the  dorsal  incision,  passing  down  the 
outer  lateral  aspect  of  the  foot  along  the  plantar  edge  of  the  fifth  metatarsal 
to  just  below  its  middle — then  gradually  rounds  into  the  sole  and  sweeps 
obliquely  across  the  plantar  surface  in  such  a  way  as  to  cross  the  fifth  meta- 
tarsal just  above  its  neck,  the  fourth  metatarsal  at  its  neck,  the  third  and 
second  opposite  their  heads,  and  then  the  first  metatarsal  at  the  metatarso- 
phalangeal joint — thence  rounds  into  the  inner  mid-lateral  aspect  of  the  foot 
and  passes  straight  up  its  border,  along  the  plantar  edge  of  the  first  meta- 
tarsal, to  become  continuous  with  the  vertical  portion  of  the  dorsal  incision 
(Fig.  346,  B,  B). 

Operation. — Deepen  the  dorsal  line  to  the  extensor  tendons  and  free 
back  the  superficial  tissues  for  about  6  mm.  (\  inch) — and  then  divide  all 
the  soft  parts  down  to  the  bones,  while  the  foot  is  fully  extended  on  the  leg 
and  the  toes  flexed  on  the  foot — and  free  the  flap  to,  and  very  slightly  above,  the 
joint-line,  hugging  the  bone  to  save  the  interosseous  vessels  and  portions  of  in- 


4o8 


AMPUTATIONS. 


terosseous  muscles.  Deepen  the  plantar  incision  to  the  flexor  tendons  and  free 
back  the  flap  of  superficial  tissues  to  the  hollow  behind  the  heads  of  the  meta- 
tarsals— and  then  divide  all  the  soft  parts  down  to  the  bones,  while  the  foot  is 
fully  Hexed  on  the  leg  and  the  toes  extended  on  the  foot — and  free  the  flap  to, 
and  very  slightly  above,  the  tarso-metatarsal  joint-line.  Both  flaps  contain  all 
the  soft  parts  to  the  bones.  Disarticulation  is  now  accomplished  from  the  dor- 
sum. Retract  the  flaps — extend  the  foot — and  begin  the  disarticulation  by 
entering  the  knife  behind  the  prominent  base  of  the  fifth  metatarsal,  at  the  outer 
side  of  the  foot — and  then,  passing  obliquely  forward  and  inward,  cut  the 
peroneus  brevis  and  tertius  tendons  and  disarticulate  the  fifth,  fourth,  and  third 
metatarsals.  Then  turn  to  the  inner  side  of  the  foot,  and  sever  the  ligaments  of 
the  first  tarso-metatarsal  joint,  and  divide  the  expansion  of  the  tibialis  anticus. 
There  remains  the  freeing  of  the  second  metatarsal,  which  is  somewhat  diffi- 
cult, unless  undertaken  in  a  definite  manner.  Hold  the  knife  like  a  dagger, 
with  the  cutting-edge  toward  the  ankle,  the  blade  pointing  forward  at  an  angle 
with  the  dorsum  of  the  foot — enter  the  point  deeply  between  the  bases  of 
first  and  second  metatarsals,  where  they  begin  to  bind — elevate  the  handle 
until  perpendicular  to  the  dorsum,  cutting,  at  the  same  time,  forward — and 
thus  the  ligaments  binding  the  base  of  the  second  metatarsal  to  the  base  of 
the  first  metatarsal  and  internal  cuneiform  are  severed  (the  manceuvre  being 
called  the  "coup  de  maitre").  Repeat  this  manoeuvre  between  the  bases 
of  the  second  and  third  metatarsals.  Complete  the  disarticulation  of  the 
second  metatarsal  by  severing,  from  the  dorsum,  the  ligaments  between 
the  middle  cuneiform  and  base  of  the  metatarsal.  Divide  any  connecting 
bands  upon  the  plantar  aspect  of  the  joints.  The  peroneus  longus  tendon 
now  alone  holds  the  metatarsal — put  this  upon  the  stretch,  dividing  it  high 
up.  The  following  arteries  are  to  be  tied — in  the  dorsal  flap;  four  dorsal 
interosseous,  communicating  branch  of  dorsalis  pedis; — in  plantar  flap;  five 
plantar  digital  branches  of  external  plantar  (and  possibly  the  external  plantar 
itself)  and  the  termination  of  the  internal  plantar.  Suture  any  open  sheaths. 
Quilt  the  muscles.  Suture  the  plantar  and  dorsal  flaps  in  one  transverse 
line.     Support  the  stump  upon  a  splint. 

Comment. — (i)  The  plantar  flap  may  be  cut  first.  (2)  The  dorsal  flap 
may  be  made  and  disarticulation  accomplished,  and  then  the  plantar  flap 
cut  from  within  outward — which  is  not  so  satisfactory  as  the  above.  (3) 
Freer  allowance  should  be  made  to  cover  the  thicker  inner  than  the  thinner 
outer  side  of  the  foot — which  is  the  reason  for  cutting  the  inner  aspect  of  the 
flap  longer.  (4)  Guard  against  making  the  dorsal  flap  (00  short  and  too 
scant  on  the  dorsal  aspects — and  also  against  making  either  flap  too  pointed. 
(5)  Guard  against  mistaking  the  scapho-cuneiform  joint  for  the  metatarso- 
cuneiform  joint.  (6)  Guard  the  plantar  tissues  while  disarticulating  the 
second  metatarsal.  (7)  The  dorsal  flap  should  include  most  of  the  tissues 
upon  the  outer  and  inner  aspect  of  the  foot.  (8)  This  method  makes  an 
excellent  and  useful  stump. 

DISARTICULATION  OF  ALL  THE  TOES  AT  THE  TARSO-METATARSAL 

JOINTS,  WITH  SAWING  OFF  OF  END  OF 

INTERNAL  CUNEIFORM, 

EY  SHORT  DORSAL  AND  LONG  PLANTAR  FLAPS  — HEV'S  OPERATION. 

Description. — This  operation  is  similar  to  Lisfranc's  as  to  incisions, 
freeing  of  flaps,  ligation  of  vessels  and  suturing  of  wound — differing  only 
in   one   respect — namely,    after   disarticulating    the    four   outer    metatarsals, 


MEDIO-TARSAL  DISARTICULATION  OF  FOOT.  409 

the  .protruding  end  of  the  innermost  cuneiform  is  sawed  off  on  a  line  with 
the  others,  and  removed  together  with  the  first  metatarsal  still  articulated. 


DISARTICULATION  OF  ANTERIOR  PART  OF  FOOT  AT  MEDIO-TARSAL 
JOINT,  IN  GENERAL. 

Best  Methods. — Short  Dorsal  and  Long  Plantar  Flaps — Chopart's 
Operation. 

Other  Methods. — Modified  Oval  (Tripier's  Operation) — medio-tarsal 
disarticulation,  with  horizontal  sawing  of  os  calcis. 


DISARTICULATION  OF  ANTERIOR  PART  OF  FOOT  AT  MEDIO-TARSAL 

JOINT 

BY  SHORT  DORSAL  AND  LONG  PLANTAR  FLAPS  — CHOPART'S  OPERATION. 

Description. — Disarticulation  of  anterior  portion  of  foot  at  astragalo- 
scaphoid  and  calcaneo-cuboid  joints,  by  means  of  a  short  dorsal  and  long 
plantar  flap — the  operation  being  somewhat  similar  to  Lisfranc's  tarso- 
metatarsal disarticulation. 

Position. — As  for  Lisfranc's  operation. 

Landmarks. — Astragalo-scaphoid  joint  (just  behind  the  tuberosity  of 
the  scaphoid) ;  calcaneo-cuboid  joint  (midway  between  the  external  malleolus 
and  tubercle  of  fifth  metatarsal);  tarso-metatarsal  joint-line;  middle  of  meta- 
tarsus. 

Incisions. — (Right  foot) — Plantar  incision — begins  on  outer  aspect  of 
foot,  little  -nearer  plantar  than  dorsal  surface,  and  at  a  point  opposite  the 
calcaneo-cuboid  joint  (see  Landmarks) — passes  straight  down  the  outer  side 
of  foot  to  near  middle  of  fifth  metatarsal — thence  rounds  inward  and  crosses 
sole  of  foot,  opposite  the  middle  of  the  metatarsals,  to  the  inner  side  of  the 
foot — rounds  into  the  inner  border  of  the  foot  and  passes  straight  up  that 
border,  little  nearer  the  plantar  than  dorsal  surface,  to  a  point  opposite  the 
astragalo-scaphoid  joint  (see  Landmarks).  Dorsal  incision — begins  by 
curving  from  the  outer  limb  of  the  plantar  incision,  just  posterior  to  the  fifth 
tarso-metatarsal  joint — and  ends  by  curving  into  the  inner  limb  of  the  plantar 
incision  just  posterior  to  the  first  tarso-metatarsal  joint — crossing  the  dorsum 
opposite  the  bases  of  the  metatarsals  (Fig.  348,  B,  B). 

Operation. — Deepen  the  plantar  incision,  the  foot  flexed  on  the  leg 
and  the  toes  extended  on  the  foot,  to  the  flexor  tendons.  Free  the  skin  and 
fascia  a  short  distance — divide  all  soft  parts  to  the  bones — and  dissect  up 
the  flap  of  the  entire  soft  parts  to  the  medio-tarsal  joint.  Deepen  the  dorsal 
incision,  the  foot  extended  on  the  leg  and  the  toes  flexed  on  the  foot,  to  the 
extensor  tendons.  Free  the  skin  and  fascia  a  short  distance — divide  all 
the  soft  parts  to  the  bones — and  dissect  up  the  flap  of  the  entire  soft  tissues 
to  the  medio-tarsal  joint.  Disarticulate  from  the  dorsum  while  the  foot 
is  forcibly  extended — rotating  the  forepart  of  the  foot  outward  while  severing 
the  ligaments  of  the  astragalo-scaphoid  joint,  and  inward  while  dividing 
those  of  the  calcaneo-cuboid  articulation.  The  tendons  of  the  tibialis  anticus 
and  posticus,  and  peroneus  tertius,  brevis,  and  longus,  are  cut  among  the 
deeper  structures.  Quilt  the  muscular  and  tendinous  tissues  of  the  two 
flaps,  especially  suturing  the  extensor  tendons  and  tibialis  anticus  of  the 
dorsal  flap,  to  the  tissues  of  the  plantar  flap — in  order  to  counteract  the 


41  o  AMPUTATIONS. 

tendency  of  the  tendo  Achillis  to  permanently  extend  the  foot.  In  the  dorsal 
flap,  the  dorsalis  pedis  and  its  tarsal  and  metatarsal  branches  are  cut — and 
in  the  plantar  flap,  the  terminations  of  external  and  internal  plantar  arteries, 
and  plantar  digital  branches. 

Comment. — (i)  Considerable  tendency  exists  for  displacement  of  the 
bones  of  the  stump  subsequent  to  healing — either  the  posterior  portion  of 
the  os  calcis  being  drawn  up  by  the  tendo  Achillis,  thus  throwing  the  head 
of  the  os  calcis  downward  to  be  pressed  upon  in  walking — or  the  stump  is 
turned  into  the  varus  position  and  the  patient  walks  upon  the  outer  border 
of  the  os  calcis.  (2)  The  proportionate  lengths  of  the  flaps  and  the  manner 
of  their  making  may  be  varied,  as  described  in  Lisfranc's  operation.  The 
total  covering  required  is  about  1^  diameters  at  the  saw-line. 


DISARTICULATION    OF    FOOT    AT    ASTRAGALO-SCAPHOID    AND    AS- 

TRAGALO-CALCANEAL  ARTICULATIONS— SUBASTRAGALOID 

DISARTICULATION— IN  GENERAL. 

Best  Methods. — Large  Interno-plantar  Flap  (Farabeuf).     Heel-flap. 

Other  Methods. — Oval,  or  Racket  Method  (Maurice  Perrin).  Oval 
Method  (Verneuil). 

Comparison. — The  interno-plantar  flap  furnishes  the  best  blood-supply 
— the  cicatrix  is  well  placed  and  the  stump  is  broad.  But  the  method  requires 
considerable  healthy,  available  tissue — the  operation  is  somewhat  difficult 
to  perform — and  the  flap  is  somewhat  unwieldy.  The  heel-flap  method  is 
a  simpler  operation  and  requires  minimum  tissue — but  gives  a  narrower 
stump. 


DISARTICULATION    OF    FOOT    AT    ASTRAGALO-SCAPHOID    AND    AS- 
TRAGALO-CALCANEAL  JOINTS— SUBASTRAGALOID  DIS- 
ARTICULATION 

BY  LARGE  INTERNO-PLANTAR  FLAP  —  FARABEUF. 

Description. — A  modified  oval  method.  The  structures  below  the 
astragalus  are  removed — the  stump  being  covered  by  a  large  flap  gotten 
from  the  sole  and  inner  border  of  the  foot — the  scar  being  horizontal  and 
upon  the  outer  and  anterior  aspects  of  the  foot. 

Position. — As  in  the  preceding  operations,  in  general — the  surgeon  so 
manipulating  the  foot  with  his  left  hand  as  to  turn  it  from  side  to  side  in 
following  the  complicated  incision. 

Landmarks. — Tendo  Achillis;  external  malleolus;  base  of  fifth  meta- 
tarsal; joint  between  scaphoid  and  cuneiforms;  joi<nt-line  between  scaphoid 
and  internal  and  middle  cuneiforms;  tendon  of  extensor  longus  hallucis, 
cuneo-metatarsal  joint  of  big  toe;  external  tuberosity  of  os  calcis. 

Incision. — Begins  at  outer  margin  of  insertion  of  tendo  Achillis — curves 
upward  to  a  point  2.5  cm.  (1  inch)  below  the  external  malleolus — passes 
horizontally  forward  at  this  level,  parallel  with  the  border  of  the  foot,  until 
a  point  is  reached  on  a  line  connecting  the  base  of  the  fifth  metatarsal  with 
the  joints  between  the  scaphoid  and  cuneiform  bones — thence  curves  sharply 
across  the  dorsum,  just  anterior  to  the  joint-fine  between  the  scaphoid  with  the 
internal  and  middle  cuneiforms,  until  the  tendon  of  the  extensor  longus  hallucis 
is  reached — thence  curves  slightly  forward  to  cross  the  inner  border  of  the 


SUBASTRAGALOID  DISARTICULATION  OF  FOOT.  411 

foot  in  the  line  of  the  cuneo-metatarsal  joint  of  great  toe — thence  sweeps 
across  the  center  of  the  sole — and,  curving  into  the  outer  border  of  the  foot, 
follows  that  border  to  the  external  tuberosity  of  the  os  calcis — thence  upward 
to  end  at  the  insertion  of  the  tendo  Achillis,  at  the  point  of  beginning  (Fig.  351). 
Operation. — The  above  incision  is  now  everywhere  deepened  to  the  bone 
along  the  line  of  retracted  skin  and  fascia,  using  a  stout  knife  and  cutting 
with  force  as  the  parts  are  put  upon  the  stretch — cutting  all  tendons  cleanly 
— and  opening  no  joints.  Now  flex  the  leg  upon  the  thigh,  turn  the  knee 
inward,  and  press  the  inner  side  of  the  leg  on  the  table,  so  that  the  outer 
side  of  the  leg  presents  and  the  foot  is  beyond  the  edge  and  kept  upon  the 
stretch.  Dissect  up,  cleanly  from  the  bones,  the  outer  dorsal  portion  of  the 
flap,  until  the  head  of  the  astragalus  is  exposed  in  front  and  the  tendo  Achillis 


*f 


Fig.  351.— SUBASTRAGALOID    DISARTICULATION    OF    FOOT    BY    LARGE     INTERNO-PLANTAR    FLAP 

(Farabeuf): — A.  Outline  of  incision  upon  outer  aspect  of  foot;  B,  Outline  of  incision  upon  inner 
aspect. 

behind — divide  the  tendo  Achillis — enter  the  astragalo-scaphoid  joint  on  its 
dorsal  aspect — keep  the  knife  in  the  interarticular  line  and  cut  backward 
between  the  astragalus  and  os  calcis,  passing  beneath  the  tip  of  the  external 
malleolus  to  the  already  cut  tendo  Achillis,  severing  all  ligaments  and  everting 
the  os  calcis  as  the  ligaments  are  cut — until  the  under  surface  of  the  astragalus 
is  free.  The  foot  is  further  twisted  into  extreme  varus,  and  the  inner  and 
under  surfaces  of  the  os  calcis  are  bared,  working  from  the  inner  toward 
the  under  and  outer  surfaces  of  the  os  calcis,  by  cutting  with  short  strokes 
of  a  strong  knife,  and  closely  hugging  the  bone  to  avoid  damaging  important 
structures  on  the  inner  aspect,  especially  the  vessels  which  supply  the  flap. 
Bv  the  time  the  externo-plantar  border  of  the  os  calcis  is  reached,  the  dorsum 
of  the  foot  will  be  looking  downward.  Free  the  skin  from  the  posterior 
surface  of  the  os  calcis  carefully  so  as  not  to  score  the  integumentary  parts. 
Sever   any   remaining   connections.     Cut    the   anterior   and    posterior   tibial 


412  AMPUTATIONS. 

nerves  high  up.  The  following  arteries  are  encountered,  in  the  direction  of 
the  incision,  and  will  require  ligation — posterior  peroneal,  anterior  peroneal, 
dorsalis  pedis,  internal  plantar  and  external  plantar.  Provide  temporary 
drainage,  by  puncturing  the  heel  portion  of  the  flap.  Quilt  the  muscles 
and  tendons.  Suture  the  flap  in  an  external  and  anterior  horizontal  line. 
Dress  the  stump  upon  a  posterior  splint. 


DISARTICULATION    OF    FOOT    AT    ASTRAGALO-SCAPHOID    AND    AS- 
TRAGALO-CALCANEAL  JOINTS— SUBASTRAGALOID  DIS- 
ARTICULATION 

BV  HEEL  FLAP. 

Description. — The  structures  removed  are  the  same  as  in  the  above 
operation.  In  the  present  instance  the  coverings  are  furnished  from  the  heel 
and  sole  tissues.  The  steps  of  the  operation  are  very  similar  to  those  of 
Syme's  disarticulation  of  the  foot  at  the  ankle-joint. 

Position. — See  Syme's  operation  (page  414). 

Landmarks. — External  and  internal  malleoli. 

Incisions. — Plantar  incision — begins  1.3  cm.  (\  inch)  below  the  tip  of 
the  external  malleolus — passes  directly  across  the  sole  of  the  foot — and  ends 
2.5  cm.  (1  inch)  below  the  posterior  border  of  the  internal  malleolus.  Dorsal 
incision — is  U-shaped,  connecting  the  upper  ends  of  the  plantar  incision- 
curving  across  the  dorsum  on  a  level  with  the  astragalo-scaphoid  joint  (Fig. 
349,  E,  and  Fig.  350,  F). 

Operation. — For  the  general  steps  of  the  operation,  see  Syme's  dis- 
articulation at  the  ankle-joint  (page  414),  which  is  similar  in  general  prin- 
ciple, though  different  in  detail.  Deepen  the  incisions  to  the  bones — dissect 
the  heel-flap  backward  and  the  dorsal  flap  upward — open  the  astragalo- 
scaphoid  joint  from  the  dorsum  and  cut  backward,  disarticulating  the  astraga- 
lus from  the  os  calcis.  The  extreme  head  of  the  astragalus  may  be  sawed 
off.  The  operation  is  concluded  as  in  Syme's — the  same  vessels  being  also 
ligated. 

Other  Amputations  About  the  Foot. — (1)  Anterior  Intertarsal  Dis- 
articulation (Jaeger's  Operation) — consists  of  a  disarticulation  between  the 
three  cuneiforms  anteriorly,  and  the  scaphoid  posteriori}- — the  cuboid  being 
sawed  across  in  a  line  with  the  disarticulation.  This  would  occupy  a  position 
between  Lisfranc's  tarso-metatarsal  disarticulation  and  Chopart's  medio- 
tarsal  disarticulation.  (2)  Amputation  Through  the  Posterior  Tarsus — if 
soft  parts  cannot  be  gotten  to  cover  Chopart's  stump,  the  articular  surfaces 
of  the  astragalus  and  os  calcis  are  sawed  off.  (3)  Subastragaloid  Osteoplastic 
Amputation  (Hancock's  Operation) — the  tuberosity  of  the  os  calcis  is  sawed 
off  and  applied  to  the  lower  surface  of  the  astragalus,  from  which  the  articular 
cartilage  has  been  removed. 


SURGICAL  ANATOMY  OF  ANKLE-JOINT. 

Bones. — Tibia;  fibula;  astragalus. 

Articulations  and  Ligaments. — Anterior  tibio-tarsal,  posterior  tibio- 
tarsal,  external  lateral  (consisting  of  anterior  astragalo-fibular,  posterior 
astragalo-fibular,  and  middle  calcaneo-fibular  fasciculi),  internal  lateral  (or 
deltoid)  ligaments,  and  synovial  membrane. 


SURGICAL  CONSIDERATIONS  IN  ANKLE  DISARTICULATIONS.      413 

Muscles. — See  under  Foot  (page  398)  and  Leg  (page  416). 

Movements  of  Ankle-joint. — Extension — by  gastrocnemius,  soleus, 
plantaris,  tibialis  posticus,  peroneus  longus,  peroneus  brevis,  flexor  longus 
digitorum,  flexor  longus  hallucis.  Flexion — by  tibialis  anticus,  peroneus  ter- 
tius,  extensor  longus  digitorum,  extensor  proprius  hallucis.  Adduction — tibialis 
anticus,  tibialis  posticus.     Abduction — Peroneus  longus,  peroneus  brevis. 

Arteries. — Following  branches  of  anterior  tibial — internal  and  external 
malleolar  and  dorsalis  pedis.  Following  branch  of  posterior  tibial — internal 
calcaneal  branch  of  posterior  tibial: — and  following  branches  of  peroneal 
branch  of  posterior  tibial;  anterior  peroneal,  posterior  peroneal,  and  external 
calcaneal. 

Veins. — Superficial — internal  saphenous  and  tributaries;  external  saphen- 
ous and  tributaries.     Deep — Two  venae  comites  accompany  each  artery. 

Nerves. — From  lumbar  plexus — internal  saphenous  from  anterior  crural. 
From  sacral  plexus — following  from  great  sciatic — external  saphenous  (from 
communicans  poplitei  and  communicans  peronei) ;  plantar  cutaneous,  articu- 
lar, internal  plantar  and  external  plantar  (from  posterior  tibial);  articular, 
muscular  and  external  (or  tarsal)  (from  anterior  tibial);  and  internal  and 
external  branches  of  musculocutaneous. 

Annular  Ligaments. — See  under  Foot  (page  397). 


SURFACE  FORM  AND  LANDMARKS  OF  ANKLE-JOINT. 

The  general  feature  of  the  ankle-joint  is  that  of  the  prominently  rounded 
superior  surface  of  the  astragalus  received  into  the  dome  of  the  tibia,  and 
bounded  laterally  by  the  descending  malleoli. 

The  line  of  the  joint  is  transverse — crossing  the  front  of  the  leg  about 
1.3  cm.  (J  inch)  above  the  tip  of  the  internal  malleolus. 

The  external  malleolus  extends  from  1.3  to  2  cm.  (J  to  f  inch)  lower  than 
the  internal — and  is  placed  upon  a  plane  about  1.3  cm.  (£  inch)  posterior 
to  the  internal  malleolus.  The  external  malleolus  is  opposite  the  center 
of  the  joint — the  internal  is  in  front  of  the  center  of  the  joint.  The  tip  of  the 
external  malleolus  is  nearer  the  posterior  border  of  the  fibula,  and  the  tip 
of  the  internal  malleolus  nearer  the  anterior  border  of  the  tibia. 

Chief  structures  about  the  ankle-joint — Anteriorly — (from  within  outward) 
tibialis  anticus,  extensor  proprius  hallucis,  anterior  tibial  artery,  anterior 
tibial  nerve,  extensor  longus  digitorum,  peroneus  tertius.  Posteriorly — tendo 
Achillis.  Internally — (from  before  backward)  tibialis  posticus,  flexor  longus 
digitorum,  companion  vein,  posterior  tibial  artery,  companion  vein,  posterior 
tibial  nerve,  flexor  longus  hallucis.  Externally — (from  before  backward) 
peroneus  brevis,  peroneus  longus,  external  calcaneal  and  termination  of 
peroneal  artery. 

The  lower  epiphysis  of  the  tibia  includes  the  articular  surface  and  internal 
malleolus,  and  unites  about  the  eighteenth  year.  The  lower  epiphvsis  of  the 
fibula  includes  the  articular  surface  and  outer  malleolus,  and  unites  about 
the  twentv-first  vear. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    DISARTICULATIONS    AT 

ANKLE-JOINT. 

Great  care  should  be  taken  of  the  blood -supply  to  the  heel  tissues  forming 
the  stump — the  chief  vessels  being  the  external  calcaneal  of  the  posterior 


41 4  AMPUTATIONS. 

peroneal,  externally;  and  the  internal  calcaneal  of  the  external  plantar, 
internally. 

In  section  of  the  lower  ends  of  the  tibia  and  fibula  most  of  the  anterior 
and  posterior  tibio-libular  and  interosseous  ligaments  are  saved. 

A  posterior  splint  is  used  in  the  dressing  following  disarticulation. 


DISARTICULATION  OF  FOOT  AT  ANKLE-JOINT,  WITH  REMOVAL  OF 

MALLEOLI  AND  ARTICULAR  SURFACE  OF 

TIBIA,  IN  GENERAL. 

Best  Method. — Heel-flap — Syme's  operation. 

Other  Methods. — Modified  Oval  Method — Roux's  operation.  Large 
Interno-plantar  Flap — Farabeuf's  operation.  Internal  Lateral  Flap.  Modi- 
fied External  Racket.     Dorsal  Flap. 


DISARTICULATION  OF  FOOT  AT  ANKLE-JOINT,  WITH  REMOVAL  OF 
MALLEOLI  AND  ARTICULAR  SURFACE  OF  TIBIA, 

BY  HEEL  FLAP  —  SYME'S  OPERATION. 

Description. — As  described  in  the  title. 

Position. — Patient  supine;  foot  elevated  and  over  edge  of  table.  As- 
sistant steadies  leg  with  one  hand  and  holds  foot  at  right  angle  to  leg  by 
grasping  toes  with  other  hand.  Surgeon  sits  for  plantar  and  stands  for 
dorsal  incisions. 

Landmarks. — Outline  of  ankle-joint;  malleoli. 

Incisions. — Plantar  incision — begins  at  tip  of  external  malleolus,  on  the 
right  side  (the  surgeon's  left  palm  resting  on  the  instep,  with  forefinger  and 
thumb  upon  the  malleoli) — passes  vertically  down  the  outer  side  of  the  foot, 
across  the  sole  and  vertically  up  the  inner  side  of  the  foot  to  a  point  1.3  cm. 
(J  inch)  below  the  tip  of  the  internal  malleolus.  This  incision  passes  exactly 
at  a  right  angle  to  the  long  axis  of  the  foot,  in  a  straight  line  between  these 
two  points — if  inclined  forward,  the  flap  is  very  difficult  to  dissect  from  the 
os  calcis — if  inclined  backward,  it  is  easier  to  separate  but  apt  to  form  a 
scanty  covering,  with  imperfect  vascular  supply.  If  the  inner  limb  of  the 
vertical  incision  passes  up  to  the  posterior  border  of  the  inner  malleolus, 
the  posterior  tibial  artery  is  more  in  danger  of  being  divided  before  its  bifurca- 
tion and  the  main  branch  of  the  flap,  the  internal  calcaneal  of  the  external 
plantar,  lost.  The  above  incision  is  made  in  two  cuts,  each  from  a  malleolus 
to  the  center  of  the  sole.  Dorsal  incision — (surgeon's  left  palm  to  sole,  with 
thumb  and  first  finger  grasping  the  margins  of  the  foot  and  extending  it) — 
connects  the  upper  ends  of  the  plantar  incision  by  an  incision  sweeping 
straight  across  the  front  of  the  ankle.  The  dorsal  and  plantar  incisions  are 
approximately  at  a  right  angle  to  each  other  (Fig.  349,  C,  C,  and  Fig.  350, 
C,  CO- 

Operation. — The  plantar  incision,  made  with  a  strong  knife,  passes 
directly  and  cleanly  to  the  bone.  The  large  heel-flap  is  freed  from  the  os 
calcis  as  far  as  its  tuberosities,  partly  by  the  use  of  the  left  thumb,  partly 
by  a  stout  knife  cutting  close  to  the  bone.  It  is  possible,  but  difficult  and 
unadvisable,  to  entirely  dissect  and  retract  the  heel-flap  from  the  tuberosities 
and  posterior  surface  of  the  os  calcis,  from  the  plantar  wound.     With  the 


PIROGOFFS  OPERATION.  415 

foot  fully  extended  the  dorsal  incision  is  now  made  directly  to  the  bone, 
cutting  the  tendons  and  ligaments  cleanly.  This  incision  cuts  directly  through 
the  anterior  ligament  of  the  ankle-joint  and  opens  the  articulation.  The 
disarticulation  is  continued  by  cutting  the  lateral  ligaments  from  within 
outward,  and  completed  by  similarly  cutting  the  posterior  ligament.  The 
tendo  Achillis  is  now  cut.  The  foot  is  then  drawn  downward  and  forward 
and  the  posterior  and  lateral  surfaces  of  the  os  calcis  dissected  free  of  the 
heel  covering  by  working  from  behind  downward  and  forward  with  short, 
close  strokes  of  the  knife  while  the  parts  are  under  tension.  The  malleoli 
are  now  closely  cleared  of  their  soft  parts,  hugging  the  bones  and  guarding 
the  flaps.  The  soft  parts  are  well  retracted  — and  the  tibia  and  fibula  are 
sawed  transversely  at  about  6  mm.  (J  inch)  above  the  inferior  border  of  the 
tibia  (which  will  remove  the  articular  surface  of  the  dome) — the  malleoli 
being  steadied  by  forceps  during  the  sawing.  Ligate  the  anterior  tibial, 
external  and  internal  plantar,  and  probably  the  external  and  internal  malleolar 
of  the  anterior  tibial,  the  anterior  peroneal,  internal  malleolar  of  posterior 
tibial,  and  internal  and  external  saphenous  veins.  Cut  all  nerves  short, 
especially  those  of  the  heel-flap,  which  is  bent  over  the  ends  of  the  sawed 
bones.  Suture  the  heel-flap  to  the  dorsal  incision— using  tension-sutures 
in  addition  to  coaptation-sutures,  if  there  be  much  strain  upon  the  suture-line. 
Institute  drainage  through  a  counter-opening  in  the  heel-flap,  if  indicated. 
So  dress  the  part,  with  a  posterior  splint  included,  as  to  draw  the  heel-flap 
forward  and  upward. 

Comment. — (1)  This  is  probably  the  best  form  of  disarticulation  about 
the  ankle  and  usually  furnishes  a  very  satisfactory  result.  (2)  It  is  advisable 
to  free  the  os  calcis  subperiosteals,  if  possible — and  also  to  leave  the  posterior 
epiphysis,  in  the  young,  in  the  flap. 


DISARTICULATION  OF  FOOT  AT  ANKLE-JOINT,  WITH  REMOVAL  OF 

MALLEOLI,  ARTICULAR  SURFACE  OF  TIBIA,  AND  ANTERIOR 

PART  OF  OS  CALCIS,— IN  GENERAL. 

Best  Method. — Heel-flap — Pirogoff's  operation. 

Other  Methods.— Racket  Method  (Pasquier-LeFort) — racket  from  inner 
side,  with  horizontal  division  of  calcaneum.  Watson's  modification  of  Piro- 
goff's Heel-flap  Method — sawing  calcaneum  from  plantar  surface  immediately 
after  plantar  incision.  Sedilot's  modification  of  Pirogoff's  operation — middle 
(internal)  oval  method,  with  oblique  sawing  of  calcaneum.  Others  have 
sawed  the  os  calcis  in  angular  and  curved  directions. 


DISARTICULATION  OF  FOOT  AT  ANKLE-JOINT,  WITH  REMOVAL  OF 

MALLEOLI.  ARTICULAR  SURFACE  OF  TIBIA,  AND  ANTERIOR 

PART  OF  OS  CALCIS, 

BV  HEEL-FLAP  — PIROGOFF'S  OPERATION. 

Description. — An  intra-calcaneal  osteoplastic  amputation  of  the  foot. 
The  operation  is  very  similar  to  Syme's,  except  that  the  anterior  and  major 
portion  of  the  os  calcis  is  sawed  off  and  the  remaining  posterior  portion, 
which  is  left  in  the  heel-flap,  is  adjusted  to  the  transversely  sawed  tibia  and 
fibula. 

Position — Landmarks. — As  in  Syme's  operation  (page  414). 


416  AMPUTATIONS. 

Incisions. — Plantar  incision  (right  foot) — begins  just  anterior  to  the 
tip  of  the  external  malleolus — passes  vertically  down  the  outer  side  of  the 
foot,  across  the  sole,  and  vertically  up  the  inner  side  of  the  foot  to  a  point 
1.3  cm.  (^  inch)  below  and  a  short  distance  anterior  to  the  tip  of  the  internal 
malleolus  (which  points  are  a  little  anterior  to  those  of  Syme's  operation). 
Dorsal  incision — is  somewhat  more  convex;  that  is,  passes  further  down  on 
the  dorsum  of  the  foot  than  does  Syme's  (Fig.  349,  D,  D',  D",  and  Fig. 
350,  D,  D',  D"). 

Operation. — These  incisions  are  made  and  deepened  in  the  same  manner 
as  in  Syme's  operation.  The  heel-flap  is  not  freed  back  from  the  plantar 
surface  of  the  os  calcis  quite  to  its  tuberosities.  The  disarticulation  is  accom- 
plished as  in  Syme's.  The  foot  is  placed  in  extreme  extension  and  the  upper 
surface  of  the  os  calcis  exposed,  but  the  tendo  Achillis  not  cut.  The  whole 
of  the  os  calcis  having  been  freed  except  its  posterior  third,  the  saw  is  applied 
(with  the  foot  in  extension)  to  the  upper  surface  of  the  os  calcis,  1.3  to  2  cm. 
(£  to  f  inch)  behind  the  astragalus,  and  made  to  saw  its  way  obliquely  down- 
ward and  forward  (or  more  nearly  vertically,  in  the  extended  position  of  the 
foot)  in  a  line  about  parallel  with  the  now  distorted  heel  incision — all  the 
soft  parts  being  carefully  retracted  the  while,  especially  the  inner  arteries. 
The  lower  ends  of  the  tibia  and  fibula  are  then  freed  as  in  Syme's  and  are 
sawed  off  in  the  same  manner,  except  that,  after  entering  the  anterior  surface 
of  the  bone  about  6  mm.  (\  inch)  above  the  inferior  border  of  the  tibia,  the 
section  is  so  made  that  the  saw  emerges  posteriorly  about  1.3  cm.  (J  inch) 
higher  than  on  the  anterior  surface  (to  be  parallel  with  the  section  of  the 
calcaneum).  Ligate  the  same  vessels  as  encountered  in  Syme's  operation. 
Cut  the  nerves  short  and  the  loose  tendons.  Approximate  the  sawed  cal- 
caneum to  the  sawed  tibia — and  suture  the  plantar  flap  to  the  dorsal  incision. 

Comment. — (1)  If  the  sawed  ends  of  the  bone  do  not  lie  in  good  apposi- 
tion, a  thin  slice  of  bone  may  be  further  removed  with  the  saw  where  indicated 
— or  the  surfaces  of  bone  may  be  nailed  or  pegged  together.  But  when 
the  proper  calculations  are  made  the  surfaces  can  generally  be  held  in  contact 
by  the  suturing  together  of  the  fibrous  tissues  surrounding  the  sawed  ends, 
with  buried  chromic  gut.  (2)  The  stump  thus  gained  is  a  little  longer  than 
in  Syme's  operation — the  flap  is  better  .nourished,  is  firmer,  contains  bone 
and  tendo  Achillis,  and  the  movement  is  greater.  But  the  bone  is  apt  to 
necrose,  or  become  displaced,  or  may  not  unite.  The  operation  is  more 
suitable  to  traumatic  cases.  An  artificial  limb  is  harder  to  fit.  The  method 
is,  altogether,  not  superior  to  Syme's. 


SURGICAL  ANATOMY  OF  LEG. 

Bones. — Tibia;  fibula. 

Articulations  and  Ligaments. — (a)  Superior  Tibiofibular  Articula- 
tion— anterior  and  posterior  superior  tibio-fibular  ligaments,  and  synovial 
membrane,  (b)  Middle  Tibio-fibular  Articulation — interosseous  membrane, 
(c)  Inferior  Tibio-fibular  Articulation — anterior  and  posterior  inferior  tibio- 
fibular and  transverse  ligaments,  inferior  interosseous  membrane,  and  synovial 
membrane. 

Muscles. — (a)  Anterior  Tibio-fibular  Region: — tibialis  anticus;  extensor 
proprius  hallucis;  extensor  longus  digitorum;  peroneus  tertius.  (b)  Posterior 
Tibio-fibular  Region: — (1)  Superficial  Muscles; — gastrocnemius,  soleus, 
plantaris.     (2)    Deep    Muscles: — popliteus,    flexor    longus    hallucis,    flexor 


SURFACE  FORM  AND    LANDMARKS  OF    LEG.  417 

longus  digitorum,  tibialis  posticus,  (c)  Outer,  or  Fibular,  Region : — peroneus 
longus,  peroneus  brevis. 

Arteries. — Following  branches  of  popliteal — inferior  muscular,  inferior 
external  articular,  inferior  internal  articular.  Anterior  tibial  and  following 
branches — posterior  recurrent  tibial,  superior  fibular,  anterior  recurrent 
tibial,  muscular,  internal  malleolar,  external  malleolar.  Posterior  tibial 
and  following  branches: — peroneal  (with  its  muscular,  nutrient,  anterior 
peroneal,  and  communicating  branches),  muscular,  nutrient,  and  communi- 
cating branches. 

Veins. — Superficial — internal  saphenous  and  tributaries — external  saphe- 
nous and  tributaries.     Deep — Two  vena?  comites  for  each  artery. 

Nerves. — (a)  From  lumbar  plexus — (1)  From  anterior  crural;  posterior 
branch  of  internal  cutaneous;  long  saphenous  branch  and  its  branches,  (b) 
From  sacral  plexus — (1)  From  great  sciatic — anterior  popliteal  and  muscular 
branches;  communicans  poplitei.  Posterior  tibial  and  muscular  branches. 
External  popliteal  (or  peroneal)  and  cutaneous  branches.  Anterior  tibial 
and  muscular  branches.  Musculocutaneous  and  muscular  and  cutaneous 
branches.     The  cross-sections  of  the  leg  are  shown  in  Figs.  56, 60,  352,  and  62. 

SURFACE  FORM  AND  LANDMARKS  OF  LEG. 

Following  parts  of  the  tibia  are  palpable — external  tuberosity  (more 
prominent);  internal  tuberosity  (broader);  tubercle;  anterior  border,  or 
crest  (for  upper  two-thirds);  internal  border;  internal  surface  (from  tuberosity 
to  malleolus) ;  internal  malleolus. 

Following  parts  of  fibula  are  palpable — head ;  lower  part  of  external  surface 
of  shaft  (between  peroneus  tertius,  and  peronei  longus  and  brevis) ;  external 
malleolus. 

The  fibula  is  on  a  plane  considerably  posterior  to  the  tibia. 

No  muscular  fibers  are  attached  to  the  lower  third  of  the  tibia. 

The  sharp  crest  of  the  tibia  has  become  rounded  in  its  lower  third. 

The  interosseous  space  is  widest  at  the  center  of  the  leg,  decreasing  in 
width  toward  both  ends. 

The  tibialis  anticus  forms  a  muscular  prominence  running  down  the  leg 
external  to  the  tibia.  The  extensor  longus  digitorum,  a  smaller  prominence, 
fills  the  rest  of  the  interval  between  the  fibula  and  the  tibialis  anticus  muscle — 
a  groove  intervening  between  these  two  muscles  above,  and  the  extensor 
proprius  hallucis  coming  to  the  front  between  them  below. 

Externally,  the  peroneus  longus,  brevis,  and  tertius  form  a  muscular 
prominence. 

The  internal  aspect  of  the  leg  is  formed-  -anteriorly,  by  the  subcutaneous 
tibia — posteriorly,  by  the  projecting  border  of  the  soleus  and  tendon  of  the 
tibialis  posticus. 

The  fleshy  mass  of  the  calf  is  formed  by  the  gastrocnemius  and  soleus, 
tapering  to  the  tendo  Achillis — and  beneath  them  the  popliteus,  flexor  longus 
hallucis,  flexor  longus  digitorum,  and  tibialis  posticus. 

A  groove  exists  between  either  malleolus  and  the  extended  tendo  Achillis. 

The  interosseous  membrane  separates  the  anterior  from  the  posterior 
tibio-fibular  muscles. 

Tendons  predominate  over  muscles  in  the  lower  third  of  the  leg. 

The  gastrocnemius  and  soleus  have  joined  by  the  time  the  lower  third 
of  the  leg  is  reached. 

The  greatest  girth  of  the  leg  is  at  about  the  junction  of  the  upper  and 
27 


418  AMPUTATIONS. 

middle    thirds — tapering    gradually    above    to    the    knee-joint — and    rapidly 
decreasing  in  size  below  toward  the  ankle. 

The  popliteal  artery  bifurcates  about  5  cm.  (2  inches)  below  the  knee- 
joint — on  a  level  with  the  lower  part  of  the  tubercle  of  the  tibia.  In  ampu- 
tating 2.5  cm.  (1  inch)  below  the  head  of  the  fibula,  one  main  artery,  the' 
popliteal,  is  cut — at  5  cm.  (2  inches),  two  main  arteries,  the  anterior  and 
posterior  tibials — and  at  7.5  cm.  (3  inches),  three  main  arteries,  the  anterior 
and  posterior  tibials  and  the  peroneal  (Holden). 


GENERAL    SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT 

THE  LEG. 

In  the  lower  and  middle  thirds  of  the  leg,  the  bulk  of  the  muscles  are 
posterior — hence  a  posterior  flap  forms  the  best  covering. 

In  the  upper  third  of  the  leg  the  bulk  of  the  muscles  are  postero-external 
—hence  a  flap  chiefly  external  furnishes  the  best  covering. 

In  all  amputations  through  the  upper  third  of  the  leg,  it  is  well  to  cut 
the  fibula  at  a  higher  level  than  the  tibia,  as  it  is  apt  to  be  drawn  out  of  posi- 
tion and  be  exposed  to  pressure. 

The  "place  of  election,"  especially  referred  to  in  older  writings,  was 
understood  to  be  a  hand's-breadth  (or  an  average  of  9  cm.,  or  3^  inches) 
below  the  knee-joint. 

The  termination  of  the  stump,  in  amputations  about  the  leg,  does  not 
directly  meet  pressure  (except  in  the  peg-leg) — the  pressure  being  borne  by 
the  lateral  aspects  of  the  hollow  modern  limb — so  that  a  terminal  scar  (except 
where  a  peg-leg  is  contemplated)  is  not  objectionable. 

It  is  especially  necessary,  in  amputating  in  the  lower  extremity,  to  dissect 
out  all  nerves  which  may  be  pressed  upon — especially  in  the  flap  forms  of 
operation. 

In  sawing  the  bones  of  the  leg,  the  prominent  border  (shin)  of  the  tibia 
should  be  beveled,  as  described  in  the  General  Principles  (page  294) . 

The  stump  should  be  dressed  upon  a  splint — and  be  kept  out  from  under 
the  bedclothes. 


AMPUTATIONS  ABOUT  THE  LEG,  IN  GENERAL. 

Best  Methods. — Oblique  Elliptical  (Guyon's  Supramalleolar  Ampu- 
tation)— for  the  supramalleolar  region.  Large  Anterior  and  Small  Posterior 
Flaps  (Farabeuf) — for  lower  third,  between  supramalleolar  region  and  lower 
limit  of  middle  third.  Large  Posterior  and  Short  Anterior  Flaps  (Hey's 
Operation) — for  middle  third.  Large  External  Flap  (Farabeuf) — for  upper 
third.  Bilateral  Hooded  Flap  (Stephen  Smith's  Operation) — for  "place  of 
election,"  or  upper  part  of  upper  third. 

Other  Methods. — Modified  Circular — for  supramalleolar  region.  Oblique 
Elliptical  (Duval) — for  lower  third.  Rectangular  Flaps  (Teale) — for  lower 
third.  Large  Posterior  and  Small  Anterior  Flaps  (Henry  Lee) — for  middle 
third.  Circular  Method.  Equal  Lateral  Flaps.  Large  Posterior  Flap. 
Large  Anterior  Flap.  Long  Anterior  and  Short  Posterior  Flaps.  Oblique 
Circular,  forming  an  anterior  flap — for  upper  and  lower  thirds.  Oblique 
Circular,  forming  an  antero-external  flap — for  middle  thirds.  Oblique 
Circular — forming  a  dorsal  flap — for  supramalleolar  region.     Long  anterior 


AMPUTATION  THROUGH  LOWER  THIRD  OF  LEG. 


419 


Curved  Flap.     Long  Anterior  Rectangular  Flap.     Large  Anterior  Semilunar 
and  Small  Posterior  Semilunar  Flaps. 


Fig.  352. — Cross-section  through  the  Lower  Third  of  the  Right  Leg: — A,  Tibialis 
anticus;  B,  Extensor  proprius  pollicis;  C,  Extensor  longus  digitorum;  D,  Anterior  tibial  artery, 
veins,  and  nerve;  E,  Tibialis  posticus;  F,  Peroneal  artery  and  veins;  G,  Peroneus  brevis;  H, 
Peroneus  longus;  I,  Flexor  longus  pollicis;  J,  J,  Gastrocnemius  and  soleus;  L,  Posterior  tibial 
artery,  veins,  and  nerve.     (The  cross-section  modified  from  Rraune.) 


AMPUTATION  OF  LEG  THROUGH  SUPRAMALLEOLAR  REGION 

BY  OBLIQUE  ELLIPTICAL  INCISION  — GUYON'S  SUPRAMALLEOLAR  OPERATION. 

Description. — An  operation  somewhat  resembling  Syme's — the  tibia 
and  fibula  being  divided  below  the  medullary  canal,  and  the  ends  of  the 
bones  covered  by  a  heel-flap  of  skin  and  muscles. 

Position. — In  operating  upon  the  leg,  in  general,  the  limb  projects  over 
the  edge  of  the  table — the  patient  being  supine — the  surgeon  standing  to 
the  outer  side  of  the  right,  and  inner  side  of  the  left — the  assistant  steadving 
the  part  to  come  away.  In  the  present  operation,  the  surgeon  grasps'  the 
foot  in  his  left  hand  and  manipulates  it  so  as  to  readily  expose  the  line 
of  incision.  On  the  right,  the  foot  is  turned  inward  and  the  incision  begins 
at  the  outer  side  of  the  heel — crosses  the  outer  aspect  of  the  foot,  which  is 
then  turned  upon  its  outer  side,  and  the  incision  carried  to  the  heel  along  the 
inner  aspect.  On  the  left,  the  incision  may  begin  in  front,  with  the  foot 
upon  its  inner  side. 

Landmarks. — Ankle-joint;  malleoli;  greatest  prominence  of  the  heel. 

Incision. — Begins,  say,  on  the  anterior  aspect  of  the  ankle,  opposite  the 


420  AMPUTATIONS. 

center  of  the  ankle-joint — curves  obliquely  downward  and  backward  over 
the  lateral  aspects  of  the  foot,  just  skirting  the  inner  malleolus,  and  passing 
slightly  in  front  of  the  external  malleolus — ending  over  the  summit  of  the 
curve  of  the  heel.  The  incision  may  be  made  from  the  instep  to  the  heel, 
or  vice  versa  (Fig.  350,  E,  E'). 

Operation. — The  above  incision  is  made  through  skin  and  fascia,  and 
is  then  everywhere  deepened  to  the  bone — except  that  the  ankle-joint  is  not 
opened,  and  the  peronei  tendons  behind  the  external  malleolus  are  not  cut, 
until  the  soft  parts  have  been  cleared  above  the  ankle-joint.  The  soft  tissues 
are  now  carefully  freed  up  about  5  cm.  (2  inches)  above  the  tips  of  the  malleoli, 
providing  a  musculo-periosteal  covering — using  great  care  to  preserve  the 
vessels  on  the  inner  aspect — the  surgeon  standing  for  the  anterior  dealing, 
and  sitting  (or  elevating  the  limb)  for  the  posterior  clearing.  The  tendo 
Achillis  is  divided.  The  peronei  tendons  are  cut  at  about  the  level  of  the 
ankle.  The  ankle-joint  is  not  opened.  The  anterior  tibial,  posterior  tibial, 
termination  of  the  peroneal,  and  anterior  peroneal  vessels  are  ligated.  The 
nerves  and  tendons  are  cut  especially  short.  It  is  probably  better  to  dissect 
out  the  posterior  tibial  nerve.  The  convex  heel-flap  is  then  sutured  to  the 
upper  concave  incision,  and  the  stump  dressed  as  in  Syme's  operation. 


AMPUTATION  THROUGH  LOWER  THIRD  OF  LEG 

EV  LARGE  POSTERIOR  AND  SMALL  ANTERIOR  FLAPS—  FARABEUF. 

Description. — The  operation  is  usually  known  as  a  large  posterior  flap 
method,  the  anterior  flap  supplying  so  small  a  part  of  the  covering.  Both 
flaps  are  of  skin  and  muscle.  The  posterior  flap,  which  forms  the  bulk  of 
the  covering,  is  derived  really  more  from  the  postero-internal  aspect,  and  the 
anterior  or  smaller  flap,  which  is  about  one-fourth  the  length  of  the  larger, 
from  the  antero-external  aspect. 

Position. — See  Guyon's  operation  (page  419) — and  under  Incision,  below. 

Landmarks. — Saw-line. 

Incisions. — Posterior  flap — begins  (on  the  right  side)  with  the  leg  turned 
to  present  the  inner  side,  at  the  saw-line,  on  the  inner  side  of  the  leg — and 
passes  vertically  down  in  front  of  the  inner  border  of  the  tibia  for  a  distance 
equal  to  about  1^  diameters  of  the  limb  at  the  saw-line — then  rounds  across 
the  posterior  aspect  of  the  leg.  The  outer  limb  of  the  incision  begins,  with 
the  leg  turned  to  present  the  outer  side,  at  the  saw-line,  on  the  outer  side 
of  the  leg — and  passes  vertically  down  just  behind  the  fibula,  for  a  distance 
equal  to  about  i|  diameters  of  the  leg  at  the  saw-line — then  rounds  across 
the  posterior  aspect  of  the  leg  to  meet  the  inner  incision.  The  anterior  flap 
is  made  by  a  transverse  incision,  slightly  convex  downward,  passing  between 
the  two  vertical  incisions,  at  a  distance  below  their  upper  ends  equal  to  about 
one-fourth  of  the  length  of  the  posterior  flap  (Fig.  352,  A). 

Operation. — These  incisions  having  been  made  through  skin  and  fascia, 
the  tendo  Achillis  is  divided  on  a  line  with  the  retracted  skin  and  the  leg 
is  turned  to  present  its  inner  side — and  the  upper  part  of  the  inner  incision 
is  deepened  for  a  length  of  about  5  cm.  (2  inches),  by  freeing  the  muscles 
from  the  tibia.  The  leg  is  now  turned  to  present  the  outer  side  and  the 
upper  end  of  the  outer  incision  is  similarly  deepened  for  a  distance  of  about 
5  cm.  (2  inches),  by  freeing  the  muscles  from  the  fibula.  The  leg  is  flexed 
during  these  incisions.  Through  these  two  opposite  openings,  the  left  thumb 
and  index  are  thrust,  meeting  in  the  center,  and  thus  the  soft  parts  are  picked 


AMPUTATION    THROUGH    LOWER    THIRD    OF    LEG. 


421 


up  and  drawn  from  the  bones,  the  limb  still  being  flexed.  A  long  knife  is 
passed  through  this  opening  and  made  to  cut  its  way  out  on  a  line  with  the 
retracted  skin,  bluntly  beveling  the  flap.  The  anterior  incision  is  now  deepened 
to  the  bones  on  a  line  with  the  retracted  skin.  The  soft  parts  are  then  freed 
back  to  the  saw-line — the  interosseous  membrane  being  divided  transversely, 
and  the  periosteum  having  been  circularly  divided  a  distance  below  the 
saw-line  sufficient  to  furnish  a  covering  of  one  diameter  of  each  bone  at  the 


■ 


Fig.  353.— Amputations  about  the  Lkg  : — A,  Through  lower  third  of  leg,  by  large  posterior 
and  small  anterior  flap  ;  B,  Through  middle  third,  by  long  posterior  and  short  anterior  (Hey's  opera- 
tion); C,  Through  upper  third,  by  bilateral  hooded  flaps  (Stephen  Smith's  operation). 


saw  line.  The  soft  parts  are  retracted  and  the  bones  are  sawed — beveling 
the  prominent  anterior  border  of  the  tibia  as  described  at  page  294.  Ligate 
the  anterior  tibial,  posterior  tibial,  peroneal  arteries,  and  internal  and  ex- 
ternal saphenous  veins.  Suture  the  periosteo-muscular  coverings  over  the 
ends  of  the  bones.  Quilting  of  the  muscles  is  particularly  indicated,  as  the 
heavy  posterior  muscles  are  apt  to  sag  backward.  Dissect  out  the  posterior 
tibial  nerve.     Dress  the  stump  on  a  posterior  splint. 


422 


AMPUTATIONS. 


OSTEOPLASTIC  AMPUTATION  OF  THE   LEG 

BY    LONG    POSTERIOR    AND    SHORT    ANTERIOR    FLAPS. 

Description. — Having  amputated  the  leg  by  a  long  posterior  and  short 
anterior  flap,  a  vertical  section  is  made  from  the  anterior  surface  of  the  tibia, 
forming  an  adherent  bone-flap — which  is  broken  backward,  and  subsequently 
applied  to  the  transversely  divided  portions  of  the  tibia  and  fibula. 

Position. — As  in  amputating  the  leg  in  antero-posterior  flap  methods 
(v.  page  420). 


Fig.  354. — Amputations  about  the  Knee  and  Leg: — A,  Disarticulation  at  the  knee- 
joint  by  an  oblique  incision;  P>,  Osteoplastic  amputation  of  the  leg  by  long  posterior  and  short 
anterior  flap. 

Landmarks. — The  saw-line. 

Incisions. — The  posterior  flap,  having  a  base  equal  to  one-half  the  cir- 
cumference of  the  limb  at  the  line  of  bone-section,  is  made  by  an  incision  begin- 
ning just  below  the  line  of  the  division  of  the  bone  and  passing  down  behind 
the  posterior  border  of  the  tibia  and  fibula,  rounding  out  into  the  posterior 
aspect  of  the  limb  at  a  distance  below  the  saw-level  equivalent  to  about  one 
diameter  of  the  limb  at  the  level  of  the  bone-section.     The  anterior  flap  is 


OSTEOPLASTIC    AMPUTATION    OF    THE    LEG. 


423 


one-third  the  length  of  the  posterior,  beginning  and  ending  in  the  same  lines 
laterally.     (Fig.  354,  B.j 

Operation. — Having  outlined  both  flaps  through  skin  and  fascia,  the  soft 
parts  of  the  posterior  flap  are  divided  to  the  bones,  cutting  obliquely  from  the 
line  of  the  retracted  skin.  This  flap  is  then  retracted,  en  masse,  up  to  the 
saw-line.     The  anterior  flap  is  dealt  with  in  the  same  way — both  flaps  con- 


Fig.  355. — Lines  of  Section  of  Bones  in  the  Osteoplastic  Amputation  of  the  Leg  : — 
Having  completed  the  division  and  retraction  of  the  soft  parts,  the  tibia  and  fibula  are  sawn 
transversely  at  H  and  F; — The  tibia  is  sawn  longitudinally  from  H  to  G,  along  AC  and  BD; — 
The  fibula' is  then  sawn  through  completely  at  E,  and  the  tibia  is  divided  at  CD,  nearly  to  but 
not  through  the  periosteum  toward  G; — The  portion  of  the  tibia  between  the  lines  AHB  and 
CGD  represents  the  osteoplastic  flap. 

sisting  of  all  the  soft  parts  down  to  but  not  including  the  periosteum.  Having 
retracted  the  soft  flaps  well  out  of  the  way,  thus  exposing  the  tibia  and  fibula 
with  their  undisturbed  periosteum,  the  bone-flap  to  be  taken  from  the  tibia 
is  planned.  A  sufficient  length  of  bone-flap  is  calculated  to  cover  the  trans- 
versely divided  ends  of  tibia  and  fibula — the  bone-flap  coming  from  the  antero- 
internal  aspect  of  the  tibia.  The  making  of  this  flap  is  somewhat  complicated 
— but  is  well  shown  in  the  diagrammatic  Figs.  355,  356,  357,  and  358.     Having 


I 


Fig.  356. — Removing  Sections  of  Tibia  and  Fibula  to  enable  the  Tibial  Bone-flap 
to  be  Hinged  over  upon  the  Sawn  Fibula: — A,  A  third  transverse  section  of  both  bones  is 
here  made  for  this  purpose,  at  a  height  above  the  preceding  section  equivalent  to  the  thickness 
of  the  bone-flap. 

completed  the  division  and  retraction  of  the  soft  parts,  the  tibia  and  fibula 
are  sawn  transversely  at  H  and  F,  Fig.  355.  The  tibia  is  sawn  longitudinally 
from  H  to  G,  along  A  C  and  B  D.  The  fibula  is  then  sawn  through  com- 
pletely at  E,  and  the  tibia  is  divided  at  C  D,  nearly  to  but  not  through  the 
periosteum  toward  G.  The  portion  of  the  tibia  between  the  lines  AHB 
and  CGD  represents  the  osteoplastic  flap.      The  periosteal  flap  is  now 


424 


AMPUTATIONS. 


broken  back  through  the  limited  portion  of  bone  still  holding  it — by  means 
of  a  chisel  inserted  in  the  saw-section  and  given  a  slight  tap.  Having  hinged 
back  the  bone-flap,  room  has  now  to  be  provided  for  its  bending  forward  over 
the  transversely  divided  tibia  and  fibula.  This  is  accomplished  by  making 
another  transverse  division  of  both  bones  at  a  height  above  the  preceding  sec- 


9      M 


r* ~vw 


j 


Fig-  357- — -The  Osteoplastic  Amputation  of  the  Leg: — The  bone-flap,  AB,  with  its 
periosteal  hinge,  K,  is  here  shown  ready  to  be  applied  to  the  transversely  divided  ends  of  the 
tibia  and  fibula,  L,  M.  Owing  to  the  removal  of  the  piece  of  tibia  and  fibula  accomplished  by 
the  last  section  (Fig.  356)  this  hinging  is  made  possible. 

tion  equivalent  to  the  thickness  of  the  bone-flap — Fig.  356.  The  completed 
bone-sections  are  shown  in  Fig.  357,  where  the  redundancy  of  periosteum  is 
shown,  furnishing  the  hinge.  The  bone-flap  is  now  dropped  over  the  ends  of 
the  bones  and  is  held  in  place  either  by  suturing  its  periosteum  to  that  of  the 
tibia  and  fibula,  or  by  carrying  an  absorbable  suture  through  a  hole  previously 


Fig.  358. — The  Osteoplastic  Amputation  of  the  Leg  : — The  tibial  flap,  with  its  adherent 
and  continuous  periosteum,  is  here  shown  applied  to  itself  and  fibula — a  suture,  passed  through 
drilled  holes,  holding  the  parts  in  contact. 

drilled  through  both  bones,  as  shown  in  Fig.  358.  Having  united  the  bone- 
flap  to  the  tibia  and  fibula,  the  larger  posterior  flap  of  soft  parts  is  brought 
over  the  bone-flap  and  sutured  to  the  contour  of  the  smaller  anterior  flap — 
the  muscle  structures  in  the  two  flaps  being  supported  by  buried  absorbable 
sutures. 


AMPUTATION  THROUGH  MIDDLE  THIRD  OF  LEG 

BY  LONG  POSTERIOR  AND  SHORT  ANTERIOR  FLAPS  —  BY  HEY'S  OPERATION. 

Description. — The    covering   is   by   skin    and    muscle   flaps,    furnished 
almost  entirely  from  the  posterior  aspect  of  the  leg.     The  method  is  fre- 


AMPUTATION    THROUGH    UPPER    THIRD    OF    LEG.  425 

quently  termed  simply  a  long  posterior  flap  operation — and  differs  but  little 
from  the  preceding  operation. 

Position. — As  in  Guyon's  operation  (page  419) — and  as  given  under 
Incision,  below. 

Landmarks. — Saw-line. 

Incisions. — The  posterior  flap  is  U-shaped — its  breadth  is  equal  to  half 
the  circumference  of  the  limb  at  the  saw-line,  and  its  length  is  equivalent 
to  one  diameter  of  the  limb  at  that  line.  It  begins  2.5  cm.  (1  inch)  below 
the  saw-line  (instead  of  at  that  line).  The  inner  limb  passes  vertically  down 
the  leg  just  behind  the  internal  border  of  the  tibia,  rounding  broadly  into 
the  posterior  aspect  of  the  limb — the  outer  limb  passing  vertically  downward 
just  behind  the  fibula,  posterior  to  the  peronei  muscles,  and  rounding  broadly 
into  the  posterior  aspect  of  the  leg  to  unite  with  the  opposite  limb  of  the 
incision.  The  anterior  flap  is  about  one-third  the  length  of  the  posterior, 
and  is  made  by  joining  the  vertical  limbs  of  the  posterior  flap,  at  their  upper 
thirds,  by  a  transverse  incision,  with  slight  downward  convexity,  across  the 
front  of  the  leg.  In  these  incisions  the  knee  is  flexed  and  the  leg  is  laid  on 
its  outer  side  while  the  inner  incision  is  being  made  from  above  downward, 
and  vice  versa  (Fig.  353,  B). 

Operation. — The  above  incisions  pass  through  the  skin  and  fascia  onlv. 
With  the  leg  flexed  on  the  thigh  and  the  knee  everted,  the  gastrocnemius  is 
held  up  by  thumb  and  first  finger  and  cut  from  without,  on  a  line  with  the 
retracted  skin  and  fascia.  The  upper  parts  of  both  vertical  incisions  are  now 
deepened — the  inner  to  the  tibia,  the  outer  to  the  fibula,  behind  the  peronei 
muscles.  The  left  thumb  and  index  are  inserted  into  these  slits  and  the 
muscles  drawn  outward.  The  muscles  having  been  detached  from  the 
bones  and  interosseous  membrane  above,  a  long  knife  is  passed  between  the 
bones  and  separated  muscles  and  is  made  to  cut  its  way  outward  along  the 
fine  of  the  retracted  skin.  The  interosseous  membrane  is  divided  transversely 
and  the  periosteum  of  the  tibia  and  fibula  circularly — and  all  the  soft  parts 
retracted  upward  for  the  2.5  cm.  (1  inch)  between  the  saw-line  and  the  begin- 
ning of  the  flaps.  The  flaps  are  now  retracted — the  bones  divided,  and  the 
prominent  crest  of  the  tibia  beveled.  The  anterior  tibial,  posterior  tibial, 
and  peroneal  arteries  are  ligated.  The  musculo-periosteal  coverings  are 
sutured  over  the  ends  of  the  bones.  The  muscles  are  quilted  with  special 
care,  owing  to  the  tendency  of  the  posterior  flap  to  sag  backward.  The 
large  posterior  and  short  anterior  flaps  are  then  sutured  together — and  the 
stump  supported  upon  a  posterior  splint. 


AMPUTATION  THROUGH  UPPER  THIRD  OF  LEG 

BY  LARGE  EXTERNAL  FLAP  —  FARABEUF. 

Description. — The  stump  is  covered  by  a  large  U-shaped  flap  of  skin 
and  muscles  raised  from  the  external  aspect  of  the  leg. 

Position. — Patient  supine;  leg  projecting  over  side  of  table,  with  knee 
flexed  and  leg  lying  on  inner  side  for  the  incision  of  the  external  flap,  and 
on  the  outer  side  for  the  transverse  incision.  Surgeon  to  outer  side  of  right 
and  inner  side  of  left  leg. 

Landmarks. — Saw-line. 

Incision. — External  flap — U-shaped,  equivalent  in  length  to  one  diameter 
of  limb  at  saw-line — begins  opposite  the  saw-line  anteriorly — passes  vertically 
downward  parallel  with  and  just  internal  to  the  anterior  border  of  the  tibia 


426 


AMPUTATIONS. 


— rounds  across  the  external  aspect  of  the  leg  and  passes  vertically  upward 
directly  opposite  the  anterior  incision — but  ends  about  4  cm.  (ij  inches) 
below  the  saw-line.  Transverse  incision — passes  transversely  across  the 
inner  aspect  of  the  limb,  with  slight  downward  convexity,  connecting  the 
upper  end  of  the  posterior  incision  with  a  point  on  the  anterior  incision  4  cm. 
(i^  inches)  below  its  beginning.     The  external  flap  may  be  cut,  or  outlined, 


1     c 


Fig- 359.— Amputations  about  the  Leg: — A,  Through  lower  third  of  leg,  by  oblique  circular 
method;  B,  Through  middle  third,  by  modified  circular  method  ;  C,  Through  upper  third,  by  large 
external  flap. 


with  one  sweep  of  the  knife — but  it  is  better  to  complete  it  in  two  strokes 
(Fig.  359,  C). 

Operation. — Beginning  with  the  external  flap,  the  above  incision  is 
deepened  along  the  line  of  the  retracted  skin — and  the  large  flap,  of  all 
the  soft  parts  to  the  bones,  raised.  To  accomplish  this,  the  incision  is  first 
deepened  along  the  anterior  limb  by  cutting  down  upon  the  anterior  border 


AMPUTATION    THROUGH    UPPER    THIRD    OF    LEG.  427 

of  the  tibia,  from  above  downward.  The  tibialis  anticus  is  thus  freed  from 
the  bone.  The  left  fingers  of  the  operator,  slipped  between  muscle  and 
bones,  draw  it  outward,  while  the  short  knife  continues  its  downward  inci- 
sions, beveling  obliquely  the  lower  portion  of  the  muscular  mass  toward  the 
extremitv  of  the  flap.  Thus  the  entire  muscle-mass  is  separated  from  the 
tibia,  interosseous  membrane,  and  fibula,  by  the  use  of  the  knife,  fingers, 
and  elevator.  Care  is  taken  that  the  anterior  tibial  artery  is  not  divided 
before  the  free  end  of  the  flap  is  reached,  the  integrity  of  which  so  largely 
depends  upon  this  vessel.  If  the  parts  are  freed  up  too  high,  especially 
posteriorlv,  where  the  vertical  incision  is  shorter  than  the  anterior,  the  anterior 
tibial  artery  may  be  severed  before  traversing  the  interosseous  membrane. 
The  transverse  incision  crossing  the  inner  aspect  of  the  limb  is  now  deepened 
by  cutting  from  without  inward  on  the  line  of  retracted  skin  and  fascia. 
The  interosseous  membrane  is  divided  transversely.  The  periosteum  is 
circularlv  divided  around  the  tibia  and  fibula.  The  periosteum  and  soft 
parts  are  then  freed  up  to  the  saw-line  and  retracted  while  the  bones  are 
divided — the  prominent  margin  of  the  tibia  being  beveled  from  above  down- 
ward, and  from  before  backward.  The  fibula  is  sawed  a  little  higher  than 
the  tibia,  and  beveled  from  above  downward,  and  from  without  inward. 
The  anterior  tibial,  posterior  tibial,  peroneal,  muscular  branches  to  the 
gastrocnemius  and  soleus,  and  nutrient  arteries  are  ligated.  All  nerve-trunks 
which  are  apt  to  be  pressed  upon  are  dissected  out.  The  muscles  are  quilted. 
The  margins  of  the  external  flap  are  sutured  to  the  inner  transverse  incision 
— and  the  limb  dressed  upon  a  posterior  splint. 

AMPUTATION  THROUGH  UPPER  THIRD  OF  LEG 

PA'  BILATERAL  HOODED  FLAPS  — STEPHEN  SMITH. 

Description. — Two  lateral  flaps  of  skin  and  fascia  are  raised  from  the 
outer  sides  of  the  leg,  by  an  incision  extending  much  higher  behind  than  in 
front— these  are  retracted  about  2.5  cm.  (1  inch)— the  muscles  circularly 
divided  and  retracted  to  the  saw-line  and  the  bones  sawed— forming  a  bilateral 
hood  over  the  ends  of  the  bones,  which  is  sutured  vertically— the  scar  being 
eventually  drawn  up  behind  the  bones. 

Position. — Patient  supine;  leg  over  edge  of  table,  held  horizontal  for 
skin  incisions  and  vertical  when  freeing  back  the  soft  parts.  The  surgeon, 
to  outer  side  of  right  and  inner  side  of  left  limbs,  places  the  right  thumb 
upon  the  crest  of  the  tibia,  to  mark  the  upper  limit  of  the  anterior  incision, 
and  the  index  posteriorly,  to  mark  the  upper  limit  of  the  posterior  incision- 
leaning  over  patient  and  cutting  from  behind  forward  on  both  sides,  the 
incisions  meeting  at  the  highest  point  of  the  anterior  incision. 

Landmarks.— Saw-line,  marking  the  upper  limit  of  the  posterior  incision 
—and  the  point  on  the  crest  of  the  tibia  marking  the  upper  limit  of  the  anterior 
incision,  and  placed  about  three-fourths  of  a  diameter  of  the  limb  at  the 
saw-line  below  the  upper  limit  of  the  posterior  incision  (Fig.  353,  C). 

Incisions. — The  surgeon,  having  grasped  the  limb  in  such  a  manner 
as  to  mark  the  upper  limit  of  the  anterior  incision  by  his  left  thumb  upon  the 
crest  of  the  tibia,  and  of  the  posterior  incision  by  his  left  index  in  the  mid- 
posterior  aspect  of  the  leg  at  the  saw-line— bends  over  the  patient's  leg  (his 
arm  being  above  and  to  the  far  side  of  the  limb)  and  inserts  the  point  of  a 
stout  knife,  held  at  a  right  angle  to  the  skin,  into  the  posterior  tissues  opposite 
the  tip  of  the  index— cuts  thence  downward,  through  skin  and  fascia— 
verticallv  downward,  at  first— and  then  soon  begins  gradually  to  sweep  to 


428 


AMPUTATIONS. 


the  side  of  the  limb  opposite  to  that  on  which  he  is  standing — and  continues 
to  pass  in  this  curvilinear  manner  until  a  little  below  the  level  marked  by  his 
left  thumb — then  curves  transversely  across  the  far  side  of  the  limb  and 
slightly  ascends  to  the  point  marked  by  the  tip  of  the  thumb.  The  knife 
is  now  removed  and  this  incision  is  repeated  upon  the  near  side  of  the  limb, 
the  knife  entering  at  the  highest  point  posteriorly,  sweeping  with  the  same 
curve  (except  that  the  flap  may  be  advantageously  made  a  little  larger  on 
the  inner  side,  to  cover  the  larger  tibia)  to  the  highest  point  anteriorly. 


, 

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Fig.  360. — Bier's  Osteoplastic  Amputation  of  the  Upper  Third  of  the  Leg: — Lines 
for"  the  incision  of  the  soft  parts,  forming  the  antero-internal  cellulocutaneous  flap. 

Operation. — Having  incised  the  skin  and  fascia,  these  flaps  are  raised 
from  their  lower  ends  for  about  2.5  cm.  (1  inch)  and  are  retracted,  when 
the  muscles  are  circularly  divided  to  the  bone — and  are  retracted  from  the 
tibia  and  fibula  up  to  a  level  far  enough  below  the  saw-line  to  furnish  a  perios- 
teal covering.  Here  the  interosseous  membrane  is  divided  transversely — 
and  the  periosteum  circularly  around  the  tibia.  All  the  soft  parts,  including 
periosteum,  are  then  retracted  above  the  saw-line  and  the  bone  divided, 
beveling  the  tibia  and  sawing  the  fibula  shorter  than  the  tibia.  The  short 
piece  of  the  fibula  may  then  be  disarticulated  and  excised.  The  anterior  and 
posterior  tibial,  peroneal,  and  muscular  arteries  are  tied.  The  musculo- 
periosteal  covering  is  sutured  over  the  tibia — the  muscles  quilted— and  the 
flaps  sutured  in  a  vertical  line— the  redundancy  of  soft  parts  being  eventually 
drawn  up  behind  the  stump.  The  hood  of  skin  and  muscle  falls  over  the 
ends  of  the  bones  and  the  stump  is  freely  movable. 


OSTEOPLASTIC  AMPUTATION  THROUGH  UPPER  THIRD  OF  LEG.     429 

OSTEOPLASTIC  AMPUTATION  THROUGH   THE  UPPER  THIRD  OF 

THE   LEG 

BY    ANTERO-INTERNAL    FLAP BIER'S    METHOD. 

Description. — An  osteoplastic  flap  is  taken  from  the  antero-internal 
aspect  of  the  tibia,  in  the  upper  third  of  the  leg,  and  applied  to  the  trans- 
versely divided  tibia  and  fibula. 

Position. — As  for  amputations  through  the  upper  part  of  the  leg  (v. 
page  425  and  427,  in  part). 

Landmarks. — The  saw-line,  which  may  be  at  any  height  of  the  leg,  but 
is  usually  in  the  neighborhood  of  the  junction  of  the  upper  and  middle  thirds. 

Incisions. — An  antero-internal  skin-and-connective-tissue  flap  is  out- 
lined, having  a  base  equal  to  half  the  circumference  of  the  limb  at  the  saw- 
line,  and  whose  length  is  somewhat  greater  than  the  diameter  at  that  line. 
The  upper  limits  of  this  flap  are  connected  by  a  semi-circular  incision  with 
slight  downward  dip  at  its  center  and  passing  posteriorly  (Fig.  360). 

Operation. — Having  carried  these  incisions  through  skin  and  fascia,  the 
large  antero-internal  flap  is  dissected  back  and  turned  upward  upon  the  limb. 
The  periosteum  is  incised  upon  the  subcutaneous  aspect  of  the  tibia — trans- 
versely at  the  lower  limit  of  the  flap,  and  vertically  along  the  borders  of  the 
tibia,  sufficiently  to  plan  for  the  formation  of  the  periosteally  covered  bone-flap. 


Figs.  361  and  362. — Bier's  Osteoplastic  Amputation  of  the  Leg: — A,  Showing  manner 
of  raising  an  osseo- periosteal  flap  from  tibia;  B,  showing  bone-flap  brought  over  sawed  ends  of 
tibia  and  fibula,  and  its  periosteal  margins  sutured  to  the  margins  of  periosteum  around  tibia 
and  fibula.  The  osseo-periosteal  flap  is  here  shown  separated  from  its  soft  parts,  to  which  it 
should  be  adherent.     (Modified  from  Bier.) 


A  bone-flap,  with  periosteum  attached,  is  now  raised  from  this  aspect  of  the 
tibia  by  means  of  a  Gigli-Haertel  saw — calculated  to  cover  the  transversely 
divided  tibia  and  fibula.  The  bone-flap  is  broken  back  at  its  base,  the  perios- 
teum maintaining  a  hinge  connection  with  the  upper  part  of  the  bone  (Fig. 
361,  A).  This  bone-flap  is  turned  upward  and  backward — and  the  limb  is 
amputated  at  the  level  of  the  upper  limit  of  the  limbs  of  the  antero-internal 
flap  by  a  transverse  incision.  The  vessels  are  secured  and  the  nerves  and 
tendons  cut  short.  Enough  of  the  upper  end  of  the  bone-flap  is  removed 
with  a  saw  to  enable  the  intervening  hinge  of  periosteum  to  bend  over  the  end 


430  AMPUTATIONS. 

of  the  bone  without  too  great  stretching.  Having  approximated  the  sawn 
bone-flap  to  the  sawn  ends  of  tibia  and  fibula,  it  is  held  in  place  by  suturing 
the  adjacents  margins  of  periosteum  with  absorbable  sutures,  as  indicated 
in  Fig.  362,  B.  The  skin-flap  is  finally  turned  down  and  sutured  to  the 
transversely  divided  skin  posteriorly. 


SURGICAL  ANATOMY  OF  THE  KNEE-JOINT. 

Bones. — Conchies  of  lemur;  tuberosities  of  tibia;  head  of  fibula;  patella. 

Articulations  and  Ligaments. — (a)  External  Ligaments — anterior,  or 
ligamentum  patellae;  fibrous  expansion  of  extensor  tendons  (central  and  two 
lateral  portions);  posterior,  or  ligamentum  posticum  Winslowii;  internal 
lateral;  anterior  external  lateral;  posterior  external  lateral;  capsular,  (b) 
Internal  Ligaments — anterior,  or  external  crucial;  posterior,  or  internal 
crucial;  internal  semilunar  fibro-cartilage;  external  semilunar  fibro- cartilage; 
transverse;  coronary  ligaments;  and  synovial  membrane  (with  the  prolonga- 
tions, ligamentum  mucosum  and  ligamenta  alaria). 

Muscles. — See  under  Muscles  of  Leg  (page  416)  and  those  of  Thigh 
(page  436)  • 

Arteries. — Following  branches  from  femoral — anastomotica  magna; 
terminal  branch  of  profunda;  descending  branch  of  external  circumflex. 
Popliteal  and  following  branches — superior  and  inferior  muscular;  cutaneous; 
superior  external  articular;  superior  internal  articular;  azygos  articular; 
inferior  external  articular;  inferior  internal  articular.  Following  branches 
from  anterior  tibial — anterior  tibial  recurrent. 

Veins. — Superficial: — internal  saphenous  and  tributaries;  external  saphe- 
nous and  tributaries.  Deep: — popliteal;  two  venae  comites  to  each  artery 
below  the  knee;  one  vena  comes  to  each  artery  above  the  knee. 

Nerves. — (a)  From  nerves  of  lumbar  plexus: — From  external  cutaneous: 
— anterior  branch.  From  anterior  crural: — middle  cutaneous;  anterior  and 
posterior  branches  of  internal  cutaneous  branch;  internal  saphenous;  nervus 
cutaneus  patellae  branch  of  internal  saphenous;  muscular  branches;  articular 
branches,  (b)  From  Sacral  Plexus: — Small  sciatic  branches.  From  great 
sciatic; — internal  popliteal,  and  its  articular,  muscular,  and  communicans 
poplitei  branches;  external  popliteal  (peroneal)  and  its  articular  branches. 

Synovial  Membrane  of  Knee-joint. — Beginning  at  the  upper  border 
of  the  patella  and  following  the  capsule  of  the  joint  upward,  it  forms  a  large 
cul-de-sac  beneath  the  quadriceps  extensor  tendon,  on  the  anterior  aspect 
of  the  thigh,  for  a  distance  of  5  to  6.5  cm.  (2  to  2^  inches)  above  the  articular 
surface  of  the  femur,  which  generally  communicates  with  a  synovial  bursa 
between  the  tendon  and  front  of  the  femur  above  the  level  of  the  attachment 
of  the  capsular  ligament.  Having  invested  the  circumference  of  the  lower 
end  of  the  femur,  it  is  reflected  upon  the  fibrous  covering  of  the  joint  formed 
by  the  capsular,  posterior,  and  lateral  ligaments,  extending  on  each  side 
of  the  patella  beneath  the  aponeurosis  of  the  vastus  internus  and  externus 
(especially  the  former).  Below  the  patella  the  synovial  membrane  is  separated 
from  the  anterior  ligament  by  the  capsular  ligament  and  adipose  tissue. 
From  the  capsule,  the  synovial  membrane  extends  down  to  the  semilunar 
cartilages,  covering  their  upper  surface,  free  border,  and  inner  surface,  and 
forming  a  cul-de-sac  between  the  groove  on  the  back  part  of  the  external 
semilunar  cartilage  and  the  popliteus  muscle,  extending  down  to  the  tibio- 
fibular ligament,  constituting  a  bursa  for  the  play  of  the  popliteus  tendon. 


SURFACE    FORM    AND    LANDMARKS    OF    KNEE-JOINT.  431 

It  is  reflected  from  the  under  surface  of  the  semilunar  cartilages  onto  the 
coronary  ligaments,  thence  to  the  head  of  the  tibia  and  a  short  way  around 
its  circumference.  The  inner  surface  of  the  ligaments  enclosing  the  joint 
is  covered  by  synovial  membrane,  and  the  crucial  ligaments  are  surrounded 
by  it,  except  where  in  contact  with  other  structures  (and  hence  excluded 
from  the  synovial  cavity).  Posteriorly  a  pouch  is  prolonged  between  the 
outer  head  of  the  gastrocnemius  and  the  external  condyle  of  the  femur,  and 
one  between  the  internal  head  of  the  gastrocnemius  and  the  internal  condyle 
of  the  femur.  For  prolongations  of  the  mucous  membrane  as  ligamentum 
mucosum  and  ligamentaria  alaria,  see  under  Ligaments. 

Bursae  About  the  Joint.— (a)  In  Front:— (1)  Between  patella  and  skin, 

(2)  Between  upper  part  of  tuberosity  of  tibia  and  ligamentum  patella\  (3) 
Between  lower  part  of  tuberosity  of  tibia  and  skin,  (b)  On  Outer  Side: — 
(1)  Beneath  outer  head  of  gastrocnemius  (sometimes  communicating  with 
joint).     (2)  i\bove  external  lateral  ligament,  between  it  and  tendon  of  biceps. 

(3)  Beneath  external  lateral  ligament,  between  it  and  tendon  of  popliteus 
(sometimes  only  an  expansion  from  following  bursa).  (4)  Beneath  tendon 
of  popliteus,  between  it  and  condyle  of  femur  (generally  an  extension  from 
synovial  membrane),  (c)  On  Inner  Side: — (1)  Beneath  inner  head  of  gastroc- 
nemius, with  prolongations  between  tendons  of  gastrocnemius  and  semi- 
membranosus (often  communicating  with  joint).  (2)  Above  internal  lateral 
ligament,  between  it  and  tendons  of  sartorius,  gracilis,  and  semitendinosus. 
(3)  Beneath  internal  lateral  ligament,  between  it  and  tendon  of  semimem- 
branosus (sometimes  only  an  expansion  from  following).  (4)  Beneath  the 
tendon  of  semimembranosus,  between  it  and  head  of  tibia.  (5)  Between 
tendons  of  semimembranosus  and  semitendinosus  (sometimes). 

Structures  in  Relation  with  Knee-joint. — (a)  Anteriorly: — quadriceps 
extensor,  (b)  Posteriorly: — expansion  from  tendon  of  semimembranosus; 
popliteal  vessels;  internal  popliteal  nerve;  popliteus;  plantaris;  inner  and 
outer  heads  of  gastrocnemius;  lymphatic  glands,  (c)  Externally: — quadriceps 
extensor;  tendon  of  biceps;  tendon  of  popliteus;  external  popliteal  nerve, 
(d)  Internally: — quadriceps  extensor;  sartorius;  gracilis;  semitendinosus; 
semimembranosus. 

Movements  of  Joint. — Flexion — by  biceps,  semitendinosus,  semi- 
membranosus— assisted  by  gracilis;  sartorius;  gastrocnemius;  popliteus; 
plantaris.  Extension — by  quadriceps  extensor.  Inward  Rotation — by  pop- 
liteus; semitendinosus — assisted  by  semimembranosus;  sartorius;  gracilis. 
Outward  Rotation — by  biceps.  The  cross-section  of  the  knee  is  shown 
in  Fig.  362. 


SURFACE  FORM  AND  LANDMARKS  OF  KNEE-JOINT. 

Bony  landmarks — patella;  condyles  of  femur;  tuberosities  of  tibia;  tubercle 
of  tibia;  head  of  fibula. 

To  find  the  articular  line  of  the  knee-joint — cross  the  leg  on  the  knee, 
when  the  inner  tuberosity  of  the  tibia  will  project  beyond  the  inner  condyle 
of  the  femur  and  make  the  articulation-line  evident.  The  depression  between 
the  outer  tuberosity  of  the  tibia  and  outer  condyle  of  the  femur  may  also 
be  made  out. 

The  upper  margin  of  the  external  tuberosity  of  the  tibia,  when  the  joint 
is  semiflexed,  not  only  represents  the  articular  line — but  also  the  lower  limit 
of  the  synovial  membrane  of  the  knee-joint. 


43  2 


AMPUTATIONS. 


The  knee-joint  lies,  about  2  cm.  (f  inch)  above  the  prominence  of  the 
tubercle  of  the  tibia — and  about  opposite  the  transverse  crease  of  skin  in  the 
popliteal  space. 

When  the  limb  is  extended,  the  joint-line  lies  slightly  above  the  apex  of 
the  patella.  When  the  limb  is  slightly  flexed,  an  instrument  passed  hori- 
zontally backward  just  below  the  apex  of  the  patella  will  enter  the  joint. 

In  full  extension  the  lower  third  of  the  patella  rests  upon  the  condyles 
of  the  femur; — in  full  flexion,  its  upper  third  is  in  contact  with  the  condyles; 
—in  semiflexion,  the  middle  third  of  the  patella  rests  upon  the  greatest  prom- 
inence of  the  femoral  condyles.  The  apex  of  the  patella,  in  extension,  corre- 
sponds with  the  upper  margin  of  the  tibia. 

The  axis  of  the  femur  inclines  inward  from  the  pelvis.  The  axis  of  the 
tibia  is  vertical. 

The  inner  aspect  of  the  inner  condyle  faces,  practically,  in  the  same 
direction  as  the  head  of  the  femur. 

Internally,  the  inner  condyle  of  the  femur  is  more  marked,  and  the  inner 
tuberosity  of  the  tibia  less.  Externally,  the  outer  tuberosity  of  the  femur 
is  less  marked,  and  the  outer  tuberosity  of  the  tibia  more. 

The  adductor  tubercle  of  the  femur  is  to  be  felt  at  the  upper  part  of  the 
inner  condyle — and  marks  the  lower  epiphysis. 

The  upper  border  of  the  tubercle  of  the  tibia  is  on  a  level  with  the  upper 
aspect  of  the  head  of  the  fibula. 

The  head  of  the  fibula  may  be  felt  at  the  outer  and  back  part,  in  the 
depression  between  the  tendon  of  the  biceps  above,  and  the  peroneus  longus 
below. 

The  hollow  of  the  popliteal  space  exists  only  upon  flexion — disappearing 
upon  extension. 

The  synovial  membrane  of  the  knee-joint  separates  the  upper  part  of 
the  ligamentum  patellae  (quadriceps  extensor  tendon)  from  the  knee-joint — 
a  bursa  separates  it  from  the  tubercle  of  the  tibia — and  another  bursa  lies 
between  the  patella  and  the  skin. 

The  synovial  membrane  extends  anteriorly  for  5  to  6.5  cm.  (2  to  2\  inches) 
above  the  joint — and,  internally,  for  about  7.5  cm.  (3  inches)  above  the 
joint  (about  2.5  cm.,  or  1  inch,  above  the  patella). 

Popliteal  structures  detectable  by  palpation — (a)  Outer  side: — ilio-tibial 
band,  tendon  of  biceps,  external  popliteal  nerve  (close  to  preceding),  (b) 
Inner  side: — tendon  of  semitendinosus  (slender),  tendon  of  semimembranosus 
(thicker),  gracilis  (appearing  as  one  tendon  with  preceding,  unless  manipu- 
lated), sartorius  (at  extreme  inner  side,  detectable  by  putting  into  action). 

The  lower  epiphysis  of  the  femur  unites  about  the  twentieth  year,  and 
the  epiphyseal  line  is  intracapsular.  The  upper  epiphysis  of  the  tibia  unites 
about  the  twentieth  year — and  the  epiphyseal  line  is  extracapsular,  and 
includes  the  tuberosities  and  tubercle  of  the  tibia.  The  epiphysis  of  the 
upper  end  of  the  fibula  unites  about  the  twenty-fifth  year. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    DISARTICULATION    AT 

THE  KNEE-JOINT. 

Following  disarticulation  through  the  knee-joint,  a  stump  usually  results 
which  is  capable  of  bearing  direct  pressure  (which,  as  a  rule,  stumps  of  the 
femur  above  the  condyles  cannot  do),  and  which  takes  an  artificial  limb  better 
— the  disarticulation  being  preferable  to  an  amputation  through  the  femoral 
condyles,  or  higher. 


DISARTICULATION    AT    KNEE-JOINT,    IN    GENERAL. 


433 


Instrument-makers  generally  object  to  a  limb  disarticulated  at  the  knee, 
as  the  artificial  knee  then  comes  in  the  upper  part  of  the  leg.  In  spite  of 
this,  however,  and  because  of  the  reasons  above  given,  disarticulation  should 
be  done  in  preference  to  amputation  through  the  thigh. 

It  is  not  necessarv  to  remove  the  remains  of  the  synovial  membrane, 
or  the  articular  cartilages — but  the  knee-joint  should  be  free  of  disease. 

The  semilunar  cartilages  should  not  be  removed — as  they  give  a  square, 
or  flat,  surface  to  rest  upon,  and  help  hold  down  the  synovial  capsule. 

The  patella  should  not  be  removed — as  it  affords  rotundity  and  firmness, 
and  the  attachment  of  the  quadriceps  extensor  tendon  is  thereby  retained. 


Fig-  363.— Cross-section  of  the  Right  Thigh  through  the  Condyles  and  Patella: — 
A,  Biceps;  B,  Popliteal  artery,  vein,  and  internal  popliteal  nerve;  C,  Outer  head  of  the  gastroc- 
nemius; D,  External  popliteal  nerve;  E,  Sartorius;  F,  Inner  head  of  the  gastrocnemius;  G, 
Semimembranosus;  H,  Tendon  of  semitendinosus;  I,  Tendon  of  gracilis.  (The  cross-section 
modified  from  Braune.) 

DISARTICULATION  AT  KNEE-JOINT,  IN  GENERAL. 
Best  Methods.— Bilateral   Hooded   Flaps — Stephen   Smith's   Method. 
Other  Methods. — Elliptical   Method   (Bauden's) — forming  an   anterior 
flap.     Oblique    Circular — forming   an    anterior   flap.     Long   Anterior   Flap. 
Long     Posterior    Flap.     Bilateral     Skin-flaps     (Pick's     operation).     Equal 
Anterior  and   Posterior   Flaps.     Lateral   Flaps.     Long   Anterior  and   Short 
Posterior  Flaps. 
28 


434  AMPUTATIONS. 


DISARTICULATION  AT  KNEE-JOINT 

BY   BILATERAL  HOODED  FLAPS  — STEPHEN  SMITH. 

Description. — The  same,  in  principle,  as  the  amputation  through  the 
upper  part  of  the  leg  by  the  same  method — except,  as  originally  planned, 
the  present  operation  furnishes  a  covering  of  skin  and  fascia  only.  For  its 
modification,  see  Comment. 

Position. — As  in  the  operation  through  the  leg  (page  427) — with  the 
minor  changes  suggested  by  the  higher  elevation. 

Landmarks. — Knee-joint  articulation;  tubercle  of  tibia. 

Incision. — The  highest  point  of  the  posterior  incision  is  opposite  the 
joint-line; — and  the  highest  point  of  the  anterior  incision  is  2.5  cm.  (1  inch) 
below  the  tuberosity  of  the  tibia.  The  surgeon's  left  thumb  marks  the 
anterior,  and  his  index  the  posterior  points,  as  in  the  last  operation.  The 
incision  begins  posteriorly  (the  surgeon  wielding  his  knife  as  in  the  above 
operation)  in  the  mid-popliteal  space,  opposite  the  interarticular  line,  as 
defined  by  the  tip  of  his  left  index — passes  thence  vertically  down  the  mid- 
posterior  aspect  for  a  short  distance  (about  5  cm.,  or  2  inches) — thence 
gradually  diverges  from  the  median  line  as  it  sweeps  downward  and  outward 
over  that  side  of  the  limb  further  from  the  surgeon  (and  over  which  he  is 
leaning)  until  about  5  cm.  (2  inches)  below  the  tubercle  of  the  tibia,  cutting 
a  flap  with  convexity  downward — thence  curves  forward  and  slightly  upward 
to  a  point  in  the  median  line  2.5  cm.  (1  inch)  below  the  tibial  tubercle,  thus 
ending  the  outline  of  the  further  flap.  The  knife  again  enters  posteriorly 
at  the  same  point,  and  makes  a  similar  incision  upon  that  side  of  the  limb 
nearer  the  operator — calculating  that  the  internal  flap  is  slightly  larger,  to 
cover  the  larger  internal  femoral  condyle — and  meeting  the  first  incision  at 
the  median  line  in  front.  The  limb  is  rotated  outward  while  the  inner  incision 
is  being  made — and  vice  versa.  The  knee  is  extended  throughout  (Fig. 
364,  B). 

Operation. — The  skin  and  fascia  are  now  freed  all  around  and  dissected 
up  from  the  muscles  and  tendons.  The  ligamentum  patellae  is  cut  trans- 
versely against  the  tuberosity  of  the  tibia  as  soon  as  reached.  The  skin  and 
fascia  flaps  are  retracted  up  to  the  joint-line.  Incise,  transversely,  the  struc- 
tures along  the  upper  margin  of  the  tibia,  on  the  anterior  and  lateral  aspects 
— ilio-tibial  band,  tendons  of  sartorius,  gracilis,  semitendinosus,  biceps,  the 
lateral  ligaments — and,  lastly,  cut  the  coronary  ligaments,  binding  down  the 
semilunar  cartilages,  attacking  them  upon  the  sides  of  the  joint — entering 
the  joint  between  the  head  of  the  tibia  and  the  semilunar  cartilages,  thus 
leaving  these  cartilages  in  the  stump,  and  completing  their  separation  by 
flexing  the  knee.  Flex  the  knee  and  cut  the  crucial  ligaments.  Extend 
the  knee  and  divide  transversely,  with  one  sweep  of  a  long  knife,  all  the  soft 
parts  opposite  the  posterior  aspect  of  the  joint — the  gastrocnemius,  popliteus, 
hamstring  tendons,  popliteal  vessels  and  nerves,  and  posterior  ligament. 
Ligate  the  popliteal  artery  and  vein,  sural,  superior  articular,  and  anastomotica 
magna  branches.  Suture  the  lateral  flaps  in  a  vertical  line — the  scar  being 
eventually  drawn  into  the  intercondyloid  notch.  Drain  temporarily  through 
the  upper  end  of  the  posterior  incision. 

Comment. — The  original  technic  may  be  advantageously  modified  by 
dissecting  up  the  lower  ends  of  the  flaps  for  about  2.5  cm.  (1  inch) — then 
dividing  all  the  soft  parts  circularly  and  retracting  these  to  the  joint-line, 


DISARTICULATION    AT    KNEE-JOINT. 


435 


including  their  fibrous  attachments  as  far  as  possible — and  then  disarticulate. 
A  much  more  substantial  covering  is  thus  gotten  for  the  femoral  condyles. 
Wherever  it  is  possible  to  quilt  muscle  tissue  into  apposition,  this  should 
be  done. 


Fig.  364.— Amputations  apout  the  Leg  and  Thigh  : — A.  Through  upper  third  of  leg,  by  equal 
lateral  flaps;  B,  Disarticulation  at  knee,  by  bilateral  hooded  flaps  (Stephen  Smith's  operation  1;  C, 
Through  lower  part  of  thigh,  by  oval  method. 


DISARTICULATION  AT  THE  KNEE-JOINT   BY  AN  OBLIQUE  CURVED 

INCISION. 

Description. — An  anterior  covering  of  soft  parts,  including  the  patella, 
is  here  furnished. 

Position.— As  in  the  disarticulation  of  Stephen  Smith,  page  434. 

Landmarks. — Knee-joint  line;  tibial  tubercle. 

Incision. — Begins  posteriorly  opposite  the  level  of  the  joint  and  ends 
anteriorly  about  8  cm.  (3  inches)  below  the  tubercle  of  the  tibia — the  line 
curving  between  these  two  elevations.  If  the  limb  be  held  in  such  a  way  as 
to  cause  the  leg  to  make  an  angle  of  135 °  with  the  thigh,  the  continuation  of 
the  posterior  aspect  of  the  long  axis  of  the  thigh  will  represent  the  line  of  the 
incision. 


436  AMPUTATIONS. 

Operation. — Divide  skin  and  fascia  along  the  above  line  and  dissect 
these  soft  parts  up  to  the  level  of  the  joint  anteriorly.  Incise  the  capsular 
ligament,  after  having  divided  the  ligamentum  patellae.  Cut  through  the 
lateral  ligaments  and  semilunar  cartilages,  leaving  the  latter  upon  the  stump. 
Divide  the  crucial  ligaments  at  their  attachment  to  the  spine  of  the  tibia. 
Divide  the  soft  parts  posteriorly  and  the  posterior  part  of  the  capsule  along 
the  upper  border  of  the  tibia,  including  the  vessels,  thus  completing  the 
disarticulation.  The  popliteal  artery  and  vein  and  articular  and  muscular 
branches  are  here  ligated — and  the  nerves  drawn  down  and  cut  short.  Tem- 
porary drainage  of  the  portion  of  the  joint  and  bursal  surfaces  left  upon  the 
thigh  is  necessary. 


SURGICAL  ANATOMY  OF  THIGH. 

Bones. — Femur. 

Muscles  of  Thigh  and  Hip-joint. — (a)  Muscles  of  Iliac  Region: — 
psoas  magnus;  psoas  parvus;  iliacus.  (b)  Of  Anterior  Femoral  Region: — 
tensor  vaginae  femoris;  sartorius;  rectus  femoris;  vastus  externus;  vastus 
internus  and  crureus;  subcrureus.  (c)  Of  Internal  Femoral  Region: — 
gracilis;  pectineus;  adductor  longus;  adductor  brevis;  adductor  magnus.  (d) 
Of  Gluteal  Region: — gluteus  maximus;  gluteus  medius;  gluteus  minimus; 
pyriformis;  obturator  internus;  gemellus  superior;  gemellus  inferior;  quadratus 
femoris;  obturator  externus.  (e)  Of  Posterior  Femoral  Region: — biceps; 
semitendinosus ;  semimembranosus. 

Arteries  of  Thigh. — Femoral  and  following  branches: — superficial  epi- 
gastric; superficial  circumflex  iliac;  superficial  external  pudic;  deep  external 
pudic;  profunda  (with  external  circumflex,  internal  circumflex,  and  three 
perforating  branches);  muscular;  anastomotica  magna.  And  also  arteries 
given  under  the  supply  to  the  hip-joint  (page  450). 

Veins  of  the  Thigh. — Superficial — internal  saphenous  and  tributaries 
(especially  external  and  internal  femoral  cutaneous).  Deep — one  vena  comes 
to  each  artery  on  anterior,  internal,  and  external  aspects;  two  venae  comites 
to  each  artery  on  posterior  aspect  and  gluteal  region. 

Nerves  of  Thigh. — (a)  From  Dorsal  Nerves: — lateral  cutaneous  branch 
of  last  dorsal,  (b)  From  Posterior  Divisions  of  Lumbar  Nerves: — cutaneous 
nerves  from  external  branches  of  three  upper  posterior  divisions,  (c)  From 
Lumbar  Plexus: — ilio-hypogastric ;  ilio-inguinal;  genito-crural;  external  cu- 
taneous; anterior  crural;  obturator;  accessory  obturator.  (d)  From  Sacral 
Plexus: — muscular;  superior  gluteal;  inferior  gluteal;  perforating  cutaneous; 
pudic;  small  sciatic;  great  sciatic  (with  internal  and  external  popliteal 
branches).     The  cross-sections  of  the  thigh  are  shown  in  Figs.  365,  50,  371, 

373,  47- 

SURFACE  FORM  AND  LANDMARKS  OF  THIGH. 

The  only  portions  of  the  femur  which  can  be  felt  are  the  outer  surface 
of  the  great  trochanter;  internal  and  external  condyles,  with  the  tuberosities 
upon  each;  and  the  adductor  tubercle  at  the  upper  part  of  the  inner  condyle. 

The  rami  of  the  pubes  and  ischia,  from  the  pubic  spines  to  the  ischial 
tuberosities,  mark  the  boundary  between  the  thigh  and  perineum. 

The  head  of  the  femur  lies  close  below  Poupart's  ligament,  just  to  the 
outer  side  of  its  center. 


SURFACE    FORM    AXD    LANDMARKS    OF    THIGH.  437 

The.femur  is  nearest  the  external  aspect  of  the  thigh  in  its  upper  third— 
about  the  center  in  the  middle  third — and  nearest  the  anterior,  or  antero- 
external,  aspect  in  the  lower  third. 

The  shaft  of  the  femur  is  nearest  the  surface  and  is  most  easily  reached 
in  its  lowest  third,  in  the  interval  between  the  vastus  externus  and  biceps. 

The  articular  surface  extends  higher  on  the  anterior  aspect  of  the  external 
than  on  the  internal  condyle  of  the  femur. 

A  transverse  section  of  the  femur  at  the  level  of  the  adductor  tubercle 
touches  the  upper  limit  of  the  articular  cartilage  and  corresponds  with  the 
epiphyseal  line. 

The  medullary  canal  is  only  present  distinctly  in  the  middle  two-fourths 
of  the  shaft  of  the  femur. 

The  thigh  is  separated  from  the  abdomen  by  the  inguinal  furrow,  the 
bottom  of  which  furrow  is  formed  by  Poupart's  ligament,  at  the  meeting 
of  the  aponeurosis  of  the  external  oblique  and  fascia  lata. 

The  skin  is  coarse  and  thick  on  the  external  aspect  of  the  thigh — fine  and 
thin  on  the  inner  aspect — and  loosely  adherent  throughout,  though  more 
adherent  at  the  intermuscular  septa. 

Dense  fascia  underlies  the  skin  throughout. 

The  outline  of  a  transverse  section  of  the  thigh  is  irregular  in  the  muscular 
— and  more  or  less  rounded  in  the  stout,  non-muscular,  and  in  children. 

Most  of  the  muscles  of  the  femoral  region  are  attached  to  the  femur — 
but  the  semitendinosus,  semimembranosus,  sartorius,  and  gracilis  are  entirely 
free,  and  the  biceps  nearly  so — therefore  very  unequal  retraction  follows  their 
section,  especially  on  the  posterior  and  internal  aspects. 

The  rectus  femoris  forms  a  prominence  below  the  anterior  superior  iliac 
spine,  in  the  angle  of  divergence  between  the  sartorius  and  the  tensor  vaginae 
femoris — and  largely  forms  the  convex  front  of  the  thigh  as  it  descends  down- 
ward.    A  furrow  on  either  side  separates  it  from  the  vasti. 

The  vastus  externus  forms  a  flattened  plane  on  the  outer  aspect  of  the 
thigh,  traversed  by  a  vertical  groove  formed  by  the  ilio-tibial  band. 

The  vastus  internus  forms  an  eminence  on  the  inner  side  of  the  lower 
half  of  the  thigh. 

When  the  sartorius  is  relaxed,  a  depression  exists  between  the  extensor 
quadriceps  and  the  adductor  muscles,  running  downward  and  inward,  from 
the  apex  of  Scarpa's  triangle  to  the  inner  side  of  the  knee — which  corresponds 
with  this  muscle. 

The  adductor  muscles,  together  with  the  gracilis,  form  the  fullness  of  the 
inner  aspect  of  the  upper  part  of  the  thigh  and  are  not  to  be  separately  identi- 
fied—except the  upper  tendon  of  the  adductor  longus  (near  the  pubic  spine), 
and  the  lower  tendon  of  the  adductor  magnus  (near  the  adductor  tubercle, 
between  the  vastus  internus  and  sartorius). 

The  muscles  on  the  inner  aspect  of  the  thigh  are  not  distinctlv  marked 
off  from  those  on  the  posterior  femoral  aspect.  But  the  muscles  on  the 
antero-external  aspect  are  more  distinctly  marked  off  from  the  posterior 
femoral  muscles  by  the  external  intermuscular  septum. 

The  tensor  vaginae  femoris  extends  downward  and  slightly  backward 
from  the  upper  part  of  the  outer  side  of  the  thigh — and  is  continued  down 
the  thigh  as  the  ilio-tibial  band — which  forms  a  furrow  to  the  outer  side 
of  the  knee. 

The  hamstring  muscles  descend  from  beneath  the  fold  of  the  buttock, 
diverging  as  thev  pass  downward  to  form  the  boundaries  of  the  popliteal 
space — the  biceps  forming  the  outer  hamstring — and   the   semitendinosus, 


438  AMPUTATIONS. 

semimembranosus,  and  gracilis  (in  order,  from  within  outward)  forming  the 
inner  hamstring. 

For  the  landmarks  of  Scarpa's  triangle  and  the  femoral  artery,  see  pages 
92  and  93,  respectively. 

The  head  of  the  femur  joins  the  shaft  at  the  eighteenth  year; — the  great 
trochanter,  the  same; — the  lesser  trochanter,  at  the  thirteenth  or  fourteenth 
year; — and  the  lower  extremity  joins  the  shaft  at  the  twentieth  year. 

The  growth,  in  length,  of  the  lower  extremity  is  chiefly  from  the  lower 
epiphysis  of  the  femur  and  the  upper  epiphysis  of  the  tibia  and  fibula. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    AMPUTATIONS    ABOUT 

THE  THIGH. 

The  thigh  is  usually  amputated  at  or  below  its  middle. 

In  the  young,  the  preservation  of  whose  epiphysis  is  important,  division 
of  the  bone  should  be  below  the  lower  epiphyseal  line  (transcondyloid)  if 
possible — and  the  covering  gotten  by  a  circular  method  of  amputation. 

Any  length  of  stump  left  is  better  than  a  hip  joint  disarticulation — for 
the  function  of  the  thigh-stump  is  partly  to  bear  weight,  but  also  to  form  a 
lever  to  move  an  artificial  limb — and  the  longer  the  lever,  the  better. 

In  amputating  through  the  thigh,  the  chief  weight  of  the  body,  as  sup- 
ported by  an  artificial  limb,  is  borne  against  the  tuberosity  of  the  ischium — and 
the  chief  pressure  of  the  artificial  apparatus  is  against  the  sides  of  the  limb  by 
the  sides  of  the  hollow  cone  of  the  apparatus.  A  terminal  scar  is,  therefore, 
not  contraindicated  where  a  hollow  form  of  artificial  limb  is  intended. 

Subtrochanteric  amputation  is  preferable  to  disarticulation  at  the  hip. 
If  it  be  found  necessary  in  the  course  of  such  an  operation,  the  amputation 
could  be  converted  into  a  disarticulation. 

In  amputating  through  the  condyles  (transcondyloid),  the  section  is  made 
through  the  condyles  on  a  level  with  the  adductor  tubercle  of  the  femur. 

In  amputating  just  above  the  condyles  (supracondyloid),  the  section  is 
made  from  1.3  to  2  cm.  (h  to  f  inch)  above  the  condyles. 

Thigh  amputations  through  the  condyles  can  generally  bear  the  pressure 
of  the  body — while  one  through  the  shaft  usually  cannot. 

The  patella  is  removed  in  amputating  through  the  condyles. 

The  general  type  of  amputation  through  the  thigh  is  by  a  longer  anterior 
and  shorter  posterior  flap — at  any  level,  but  especially  throughout  the  upper 
two-thirds. 

Greater  retraction  occurs  upon  the  posterior  and  inner  aspects  of  the 
thigh,  where  additional  allowances  should  be  made.  The  lower  the  ampu- 
tation through  the  thigh,  the  greater  will  be  the  retraction. 

In  planning  a  method  which  will  give  a  terminal  scar,  dissect  out  any 
nerves  which  might  be  pressed  over  the  end  of  the  bone. 

In  antero-posterior  flaps  cut  above  the  center  of  the  thigh,  the  femoral 
and  profunda  arteries  will  be  cut  in  the  anterior  flap; — in  similar  flaps  below 
the  center  of  the  thigh,  the  femoral  artery  will  be  cut  in  the  posterior  flap 
and  is  in  danger  of  being  split; — and  in  amputations  through  the  middle  of 
the  thigh,  the  antero-posterior  flaps  should  be  shifted  so  as  to  become  antero- 
external  and  postero-internal,  in  order  to  avoid  the  risk  of  splitting  the  main 
artery. 

In  longer  anterior  and  shorter  posterior  flaps,  as  compared  with  equal 
anterior  and  posterior  flaps,  the  longer  anterior  flap  drops  over  the  end  of 


SURGICAL    CONSIDERATION'S    IN    AMPUTATIONS    ABOUT    THIGH.       439 

the  bone,  and  the  shorter  posterior  flap  is  not  heavy  enough  to  sag  backward — 
as  is  apt  to  be  the  case  in  equal  flaps  (and  especially  in  predominating  posterior 
flaps) . 

Flaps  are  much  more  accurately  fashioned  if  cut  from  without — and  the 
anterior  one  always  should  be.  If  the  posterior  one  must  be  cut  by  trans- 
fixion, first  outline  it  through  skin  and  fascia  with  a  small  knife,  and  then, 
transfixing,  cut  outward  on  a  line  with  the  retracted  skin  and  fascia. 

Where  speed  is  requisite  (as  in  the  very  old,  or  in  emergencv),  the  quickest 
methods  of  amputating  through  the  thigh,  are,  by  the  circular  method  through 


Fig-  365- — Transverse  Section  through  the  Lower  Third  of  the  Right  Thigh: — 
A,  Y;istus  externus;  B,  D,  Biceps;  C,  Great  sciatic  nerve  and  vessels;  E,  Semitendinosus;  F, 
Rectus;  G,  I,  Vastus  internus;  H,  Crureus;  J,  Femoral  vessels  and  long  saphenous  nerve;  K, 
Sartorius;  L,  Adductor  magnus;  M,  Semimembranosus;  N,  Gracilis.  (The  cross-section  modi- 
fied from  Braune  ) 

the  lower  third;  and  antero-posterior  flap  cut  by  transfixion  through  the 
upper  two-thirds. 

Owing  to  the  extent  and  inequality  of  retraction  of  muscles  in  amputating 
through  all  parts  of  the  thigh,  a  conical  stump  is  not  uncommon. 

Hemorrhage  is  controlled,  in  operating  through  the  middle  and  lower 


440  AMPUTATIONS. 

thirds,  by  a  rubber  tourniquet  ordinarily  applied,  just  below  the  hip-joint. 
In  amputating  higher,  the  tourniquet  should  be  applied  as  high  as  possible 
in  the  form  of  a  spica,  passing  around  the  groin  and  pelvis.  In  both  cases, 
especially  the  latter,  the  tubing  should  be  held  in  place  by  a  loop  of  bandage 
previously  laid  under  the  tubing  or  tourniquet,  anteriorly  and  posteriorly, 
to  be  subsequently  drawn  upward. 

The  femur  is  to  be  carefully  sawed  at  a  right  angle  to  its  length — sawing 
carefully  near  the  linea'  asperse,  to  avoid  splintering. 

The  stump  should  be  dressed  with  a  posterior  splint  included  and  placed 
upon  an  inclined  plane,  to  relax  the  quadriceps  extensor  pull. 


AMPUTATIONS  THROUGH  THE  THIGH,  IN  GENERAL. 

Best  Methods. — Shorter  Anterior  and  Longer  Posterior  Flaps  (Lister's 
Modification  of  Carden's  operation) — for  transcondyloid  region.  Longer 
Anterior  and  Shorter  Posterior  Flaps  (Gritti-Stokes's  Method) — for  supra- 
condvloid  osteoplastic  operation.  Long  Anterior  and  Short  Posterior  Flaps 
— for  thigh  throughout.  Equal  Anterior  and  Posterior  Flaps — for  thigh 
throughout,  where  the  tissue  is  limited.  Oblique  Circular,  or  Elliptical, 
Method — for  lower  third.  External  Oval  Method — for  subtrochanteric 
region. 

Other  Methods. — Long  x\nterior  Flap — Carden's  transcondyloid  opera- 
tion. Long  Anterior  and  Short  Posterior  Flaps — Farabeuf's  Modification 
of  Carden's  transcondyloid  operation.  Osteoplastic  Transcondyloid  Method 
of  Sabanajeff.  Long  Anterior  Rectangular  Flap — Gritti's  osteoplastic  supra- 
condyloid  operation.  Circular.  Modified  Circular.  Long  Anterior  Flap. 
Oval  Method — throughout.  Bilateral  Hooded  Flaps  of  Stephen  Smith — for 
lower  half.     Rectangular  Flaps  of  Teale — for  lower  half. 


AMPUTATION  THROUGH  CONDYLES  OF  FEMUR— TRANSCONDYLOID 

AMPUTATION 

BY  SHORTER  ANTERIOR  AND  LONGER  POSTERIOR  FLAPS  — LISTER'S  MODIFICATION 
OF  CARDEN'S  TRANSCONDYLOID  OPERATION. 

Description. — Carden's  operation  consists  in  a  division  of  the  femur  on 
a  level  with  the  adductor  tubercle,  together  with  the  removal  of  the  patella 
— the  covering  being  gotten  from  a  single  anterior  flap.  Lister's  modification 
consists  in  adding  a  posterior  flap  to  the  anterior  flap,  and  then  freeing  the 
soft  parts  considerably  above  the  base  of  the  flaps. 

Position. — Patient  on  back;  drawn  down  on  table  so  that  buttocks  are 
near,  or  are  on,  the  edge  of  the  table.  Surgeon  on  outer  side  of  right  and 
inner  side  of  left  limbs.  One  assistant  steadies  and  supports  the  part  below 
the  site  of  operation— and  another  holds  the  limb,  or  retracts  the  parts,  above 
the  site  of  amputation. 

Landmarks. — Adductor  magnus  tubercle;  knee-joint;  tubercle  of  tibia. 

Incisions. — Anterior  incision — crosses  the  front  of  the  knee  with  slight 
downward  convexity — beginning  on  the  horizontal  line  of  the  knee-joint  and 
in  a  vertical  line  with  the  prominences  of  the  tuberosities  of  the  femoral 
condyles,  and  crossing  the  ligamentum  patellae  just  above  its  center.  The 
left  thumb  and  index  mark  the  two  ends  of  this  incision,  and  the  knee  is 
slightly  flexed  and  rotated  from  side  to  side  during  its  making.     Posterior 


AMPUTATION    ABOVE    CONDYLES    OF    FEMUR.  441 

incision— joins  the  posterior  extremities  of  the  anterior  incision  at  an  angle 
of  45  degrees  to  the  axis  of  the  leg  (Fig.  366,  A,  A'). 

Operation.— These  incisions  pass  through  skin  and  fascia,  and  the  flaps 
outlined  by  them  are  then  dissected  upward  as  in  a  circular  amputation.  The 
dissection  is  carried  on  close  to  muscles,  tendons,  and  patella.  The  hamstring 
muscles  are  cut  as  soon  as  encountered,  dividing  them  transversely.  The 
quadriceps  extensor  tendon  is  similarly  cut  transversely  as  soon  as  the  upper 
border  of  the  patella  is  reached.  The  soft  parts,  including  as  much  of  a 
capsulo-periosteal  covering  as  possible,  are  then  retracted  to  the  level  of  the 
adductor  tubercle.  The  condyles  of  the  femur  are  then  sawed  through  at 
that  level,  transversely  to  the  axis  of  the  limb  (not  of  the  bone).  Ligate  the 
popliteal,  or  its  anterior  and  posterior  tibial  divisions,  and  muscular,  articular, 
and  anastomotica  magna  branches.  Suture  the  capsulo-periosteal  covering 
over  the  end  of  the  bone.  Suture  the  anterior  and  posterior  flap  margins 
together.  Dress  the  stump  upon  a  posterior  splint  and  place  upon  an  inclined 
plane. 

Comment. — (i)  The  scar  is  drawn  posteriorly,  out  of  the  way  of  pressure. 
(2)  The  patella  may  be  raised  in  the  anterior  flap  and  subsequently  dissected 
out,  especially  if  the  parts  be  thick  and  unyielding. 


AMPUTATION  JUST  ABOVE  CONDYLES  OF  FEMUR,  WITH  SPLITTING 

OF  PATELLA, 

BY  LONGER  ANTERIOR  AND  SHORTER  POSTERIOR  FLAPS  — GRITTI-STOKES'S  SUPRA- 
CONDVLOID  OSTEOPLASTIC  AMPUTATION. 

Description. — Gritti's  operation  consists  in  the  division  of  the  femoral 
condyles  at  the  level  of  the  adductor  magnus  tubercles;  the  removal  of  the 
articular  surface  from  the  patella;  the  application  of  the  sawed  patella  into 
contact  with  the  sawed  femur;  and  the  covering  of  the  stump  with  a  long 
rectangular  anterior  flap.  Stokes's  modification  consists  in  dividing  the 
femur  2  to  2.5  cm.  (f  to  1  inch)  above  the  adductor  tubercle  (where  the  trans- 
verse section  of  the  femur  more  nearly  corresponds  with  the  size  of  the  split 
patella) — the  stump  being  then  covered  by  an  anterior  longer  and  posterior 
shorter  flap.  The  object  being,  in  the  latter  case,  to  approximate  bone- 
sections  of  nearer  similar  size,  and  to  bring  them  into  contact  with  less  tension. 

Position — Landmarks. — As  in  the  above  operation. 

Incisions. — Anterior  longer  flap — begins  2.5  cm.  (1  inch)  directly  above 
the  prominence  of  one  condyle  and  ends  the  same  distance  directly  above  the 
prominence  of  the  opposite  condyle — crossing  the  front  of  the  knee,  with 
broad  curve,  just  below  the  tubercle  of  the  tibia.  Posterior  shorter  flap — 
passes,  in  a  broad  curve,  between  the  points  of  beginning  and  ending  of  the 
anterior  flap — being  one-third  the  length  of  the  anterior  flap  (Fig.  366,  B, 
B',  B"). 

Operation. — These  flaps,  having  been  outlined  through  skin  and  fascia, 
are  now  dissected  upward.  The  skin  and  fascia  of  the  anterior  flap  is  raised 
from  its  lower  edge  until  the  ligamentum  patelke  is  reached — which  is  cut 
transversely — and  the  flap  further  freed  and  turned  up  with  the  patella  in  it. 
The  posterior  flap  of  skin  and  fascia  is  then  freed  upward  from  the  muscle 
structures.  These  flaps  are  now  retracted  to  the  saw-line  (2  to  2.5  cm.,  or 
f  to  1  inch,  above  the  adductor  magnus  tubercle)  and  all  the  soft  parts,  in- 


44: 


AMPUTATIONS. 


eluding  periosteum,  are  circularly  divided  to  the  bone,  after  which  the  bone 
is  sawed.  The  main  vessels  may  be  now  tied  before  the  section  of  the  patella, 
which  is  the  most  difficult  part  of  the  operation,  is  done.     These  vessels  are 


Fig. 366.— Amputations  about  Knee  and  Thigh  : — A,  Lister's  modification  of  Garden's  trans- 
condyloid  amputation  of  thigh;  A'.  Division  ol  femur  in  Lister's  operation,  on  level  with  adductor 
tubercle;  B,  Gritti-Stokcs's  supracondyloid  amputation  of  thigh  ;  with  dotted  lines,  B'  and  B",  show- 
ing division  of  femur  above  level  of  adductor  tubercle,  and  splitting  of  patella;  C,  Through  lower 
part  of  thigh,  by  long  anterior  and  short  posterior  flaps. 


the  popliteal,  muscular,  articular,  anastomotic^  magna.  The  patella  is 
grasped  firmly  by  lion-jaw  forceps,  and  held  in  such  a  way  as  to  present  its 
articular  surface  horizontally.  A  section  of  the  bone  is  made  in  such  a 
manner  as  to  remove  the  articular  surface  of  the  patella.  This  is  best  accom- 
plished with  a  narrow,  thin  saw.  It  may  also  be  done  with  a  broad  chisel, 
and,  less  satisfactorily,  with  cutting  pliers.  The  cut  surface  of  the  patella 
is  then  approximated  to  the  sawed  end  of  the  femur.  It  may  be  held  in 
place  by  inserting  two  or  three  ivory  or  steel  pegs  through  previously  drilled 
holes  in  the  patella — or  by  wire  or  chromic  gut  suturing  through  drill-holes 
near  the  margins  of  patella  and  femur — or  by  closely  suturing  fibrous  parts 
about  the  patella  to  the  fibrous  or  periosteal  parts  about  the  lower  end  of  the 
femur.     The  anterior  and  posterior  flaps  are  then  sutured  together.     Firm 


FEMOROTIBIAL    OSTEOPLASTIC    AMPUTATION    OF    LOWER    LIMB.     443 

pressure  is  used  against  the  stump,  in  the  dressing,  to  aid  in  steadying  the 
patella  against  the  femur. 

Comment. — The  scar  is  drawn  up  posteriorly  out  of  the  way  of  pressure. 
This  operation  is  comparable  with  Pirogoff's  osteoplastic  amputation  of 
the  leg. 

FEMOROTIBIAL   OSTEOPLASTIC  AMPUTATION  OF  THE  LOWER  LIMB 

BY    LONGER    ANTERIOR    AND    SHORTER    POSTERIOR   FLAPS. 
SSABANAJEFF'S   OPERATION. 

Description. — The  limb  is  amputated  through  the  condyles  of  the  femur- 
To  this  sawn  surface  a  bone-flap,  with  adherent  soft  parts,  is  applied.  The 
osteoplastic  flap  is  derived  from  the  upper  anterior  aspect  of  the  tibia. 

Position. — As  for  disarticulation  at  the  knee-joint  (p.  434,  in  part). 

Landmarks. — Head  of  fibula;  internal  lateral  ligament;  tubercle  of  tibia; 
tibio-fibular  articulation;  knee-joint. 


Fig.  367. — Ssabanajeff's  Femorotibial 
Osteoplastic  Amputation  of  the  Lower 
Limb: — Lines  of  incision  of  the  soft  parts 
outlining  long  anterior  and  short  posterior 
flaps. 


Fig.  368. — Ssabanajeff's  Femorotibial 
Osteoplastic  Amputation  of  the  Lower 
Limb: — Lines  of  bone-sections; — A,  Portion  of 
femoral  condyles  removed;  B,  Rectangular 
piece  of  tibia,  with  attached  patellar  tendon, 
removed  from  tibia.  (Modified  from  Ssaban- 
ajeff.) 


Incisions. — Anterior  flap, — the  vertical  limbs  pass  down  the  mid-lateral 
aspects  of  the  leg,  from  the  head  of  the  fibula  on  one  side,  and  the  internal 
lateral  ligament  on  the  other,  to  near  the  junction  of  the  middle  and  upper 
thirds  of  the  limb,  where  they  round  out  and  meet  in  the  anterior  aspect  of  the 
part.     Posterior  flap  is  similar  in  form  and  about  half  the  length  of  the  anterior 

(Fig-  367)-  ,  .  ,   ,      . 

Operation. — Having  outlined  both   flaps  through   skin  and  fascia,   the 

posterior  flap  of  skin  and  fascia  alone  is  dissected  up  to  the  articulations 


444  AMPUTATIONS. 

between  tibia  and  fibula  and  between  tibia  and  femur.  The  knee-joint  and 
the  tibiofibular  joint  are  now  opened  from  behind.  Divide  the  lateral, 
posterior,  and  crucial  ligaments,  after  having  severed  the  overlying  soft  struc- 
tures. The  leg  is  now  bent  forward,  so  that  the  anterior  surface  of  leg  and 
thigh  lie  in  contact — thus  exposing  the  ends  of  the  bones  for  sawing.  The 
lower  end  of  the  femur  is  divided  transversely  through  the  expansion  of  the 
condyles  (Fig.  368,  A).  Finally,  a  bone-flap  is  made  from  the  upper  and 
anterior  aspect  of  the  tibia  as  indicated  in  Fig.  368,  B,  with  the  attachment 


Fig.  369. — Ssabanajeff's  Femorotibial  Osteoplastic  Amputation  or  the  Lower 
Limb: — The  rectangular  portion  of  the  excised  tibia,  with  its  attached  tendon,  is  here  shown 
held  in  contact  with  the  sawn  femoral  condyles  by  a  kangaroo  tendon  or  wire  suture,  passed 
through  the  drilled  bone.     (Modified  from  Ssabanajeff.) 

of  the  ligamentum  patellae  preserved,  the  saw  travelling  first  down  the  long 
axis  of  the  tibia  to  below  the  attachment  of  the  patellar  ligament,  thence 
transversely  outward  to  its  anterior  surface.  The  sawn  surface  of  the  tibial 
bone-flap  is  then  applied  to  the  transversely  sawn  femoral  condyles,  the  patellar 
ligament  hinging  around  the  anterior  aspect  of  the  bone  sections.  The 
femoral  condyles  and  the  tibial  bone-flaps  may  be  drilled  and  sutured  with 
kangaroo  tendon,  as  indicated  in  Fig.  369,  or  the  bony  surfaces  may  be  held 
in  contact  simply  by  the  peripheral  suturing  of  the  soft  parts.  The  longer 
anterior  flap  is  now  carried  backward  and  sutured  to  the  posterior  flap,  by 
deep  and  superficial  sutures. 


AMPUTATION  THROUGH  LOWER  THIRD  OF  THIGH 

BY  OBLIQUE  CIRCULAR  METHOD. 

Description. — Owing  to  greater  retraction  upon  the  posterior  and  inner 
aspects  of  the  thigh,  and  in  order,  therefore,  that  the  incision  may  eventually 
occupy  the  same  height  around  the  entire  circumference  of  the  limb,  the 
circular  incision  is  placed  obliquely — so  that  it  is  lowest  where  the  muscular 
retraction  is  greatest,  namely,  at  the  postero-internal  aspect  of  the  thigh. 

Position. — As  in  the  transcondyloid  operation. 

Landmarks. — Saw-line. 

Incision. — The  highest  part  of  the  circular  incision  is  antero-external 
and  is  a  little  more  than  half  the  diameter  of  the  limb  (at  the  saw-line)  below 
the  bone-section.  The  lowest  part  of  the  circular  incision  is  postero-internal 
and  is  little  less  than  one  diameter  of  the  limb  (at  the  saw-line)  below  the 


AMPUTATION    THROUGH    LOWER    THIRD    OF    THIGH. 


445 


bone-section — the  two  calculations  of  covering  thus  providing  i^  diameters 
of  covering  in  the  aggregate.  Such  an  incision  is  hard  to  follow  unless  pre- 
viously marked  (Fig.  370,  A). 

Operation.— The  above  incision  through  skin  and  fascia  is  made  with 


Fig.370—  Amputations  about  Thigh  and  Hip-joint  :— A,  Through  lower  part  of  thigh,  by  oblique 
circular  method  ;  B,  Disarticulation  at  hip-joint,  by  anterior  racket. 


two  strokes  of  a  long  knife — the  limb  being  conveniently  rotated  during  the 
manoeuvre,  as  described  under  the  "  Circular  Method  of  Amputation,"  page 
303.  The  skin  and  fascia  are  then  obliquely  retracted  a  short  way,  parallel 
with  the  original  incision — and  the  more  superficial  muscles  circularly,   or 


446  AMPUTATIONS. 

slightly  obliquely,  divided.  These  are  further  retracted  and  the  deeper  mus- 
cles circularly,  or  slightly  obliquely,  divided  to  and  including  the  periosteum,  to 
the  bone — cutting  each  time  parallel  with  the  skin  incision.  The  skin,  mus- 
cles, and  periosteum  are  freed  up  to  just  above  the  saw-line,  and  retracted— as 
in  the  ordinary  infundibular  form  of  circular  amputation — and  the  bone  sawed. 
The  femoral,  anastomotiea  magna,  descending  branches  of  the  external  cir- 
cumflex, perforating  and  muscular  branches  will  be  cut  and  require  ligature. 
The  muscles  are  quilted  in  two  tiers.  The  skin  is  sutured  so  as  to  make  an 
antero-posterior  scar. 

Comment. — (i)  This  may  be  called  an  elliptical  method,  as  well  as  an 
oblique  circular.  It  is  not  appropriate  except  at  the  lower  third  of  the  thigh 
— where  it  is  excellent.  (2)  Where  great  difficulty  is  experienced  in  freeing 
back  the  soft  parts,  the  circular  operation  may  be  modified  by  adding  one  or 
two  short  lateral  vertical  incisions,  thus  forming  two  antero-posterior  in- 
tegumentary flaps — and  dividing  the  muscles  circularly  after  retracting  the 
skin.     This,  however,  constitutes  the  modified  form  of  circular  amputation. 


AMPUTATION   THROUGH    LOWER,   MIDDLE,   OR   UPPER   THIRD   OF 

THIGH 

BY  LONG  ANTERIOR  AND  SHORT  POSTERIOR  FLAPS. 

Description. — Two  U-shaped  flaps  of  skin  and  muscle  are  raised,  ante- 
riorly and  posteriorly — the  latter  being  one-fourth  the  length  of  the  anterior 
and  a  little  narrower  at  the  base. 

Position — Landmarks. — As  in  the  above  operation. 

Incisions. — Anterior  flap — is  equal,  in  length,  to  i^  diameters  of  the 
thigh  at  the  saw-line,  and,  in  width,  a  little  more  than  ^  circumference.  It 
begins  (on  right  side)  (with  thigh  rotated  outward)  opposite  the  saw-line, 
at  about  the  middle  of  its  inner  aspect,  or  a  fraction  behind — passes  vertically 
down  the  inner  side  of  thigh — rounds  broadly  across  the  anterior  surface, 
at  a  distance  below  the  saw-line  equal  to  1^  diameters,  and  into  the  outer 
aspect — and  passes  vertically  upward  (the  thigh  now  rotated  inward)  to  a 
corresponding  point  on  the  opposite  side.  Posterior  flap — begins  and  ends 
at  the  upper  limits  of  the  anterior  flap — rounding  across  the  posterior  surface 
at  a  distance  below  the  saw-line  equal  to  a  half-diameter — the  surgeon's 
hand  passing  beneath  the  thigh.  In  the  above  calculations,  extra  length  is 
allowed,  because  of  the  extra  retraction  (Fig.  366,  C). 

Operation. — The  tissues  outlined  in  the  anterior  flap  are  now  picked  up 
by  the  surgeon's  left  hand,  and,  along  the  line  of  the  retracted  flap,  the  muscles 
are  divided  obliquely  from  without  inward  and  upward — so  beveling  the  flap 
that  its  extremity  will  consist  of  skin  and  fascia  alone.  The  muscle  tissue  will 
begin  to  enter  into  the  formation  of  the  flap  just  above  the  extremity,  and  in- 
creases in  thickness  to  the  bone — into  contact  with  which  the  incision  will  come 
at  about  one-half  to  three-fourths  the  diameter  of  the  femur  below  the  saw-line, 
at  which  level  the  whole  thickness  of  the  muscle  will  be  represented.  The 
thigh  is  then  elevated  and  the  posterior  flap  similarly  cut,  being  obliquely 
beveled  from  without  inward  and  from  below  upward,  leaving  skin  and 
fascia  at  the  lower  end  of  the  'flap  and  full  thickness  of  the  muscles  at  the 
upper  end,  where  the  bone  is  reached  the  same  distance  below  the  saw-line 
as  in  the  anterior  flap.  At  the  level  at  which  the  bone  has  been  reached  in 
the  upward  cutting  of  the  flaps,  a  circular  sweep  of  the  knife  around  the 
femur  frees  the  periosteum.     The  soft  parts,  including  the  periosteum,  are 


FLAP    AMPUTATIONS    OF    THIGH. 


447 


then  freed  upward  to  just  above  the  saw-line  (which  is  everywhere  easily 
accomplished  except  at  the  linea  aspera  posteriorly)  and  the  bone  sawed'. 
If  the  flaps  have  been  made  above  the  middle  of  the  thigh,  the  femoral,  pro- 
funda, descending  branches  of  the  external  circumflex,  and  muscular  branches 
will  be  cut  in  the  anterior  flap — and  branches  of  the  perforating  arteries  in 
the  posterior  flap.  If  the  flaps  have  been  made  below  the  middle  of  the 
thigh,  the  descending  branches  of  the  external  circumflex  and  muscular 
branches  will  be   cut   in   the  anterior  flan — and   the  femoral,   anastomotica 


Fig.  371. — Transverse  Section  through  the  Upper  Third  of  the  Left  Thigh :— 
P,  Adductor  longus;  A,  Gracilis;  B,  Obturator  nerve  and  vessels;  C,  Deep  femoral  vessels;  D, 
Adductor  magnus;  E,  Semimembranosus;  F,  G,  Semitendinosus;  H,  Biceps;  I,  Sartorius;  J, 
Rectus;  K,  Superficial  femoral  artery,  vein,  and  saphenous  nerve;  L,  Vastus  internus;  M,  Crureus; 
N,  Vastus  externus;  O,  Gluteus  maximus.     (The  cross-section  modified  from  Braune.) 


magna,  and  branches  of  the  perforating  in  the  posterior  flap.  Suture  the 
musculo-periosteal  covering  over  the  end  of  the  bone.  Quilt  the  heavy 
muscles  of  the  flaps  in  at  least  two  tiers,  with  buried  chromic  gut  sutures. 
The  anterior  flap  will  drop  over  the  end  of  the  bone  and  be  sutured  to  the 
posterior  flap.  The  flaps  are  well  supported  by  the  pressure  of  the  dressing, 
in  which  a  posterior  splint  has  been  included — and  the  limb  placed  upon 
an  inclined  plane. 

Comment. — The  flaps  may  be  cut  by  transfixion,  after  outlining  through 
skin  and  fascia — but  less  satisfactorilv. 


448 


AMPUTATIONS. 


AMPUTATION    THROUGH    LOWER,    MIDDLE,   OR   UPPER    THIRD  OF 

THIGH 

BY  EQUAL  ANTERIOR  AND    POSTERIOR    FLAPS. 

Description. — Same  in  all  essential  respects,  except  as  to  difference  in 
length  of  flaps,  as  amputation  by  long  anterior  and  short  posterior  flaps. 


Fig.  372. — Amputations  about  Thigh  and  at  Hip-joint: — A,  Through  middle  of  thigh,  by 
equal  anterior  and  posterior  flaps  ;  B,  Disarticulation  at  hip-joint,  by  external  racket  method  ;  C,  At 
hip-joint,  by  long  anterior  and  short  posterior  flaps. 

Position — Landmarks. — As  in  the  last  operation. 

Incisions. — Anterior  flap — is,  in  length,  three-fourths  the  diameter  of 
the  limb  at  the  saw-line.     Posterior  flap — is,  in  length,  one  diameter  of  the 


AMPUTATION    OF    THIGH    JUST    BELOW    THE    TROCHANTERS.       449 

limb — its  greater  retraction  eventually  reducing  its  length  to  that  of  the 
anterior  flap.  The  width  of  both  is  equivalent  to  half  the  circumference  of 
the  limb  at  the  saw-line  (Fig.  372,  A). 

Operation. — As  in  the  preceding.    The  vessels  severed  are  also  the  same. 

Comment. — (i)  The  method  by  equal  flaps  is  indicated  only  where  the 
anterior  tissues  are  limited.  (2)  Less  sacrifice  of  length  of  limb  is  involved. 
(3)  These  flaps  are  frequently  cut  by  transfixion,  without  even  outlining 
through  the  integumentary  tissues  in  advance — but  such  technic  is  not  ad- 
visable. 


Fig-  373- — Cross-section  through  the  Left  Thigh  at  the  Level  of  the  Lesser 
Trochanter: — A,  Sartorius;  B,  Rectus;  C,  Superficial  femoral  artery,  vein,  and  anterior  crural 
nerve;  D,  Profunda  femoral  artery  and  vein;  E,  Crureus;  F,  Iliacus;  G,  Tensor  vagina?  femoris; 
H,  Pectineus;  I,  Vastus  externus;  J,  Sciatic  nerve  and  artery;  K,  Semimembranosus;  L, Biceps 
and  semitendinosus;  M,  Gluteus  maximus;  N,  Adductor  magnus;  O,  adductor  brevis;  P,  Adduc- 
tor longus;  R,  Gracilis.     (The  cross-section  modified  from  Braune.) 


AMPUTATION  OF  THIGH  JUST  BELOW  THE  TROCHANTERS 

BY  EXTERNAL  OVAL  METHOD. 

Description.— Similar  in  principle  to  disarticulation  of  the  hip-joint  by 
the  external  racket  method  (page  458) — except  that  the  vertical  incision 
begins  lower,  and  the  bone  is  divided  below  the  lesser  trochanter. 

Position. — As  in  disarticulation  of  the  hip-joint  by  the  external  racket 
method  (page  458). 

Landmarks. — Great  trochanter;  lesser  trochanter. 
29 


450  AMPUTATIONS. 

Incision. — With  the  limb  adducted,  rotated  in  and  slightly  flexed,  the 
vertical  portion  of  the  incision  begins  over  the  prominence  of  the  great  tro- 
chanter, in  the  mid-outer  aspect  of  the  limb — passes  vertically  down  the  outer 
side  of  the  thigh  for  about  10  cm.  (4  inches) — thence  the  limbs  of  the  oval 
diverge  to  pass  over  the  anterior  and  posterior  aspects  of  the  thigh  and  meet 
in  the  center  of  its  inner  side,  at  a  point  about  5  cm.  (2  inches)  lower  than  the 
lower  end  of  the  vertical  incision.  Thus  an  inverted  Y  is  formed  upon  the 
outer  side  of  the  thigh. 

Operation. — The  skin  and  fascia  are  dissected  up  along  the  oval  portion 
of  the  incision  for  about  5  cm.  (2  inches).  The  vertical  incision  is  then 
deepened  to  the  bone.  Through  the  vertical  incision  the  shaft  is  freed  as 
extensively  as  possible.  The  muscles  are  now  circularly  divided  on  a  line 
with  the  retracted  skin  and  fascia.  The  soft  parts  are  entirely  freed  from 
the  bone  up  to  the  saw-line — providing  a  musculo-periosteal  covering  when 
near  that  line.  The  soft  tissues  are  retracted  and  the  femur  sawed.  Ligate 
the  femoral  artery  and  vein,  profunda  artery  and  vein,  internal  circumflex, 
descending  (and  possibly  transverse)  branch  of  external  circumflex,  comes 
nervi  ischiadici,  and  many  muscular  branches.  Suture  the  musculo-periosteal 
flap.  Quilt  the  muscles  with  two  tiers  of  gut  sutures,  along  both  vertical 
and  oval  portions  of  incision.  Suture  skin  in  a  horizontal  line,  forming 
externo-terminal  scar.  Include  splint  in  dressing  and  place  on  an  inclined 
plane. 

SURGICAL  ANATOMY  OF  HIP- JOINT. 

Bones. — Os  innominatum;  femur. 

Articulations  and  Ligaments. — Capsular  (with  following  auxiliary 
bands — pectineo-capsular,  ilio-trochanteric,  and  ischio-capsular) ;  ilio-femoral 
(also  an  auxiliary  portion  of  capsular  ligament);  ligamentum  teres;  cotyloid; 
transverse;  and  synovial  membrane. 

Synovial  Membrane  of  Hip-joint. — Beginning  at  border  of  carti- 
laginous surface  of  head  of  femur — covers  neck  of  femur  within  joint — is 
reflected  to  inner  surface  of  capsular  ligament — covers  both  surfaces  of 
cotyloid  ligament  and  fat  at  bottom  of  acetabulum — and  is  prolonged  around 
ligamentum  teres  to  head  of  femur. 

Muscles  of  Region  of  Hip-joint. — Mentioned  in  connection  with  the 
Thigh  (page  436). 

Muscles  in  Relation  with  Hip-joint. — Anteriorly: — psoas  and  iliacus 
Posteriorlv: — pyriformis;  gemellus  superior;  obturator  internus;  gemellus  in- 
ferior; obturator  externus;  quadratus  femoris.  Superiorly: — straight  and 
reflected  tendons  of  rectus;  and  gluteus  minimus.  Internally: — obturator 
externus  and  pectineus. 

Bursae  in  Relation  with  Hip-joint. — Between  great  trochanter  and 
gluteus  maximus.  Between  vastus  externus  and  gluteus  maximus.  Between 
front  of  joint,  and  psoas  and  iliacus  (often  communicating  with  joint). 

Movements  of  Hip-joint. — Flexion: — by  psoas,  iliacus,  rectus,  sar- 
torius,  pectineus,  adductor  longus,  adductor  brevis,  anterior  fibers  of  gluteus 
medius,  and  minimus.  Extension: — by  gluteus  maximus,  biceps,  semi- 
tendinosus,  semimembranosus,  gracilis.  Adduction: — by  adductor  magnus, 
longus  and  brevis,  pectineus,  gracilis.  Abduction: — by  gluteus  maximus, 
medius  and  minimus.  Inward  Rotation: — anterior  fibers  of  gluteus  medius, 
gluteus  minimus,  and  tensor  vaginae  femoris.  Outward  Rotation: — posterior 
fibers  of  gluteus  medius,  pyriformis,  obturator  externus,  obturator  internus, 


SURFACE    FORM    AND    LANDMARKS    OF    HIP-JOINT.  451 

gemellus  superior  and  inferior,  quadratus  femoris,  psoas,  iliacus,  gluteus 
maximus,  adductor  magnus,  longus  and  brevis,  pectineus,  sartorius. 

Arteries  of  Region  of  Hip-joint.— (a)  From  Internal  Iliac— obturator; 
internal  pudic;  sciatic:  ilio-lumbar;  lateral  sacral;  gluteal,  (b)  From  External 
Iliac — deep  circumflex  iliac,  (c)  From  Femoral — see  Arteries  of  Thigh, 
page  436- 

Veins  of  Region  of  Hip-joint.— Superficial:— tributaries  of  internal 
saphenous.  Deep: — accompany  corresponding  arteries.  See  Veins  of  Thigh, 
page  436. 

Nerves  of  Region  of  Hip-joint.— (a)  From  Dorsal  Nerves:— lateral 
cutaneous  branch  of  last  dorsal,  (b)  From  Posterior  Divisions  of  Lumbar 
Nerves: — cutaneous  nerves  from  external  branches  of  three  upper  posterior 
divisions,  (c)  From  Lumbar  Plexus: — ilio-hypogastric,  ilio-inguinal,  genito- 
crural,  external  cutaneous,  anterior  crural,  obturator,  accessory  obturator, 
(d)  From  Posterior  Divisions  of  the  Five  Sacral  and  First  Coccygeal  Nerves: 
— external  branches,  (e)  From  the  Sacral  Plexus: — muscular,  superior 
gluteal,  inferior  gluteal,  perforating  cutaneous,  pudic,  small  sciatic,  great 
sciatic.     The  cross-section  of  the  hip-joint  is  shown  in  Fig.  47. 

SURFACE    FORM    AND    LANDMARKS    OF    HIP-JOINT    AND    VICINITY. 

Spine  of  the  os  pubis  is  palpable,  and  is  nearly  on  a  level  with  the  upper 
border  of  the  great  trochanter — and  the  upper  border  of  the  great  trochanter 
is  on  a  level  with  the  center  of  the  hip-joint. 

Top  of  the  great  trochanter  is  about  2  cm.  (f  inch)  below  the  level  of  the 
head  of  the  femur. 

Great  trochanter  is  from  7.5  to  10  cm.  (3  to  4  inches)  below  the  iliac 
crest,  and  a  little  in  front  of  its  center. 

Head  of  the  femur  lies  just  below  Poupart's  ligament — and  just  external 
to  its  center. 

Nelaton's  line  runs  from  the  anterior  superior  iliac  spine  to  the  most 
prominent  part  of  the  tuberosity  of  the  ischium.  It  runs  through  the  center 
of  the  acetabulum  and  indicates  the  level  of  the  hip-joint. 

Bryant's  line — (with  patient  flat  on  back) — first  line  is  dropped  vertically 
to  the  table,  from  the  anterior  superior  iliac  spine; — second  line  passes,  in  a 
straight  direction,  in  a  line  with  the  long  axis  of  the  thigh,  from  the  top  of 
the  great  trochanter  to  meet  first  line; — third  line  runs  from  the  anterior 
superior  iliac  spine  to  the  top  of  the  great  trochanter.  On  the  damaged  or 
diseased  side,  the  second  line  will  be  shortened. 

Anterior  superior  iliac  spine  and  the  crest  of  the  ilium  are  palpable. 

Posterior  superior  iliac  spine  is  marked  by  a  depression  on  each  side  of, 
and  on  a  level  with,  the  spinous  process  of  the  second  sacral  vertebra — and 
is  just  behind  the  center  of  the  sacro-iliac  articulation. 

The  anterior  inferior  iliac  spine  is  about  2  cm.  (f  inch)  above  the  upper 
border  of  the  acetabulum: 

Line  from  the  posterior  superior  iliac  spine  to  the  outer  part  of  the  tuber- 
osity of  the  ischium  will  cross  the  posterior  inferior  iliac  spine  nearly  5  cm. 
(2  inches)  below  the  posterior  superior  iliac  spine — and  the  ischial  spine 
about  10  cm.  (4  inches)  below  the  posterior  superior  iliac  spine. 

Tuberosities  of  the  ischia  are  palpable  on  either  side  of  the  anus,  beneath 
the  lower  border  of  the  glutei  maximi,  especially  when  the  hip  is  flexed. 
They  are  covered,  in  standing,  by  the  lower  margin  of  the  glutei  maximi — 
and,  when  sitting,  by  the  dense  skin  and  fascia  alone. 


45 2  AMPUTATIONS. 

Third  sacral  spine  is  on  a  level  with  the  lowest  limit  of  the  spinal  mem- 
branes and  the  cerebrospinal  fluid,  and  is  opposite  the  upper  border  of  the 
great  sacro-sciatic  notch. 

First  piece  of  the  sacrum  is  on  a  level  with  the  spine  of  the  ischium. 

Apex  of  the  coccyx  is  just  behind  the  last  piece  of  the  rectum. 

Gluteus  maximus  forms  the  rounded  outline  of  the  buttock — its  lower 
border  being  more  oblique  and  higher  than  the  fold  of  the  buttock.  A  line 
from  the  side  of  the  coccyx  to  the  lower  border  of  the  great  trochanter  corre- 
sponds with  the  lower  border  of  the  gluteus  maximus. 

Fold  of  the  buttock  is  caused  by  the  creasing  of  the  skin  in  flexion  and 
extension,  and  does  not  correspond  with  the  lower  margin  of  the  gluteus 
maximus  but  is  lower  and  less  oblique. 

The  antero-internal  margin  of  the  acetabulum  is  about  5  cm.  (2  inches) 
external  to  the  pubic  spine. 

Edge  of  the  great  sacro-sciatic  ligament  can  be  felt  by  pressing  deeply 
under  the  lower  edge  of  the  gluteus  maximus. 

Femoral  artery  is  separated  from  the  capsule  of  the  hip-joint  by  the  psoas 
magnus,  upon  which  it  rests. 

For  the  landmarks  of  the  gluteal,  sciatic,  and  pudic  arteries,  see  under 
the  Ligations  of  those  arteries  (pages  87,  84,  and  85). 

Ossification  in  the  head  of  the  femur  begins  at  the  end  of  the  first  year, 
uniting  with  the  shaft  at  the  eighteenth  year; — that  in  the  great  trochanter 
begins  in  the  fourth  year,  and  that  in  the  lesser  trochanter  at  the  thirteenth 
to  fourteenth  year,  uniting,  in  both  cases,  about  the  eighteenth  year.  The 
epiphyseal  line  of  the  head  of  the  femur  is  entirely  within  the  capsular  ligament. 


GENERAL    SURGICAL    CONSIDERATIONS    IN    DISARTICULATION    AT 

THE  HIP- JOINT. 

The  question  of  control  of  hemorrhage  is  the  most  serious  problem  in 
hip-joint  disarticulations. 

The  methods  of  hemorrhage-control  are  the  following; — Wyeth's  mattress- 
neeclles  and  tourniquet;  elastic  tourniquet;  preliminary  ligation  of  femoral; 
Senn's  method;  ligation  of  femoral  during  amputation;  digital  compression 
of  the  femoral,  or  of  the  external  iliac,  above  the  amputation-site;  digital 
compression  of  the  femoral  in  the  flap,  as  cut;  Trendelenburg's  rod  beneath 
the  femoral  vessels,  with  rubber  tubing  wound  in  figure-of-eight  fashion  over 
it;  Thomas'  Forceps  Tourniquet.  The  first  three  of  the  above  methods  are 
the  best.  Such  methods  as  pressure  of  the  abdominal  aorta,  either  extra- 
or  intra-abdominally,  or  through  the  rectum,  are  now  not  usually  resorted  to. 

Only  some  form  of  circularly  surrounding  tourniquet  controls  hemorrhage 
from  branches  of  the  internal  iliac,  as  well  as  from  the  femoral.  When 
hemorrhage  is  once  controlled,  any  form  of  disarticulation  may  be  adopted. 

Manner  of  applying  Wyeth's  mattress-needles  and  tourniquet: — Two 
steel  needles  from  3  to  5  mm.  (T2g  to  T3?  inch)  in  diameter  and  25.5  cm.  (10 
inches)  in  length  are  inserted  and  capped  with  corks  (to  prevent  their  points 
from  injuring  operator  and  assistants).  The  outer  needle  enters  the  tissues 
of  the  outer  aspect  of  the  thigh  6  mm.  Q  inch)  below  and  just  to  the  inner 
side  of  the  anterior  superior  iliac  spine — traverses  the  superficial  muscles 
and  fascia  upon  the  outer  side  of  the  hip,  and  emerges  on  a  level  with,  and 
about  7.5  cm.  (3  inches)  external  to,  the  entrance.     The  inner  needle  enters 


GENERAL    CONSIDERATIONS    IN    HIP-JOINT    DISARTICULATION.      453 

the  tissues  of  the  inner  aspect  of  the  thigh  internal  to  the  saphenous  opening, 
and  about  1.3  cm.  (£  inch)  below  the  crotch — traverses  the  adductors — and 
emerges  2.5  cm.  (1  inch)  below  the  tuberosity  of  the  ischium.    White  rubber 


Fig.  374. — Manner  of  Inserting  the  Wyeth  Pins: — The  outer  pin. 

tubing,  about  7  mm.  (J  inch)  in  diameter,  is  wound  tightly  four  or  five  times 
around  the  thigh  above  the  fixation-needles,  and   clamped.     This  rubber 


-^^^ 

/^     --c 

\x 

i  mm 

0% 

*  \      u      C^j^ 

»-. 

Fig-  375- — Manner  of  Inserting  the  Wyeth  Pins: — The  inner  pin.    After  both  pins  have  been 
inserted,  the  rubber  tubing  is  applied  above  them,  as  shown  in  their  use  at  the  shoulder-joint. 


band  compresses  the  common  femoral  against  the  rim  of  the  pelvis,  anteriorly 
— and  the  gluteal,  sciatic,  and  internal  pudic  against  the  margin  of  the  great 
sacro-sciatic  notch,  posteriorly  (Fig.  268,  left  hip). 


454  AMPUTATIONS. 

Manner  of  applying  the  ordinary  rubber  tourniquet  (Jordan  Lloyd's 
method) — First  elevate  the  limb  to  a  vertical  position,  and  hold  thus  for  a 
few  minutes,  further  aiding  the  emptying  of  blood  from  the  limb  by  down- 
ward massage.  A  strip  of  sterilized  roller  bandage  is  laid  down  the  outer, 
and  one  down  the  inner  aspect  of  the  thigh.  A  sterilized  pad  is  placed  over 
the  external  iliac  artery.  Rubber  tubing,  about  1.8  m.  (6  feet)  long,  is 
passed  around  the  thigh  in  several  tight  turns,  over  the  pad  and  pieces  of 
roller  bandage.  The  center  of  these  turns  is  placed  between  the  tuberosity 
of  the  ischium  and  the  anus  (of  the  operated  side) — the  tubing  being  brought 
up  so  as  to  pass  over  the  center  of  the  iliac  crest.  The  two  ends  of  the  tubing 
are  finally  grasped  firmly  in  either  hand  and  tightly  drawn  upward  and 
forward  and  made  to  cross  each  other  above  the  center  of  the  iliac  crest. 
At  the  point  of  crossing,  an  assistant,  with  the  back  of  the  hand  (the  right 
hand  for  the  left  side,  and  vice  versa)  to  the  patient's  body,  grasps  and  holds 
the  crossed  rubber  band.  Or  the  two  ends  may  be  carried  around  the  trunk, 
brought  back  again,  and  make  a  second  similar  traversing  as  the  first  spica 
— the  two  ends  being  then  tied,  or  clamped,  above  the  center  of  the  iliac 
crest  (of  the  same  or  opposite  side).  The  two  roller  bandages  forming  the 
two  loops  are  now  drawn  upward  to  hold  the  tourniquet  in  place  and  lift  it 
further  from  the  field  of  operation — one  coming  up  from  in  front  of  the  anterior 
superior  iliac  spine,  and  the  other  from  opposite  the  ischial  tuberosity.  The 
anterior  part  of  the  tourniquet,  running  above  and  parallel  with  Poupart's 
ligament,  compresses  the  external  iliac  under  the  pad — the  posterior  part, 
running  across  the  great  sacro-sciatic  notch,  compresses  the  gluteal,  sciatic, 
and  internal  pudic  (Fig.  268,  right  hip). 

Manner  of  preliminary  ligation  of  femoral: — see  under  Ligations,  page 
93,  and  Figs.  268  (left  thigh)  and  46. 

Manner  of  applving  Senn's  method  of  hemorrhage-control  in  disarticula- 
tion at  the  hip-joint— A  straight  incision  of  about  20  cm.  (8  inches)  is  made 
over  the  central  aspect  of  the  great  trochanter,  in  the  long  axis  of  the  limb, 
and  commencing  about  7.5  cm.  (3  inches)  above  the  superior  border  of  the 
great  trochanter.  As  soon  as  the  femur  has  been  exposed  and  the  head  of 
the  bone  disarticulated,  a  pair  of  hemostatic  forceps  is  introduced  closed 
behind  the  femur,  and  on  a  level  which  would  correspond  with  that  of  the 
trochanter  minor  when  in  normal  position  (that  is,  prior  to  disarticulation) — 
and  is  pushed  inward  and  downward  below  the  ramus  of  the  ischium  and 
just  posterior  to  the  adductor  muscles — until  felt  through  the  skin  on  the 
inner  aspect  of  the  thigh,  when  an  incision  is  made  over  its  tip  and  the  instru- 
ment oressed  on  through.  By  opening  the  blades,  the  tunnel  through  the 
soft  parts  is  enlarged — and  the  forceps  are  then  made  to  seize  a  piece  of 
rubber  tubing  at  its  center  and  draw  the  doubled  portion  backward  through 
the  wound  at  the  outer  aspect  of  the  thigh,  leaving  the  free  ends  protruding 
through  the  inner  opening.  The  portion  of  the  tube  grasped  by  forceps  is 
then  cut  in  two.  The  limb  is  now  held  elevated  a  few  moments,  during 
which  the  return  of  blood  to  the  trunk  is  further  aided  by  downward  massage. 
The  anterior  half  of  the  tube  is  then  carried  firmly  around  the  anterior  portion 
of  the  soft  parts  and  tied  or  clamped — and  the  posterior  around  the  posterior 
portion,  and  similarly  tied  or  clamped — thus  controlling  all  circulation  prox- 
imal to  the  tubing — the  tubing  being  prevented  from  slipping  by  the  tun- 
neling of  the  soft  parts.     The  operation  is  then  completed. 

The  method  by  Trendelenburg's  rod  (Fig.  376)  and  Thomas'  Forceps 
Tourniquet  (Fig.  377)  are  sufficiently  described  by  their  illustrations  and 
legends. 


GENERAL    CONSIDERATIONS    IN    HIP-JOINT    DISARTICULATION.     455 


I 


fig.  376. — Manner  of  Using  Trendelenburg's  Rod  for  the  Control  of  Hemorrhage 
in  Amputations  near  the  Hip-joint: — The  rod  is  thrust  through  the  limb  beneath  the  femoral 
vessels,  which  are  then  constricted  by  a  rubber  band  wound  in  figure-of-eight  fashion  about  the 
rod.     (The  cross-section  adapted  from  Braune.) 

Where  the  disarticulation  has  been  done  by  a  method  allowing  of  free 
exposure  of  the  femur  in  advance  of  disarticulation,  the  shaft  can  be  largely 


Fig.  377. — Thomas'  Forceps  Tourniquet  for  Controlling  Hemorrhage  During 
Operations  upon  the  Extremities: — The  probe-pointed  blade  passes  under  the  femoral 
vessels,  and  the  serrated  blade  over  these  structures — the  former  coming  out  through  a  pre- 
viously cut  exit,  after  which  the  blades  are  clamped. 

freed  subperiosteally — with  the  result  that  a  sufficient  growth  of  bone  usually 
occurs  to  enable  the  stump  to  be  freely  moved  in  all  directions. 


456  AMPUTATIONS. 

Temporary  drainage  is  indicated — and  should  be  provided  through  an 
opening  made  posteriorly,  if  no  dependent  opening  exist  as  a  result  of  the 
operation. 

Sutures  are  left  in  an  extra  length  of  time — and  the  flaps  are  subsequently 
temporarily  supported  by  strapping. 

The  stump  should  be  rather  firmly  bandaged  and  supported  upon  a 
pillow. 


DISARTICULATION  AT  HIP- JOINT,  IN  GENERAL. 

Best  Methods.— Wyeth's  Method.  External  Racket  Method.  Anterior 
Racket  Method. 

Other  Methods. — Furneaux  Jordan's  Method  (external  vertical  incision, 
with  circular  division  of  muscles).  Long  Anterior  and  Short  Posterior  Flaps. 
Equal  Anterior  and  Posterior  Flaps.  Equal  Lateral  Flaps.  Antero-internal 
and  Postero-external  Flaps.  Modified  Circular  Method.  Single  Internal 
Flap.  Esmarch's  Method  (circular  division  of  muscles  and  bone,  with 
dissection  out  of  the  bone  through  an  external  vertical  incision). 


DISARTICULATION  AT  HIP- JOINT 

BY  WYETH'S  METHOD. 

Description. — Having  controlled  hemorrhage  by  means  of  rubber-tubing 
wound  around  the  thigh  at  its  junction  with  the  pelvis,  above  two  large  pins 
introduced  in  a  special  manner,  a  circular  incision  is  made  around  the  thigh, 
followed  by  a  vertical  external  incision,  and  disarticulation  at  the  hip-joint 
accomplished. 

Position. — Patient  supine,  drawn  to  foot  of  table  until  the  sacrum  rests 
upon  the  corner,  with  hip  projecting  beyond,  and  kept  from  slipping  from 
table  by  being  steadily  held.  Surgeon  generally  stands  upon  the  outer  side 
of  both,  thighs,  although  it  is  more  convenient  to  be  upon  the  inner  side  of  the 
left  limb.  An  assistant  holds  and  manipulates  the  limb  projecting  over  the 
table.  Another  assistant  steadies  the  pelvis  and  guards  the  method  of  hemor- 
rhage-control. 

Control  of  Hemorrhage. — Special  pins  are  introduced  in  the  manner 
described  under  General  Surgical  Considerations  (page  45  2).  Previous  to 
the  application  of  the  pins,  the  limb  should  be  constricted  by  an  Esmarch 
rubber  bandage,  from  the  toes  to  the  hip-joint — unless  contraindicated. 

Landmarks. — Great  trochanter;  points  for  the  passage  of  the  pins  (page 

389)- 

Incisions. — A  circular  incision  is  made  around  the  thigh  about  15.3  cm. 
(6  inches)  below  the  center  of  the  anterior  aspect  of  the  rubber  tourniquet. 
The  vertical  incision  passes  vertically  down  the  external  aspect  of  the  thigh, 
directly  over  the  great  trochanter — passing  in  a  straight  line  from  the  tourni- 
quet to  the  circular  incision  (Fig.  378,  B). 

Operation. — The  circular  incision  passes  through  skin  and  fascia  alone. 
These  are  dissected  up  to  the  level  of  the  lesser  trochanter— that  is,  for  about 
5  cm.  (2  inches).  At  this  level  the  muscles  are  circularly  divided  to  the  bone, 
on  a  line  with  the  retracted  skin  and  fascia.  The  vertical  incision  is  now 
made  from  the  tourniquet  down  to  the  circular  division,  passing  directly 
over  the  great  trochanter.  The  larger  vessels  are  at  once  tied— the  femoral 
and  profunda  arteries  and  veins,  and  any  other  prominent  vessel.     Through 


DISARTICULATION    AT    HIP-TOIXT. 


457 


the  vertical  incision,  which  has  extended,  at  one  sweep,  directly  through 
skin,  fascia,  muscles,  and  periosteum  to  the  bone,  the  soft  parts  are  all  cleared, 
as  subperiosteal!}-  as  possible,  from  the  shaft  and  tuberosities  of  the  femur. 
Retract  the  soft  parts  and  divide  the  capsular  ligament  transversely  over  its 


Fig.  378.— Amputations  through  Thigh  and  at  Hip-joint: — A,  Through  lower  part  of  thigh,  by 
modified  circular;  B,  Disarticulation  at  hip-joint,  by  Wyeth's  method. 


outer  aspect.  Manipulate  the  limb  as  a  lever,  nicking  the  cotyloid  ligament 
to  let  in  air — cut  the  ligamentum  teres — and  disarticulate  by  thrusting  the 
head  of  the  femur  upward  and  outward.  If  not  already  severed,  divide  the 
posterior  aspect  of  the  capsule,  and  any  retaining  structures — and  remove 
the  limb.     If  the  enucleation  be  difficult,  which  is  rarelv  the  case  in  this 


458  AMPUTATIONS. 

extensive  exposure,  the  margin  of  the  acetabulum  can  be  chipped  away 
with  a  chisel  sufficiently  to  let  in  air — or,  if  all  the  vessels  be  ligatured, 
the  tourniquet  may  be  removed  carefully  and  slowly  and  the  disarticula- 
tion completed.  The  remaining  vessels  in  the  posterior  aspect  of  the  wound 
are  now  ligated — these  are  chiefly  the  branches  of  the  sciatic,  obturator,  ex- 
ternal and  internal  circumflex,  and  perforating.  Having  trimmed  away  all 
tags  of  tissue,  the  heavy  muscles  are  to  be  quilted  together  with  especial 
care,  by  means  of  two  or  three  tiers  of  chromic  gut  sutures.  Drainage  is 
to  be  established — the  margins  of  the  wound  united  in  one  continuous 
termino-external  suture-line — firm  compression  made  in  dressing  the  wound 
— and  the  stump  supported  upon  a  pillow. 

Comment. — This  method  probably  represents  the  safest,  simplest,  and 
best  manner  of  disarticulating  at  the  hip-joint. 


DISARTICULATION  AT  HIP- JOINT 

BY  EXTERNAL  RACKET  METHOD. 

Description. — The  queue  of  the  incision  is  placed  over  the  external 
aspect  of  the  joint — the  limbs  of  the  incision  encircling  the  anterior,  internal, 
and  posterior  aspects  of  the  thigh.  Hemorrhage  is  controlled  by  an  ordinary 
rubber  tourniquet. 

Position. — Patient  is  sufficiently  turned  to  the  opposite  side  to  expose 
the  area,  and  is  drawn  to  the  end  of  the  table  so  that  the  pelvis  rests  upon 
the  edge  of  the  table  and  the  hips  project  beyond — the  limb  is  adducted, 
rotated  inward,  and  slightly  flexed.  Surgeon  and  'assistants  stand  as  in  the 
last  operation. 

Control  of  Hemorrhage. — For  the  description  of  the  application  of  the 
rubber  tourniquet,  see  General  Surgical  Considerations,  page  452.  Also  see 
Hemorrhage-control,  under  the  last  operation,  for  reference  to  the  Esmarch 
bandage. 

Landmarks. — Great  trochanter. 

Incision. — The  queue  begins  about  5  cm.  (2  inches)  above  the  upper 
border  of  the  great  trochanter — passes  vertically  down  the  limb,  along  the 
posterior  border  of  the  great  trochanter,  for  about  17  cm.  (7  inches) — the 
two  limbs  of  the  racket  here  diverge  to  encircle  anteriorly  and  posteriorly, 
meeting  upon  the  center  of  the  inner  aspect  of  the  thigh,  about  5  cm.  (2  inches) 
lower  down  than  the  termination  of  the  vertical  portion  of  the  incision — 
forming  an  inverted  Y  on  the  outer  aspect  of  the  thigh.  The  limb  is  rotated 
as  the  incision  is  made  (Fig.  372,  B). 

Operation. — These  incisions  pass,  at  first,  through  skin  and  fascia  only. 
The  skin  and  fascia  of  the  oval  portion  of  the  incision  are  then  dissected  up 
for  about  5  cm.  (2  inches).  The  vertical  portion  of  the  incision  is  now  deep- 
ened to  the  bone — with  the  limb  in  the  original  position.  The  anterior, 
superior,  and  posterior  borders  of  the  great  trochanter  are  cleared  of  muscles 
in  the  order  named — as  subperiosteal^  as  circumstances  allow.  The  shaft 
of  the  femur  is  cleared,  as  far  as  possible,  to  the  extent  of  the  vertical  incision. 
Adduct  the  limb  strongly  and  divide  the  superior  and  posterior  parts  of  the 
capsule  transversely — flex  the  limb  and  divide  the  anterior  part  of  the  capsule 
— rotate  outward  and  cut  the  round  ligament — and  then  disarticulate.  Having 
ascertained  that  the  tourniquet  is  compressing  the  parts  well,  after  the  dis- 
articulation of  the  head  of  the  femur,  the  muscles  are  circularly  divided  on 
a  level  with  the  retracted  skin  and  fascia  of  the  oval  incision.     The  important 


DISARTICULATION    AT    HIP-JOINT.  459 

vessels  are  at  once  ligated — consisting  of  the  femoral  and  profunda  arteries 
and  veins,  the  internal  circumflex  (and  possibly  the  transverse  branch  of  the 
external  circumflex),  comes  nervi  ischiadici,  and  muscular  branches.  The 
muscles  are  quilted  in  two  or  three  tiers,  with  buried  chromic  gut  sutures, 
along  both  the  vertical  and  oval  portions  of  the  wound.  The  suture-line  of 
the  skin  margins  will  be  termino-external,  in  one  straight  line. 

Comment. — The  approach  to  the  bone  is  through  a  region  less  vascular 
than  by  the  anterior  racket  method.  The  hip-joint  can  be  preliminarily 
examined,  in  case  disarticulation  prove  unnecessary.  Disarticulation  can 
be  effected  before  severing  the  vessels.  The  subperiosteal  method  can  be 
more  easily  carried  out  than  by  an  anterior  approach.  The  branches  of  the 
internal  pudic  are  comparatively  little  involved — there  is  a  low  transverse 
division  of  the  muscles — and  good  drainage  is  secured.  The  method  is 
probably  better  than  disarticulation  by  the  anterior  racket  method. 


DISARTICULATION  AT  HIP- JOINT 

BY  ANTERIOR  RACKET  METHOD. 

Description. — The  queue  of  the  racket,  or  oval,  is  placed  anteriorly — 
the  limbs  of  the  oval  encircling  the  external,  internal,  and  posterior  surfaces. 
No  tourniquet  is  used.  The  femoral  is  ligated  during  operation,  and  the 
remaining  vessels  as  encountered. 

Control  of  Hemorrhage. — Utilizing  the  queue  of  the  incision,  the  common 
femoral  artery  and  vein  are  exposed  and  ligated — during  the  progress  of 
the  operation.     Other  vessels  are  secured  as  exposed. 

Position. — Patient  supine — otherwise  as  in  the  external  racket  method 
(page  458). 

Landmarks. — Center  of  Poupart's  ligament;  course  of  femoral  artery. 

Incision. — The  queue  begins  at  the  center  of  Poupart's  ligament — 
passes  down  along  the  femoral  artery  for  about  7.5  cm.  (3  inches) — thence 
curves  inward  and  crosses  the  inner  aspect  of  the  thigh  about  10  cm.  (4  inches) 
below  the  genito-crural  fold — continues  across  the  posterior  aspect  of  the 
thigh — crosses  the  outer  side  of  the  limb  a  short  distance  below  the  base  of 
the  great  trochanter — and  thence  ascends  upward  and  inward  obliquely 
across  the  anterior  aspect  to  join  the  vertical  incision  about  5  cm.  (2  inches) 
below  its  commencement  at  Poupart's  ligament  (Fig.  370,  B). 

Operation. — This  incision  passes  well  through  skin  and  fascia  only, 
which  are  allowed  to  fully  retract — and  is  made  with  several  sweeps  of  the 
knife,  while  the  limb  is  manipulated  as  indicated.  Through  the  vertical 
portion  of  the  racket  incision,  the  common  femoral  artery  and  vein  are  early 
exposed  and  each  ligated  in  two  places  and  severed  between  the  ligatures. 
The  skin  and  fascia  are  fully  freed  around  the  entire  incision,  without  any 
special  dissection.  The  muscles  on  the  outer  side  (sartorius,  rectus,  tensor 
vagina?  femoris)  are  divided  and  the  external  circumflex  artery  doubly  ligated 
and  severed.  Passing  backward,  rotate  the  thigh  inward  and  cut  the  insertion 
of  the  gluteus  maximus.  Passing  forward,  rotate  the  thigh  outward  and 
cut  the  psoas — and  retract  the  parts  and  doubly  ligate  and  divide  the  internal 
circumflex  artery.  Divide  the  muscles  of  the  internal  flap  on  a  level  with 
the  retracted  skin  (pectineus,  gracilis,  and  adductors),  ligating  the  muscular 
branches.  Adduct  and  rotate  the  thigh  inward — severing  the  muscles  attached 
to  the  great  trochanter.  Abduct  and  rotate  the  thigh  outward — cut  the 
capsule    transverselv — disarticulate — sever    the    round    ligament — and    the 


460  AMPUTATIONS. 

obturator  externus  tendon,  if  still  undivided.  The  head  of  the  bone  is  now 
drawn  forward  and  outward — a  long  knife  is  carried  behind  the  bone,  passing 
downward  and  backward  and  dividing  the  remaining  parts  at  the  posterior 
aspect,  on  a  level  with  the  retracted  skin  (hamstrings,  parts  of  the  adductors 
and  sciatic  nerve) — ligating  the  perforating  and  muscular  branches.  The 
muscles  are  quilted  in  two  or  three  tiers — after  having  severed  all  tags  of 
tissue  and  instituted  drainage.  The  margins  of  skin  are  sutured  in  a  single 
vertical  line.     The  stump  is  dressed  as  in  the  preceding  operations. 

Comment. — While  possessing  many  good  points  in  common  with  the 
method  by  external  racket  incision,  the  anterior  racket  method  possesses  the 
further  advantage  that  the  hip-joint  is  more  easily  and  directly  reached,  and 
disarticulation  more  readily  accomplished.  No  special  form  of  tourniquet 
control  is  necessary.  There  is,  however,  not  so  good  an  opportunity  afforded 
for  a  preliminary  examination  of  the  hip-joint,  with  possible  excision  sub- 
stituted for  amputation.  The  operation  is  longer,  owing  to  the  slower  hemor- 
rhage-control. 

INTERILIO-ABDOMINAL  AMPUTATION 

BY   AX    INTERNAL  FLAP KEEN'S   OPERATION. 

Description. — Consists  of  the  removal  of  the  entire  lower  extremity, 
with  a  portion  or  all  of  the  ilium.  Indicated  in  extensive  growths  in  the 
region  of  the  hip-joint. 

Position. — The  patient  is  supine,  with  the  hip-joint  projecting  over  the 
end  of  the  table,  during  the  outlining  and  making  of  the  internal  flap — and 
is  then  turned  toward  the  opposite  side  during  the  exposure  of  the  iliac  portion 
of  the  wound. 

Landmarks. — Spine  of  pubis;  Poupart's  ligament;  crest  of  the  ilium; 
posterior  superior  iliac  spine. 

Incision. — Iliac  incision  extends  from  the  spine  of  the  pubis,  2  cm.  (f  in.) 
above  and  parallel  with  Poupart's  ligament  and  the  crest  of  the  ilium  to  about 
its  middle.  Subsequently,  after  ligating  the  internal  iliac  artery,  this  incision 
is  continued  around  nearly  to  the  posterior  superior  iliac  spine.  Thigh  incision 
begins  just  external  to  the  middle  of  Poupart's  ligament  and  passes  downward 
to  a  point  a  little  below  the  middle  of  the  thigh — then  horizontally  to  the 
median  line  of  the  thigh  posteriorly — and  then  upward  to  the  posterior  end  of 
the  first  incision,  i.  e.,  slightly  external  to  the  posterior  superior  iliac  spine 

(Fig-  379)- 

Operation. — (1)  Having  divided  skin,  fascia,  and  muscles  in  the  incision 
extending  from  the  pubic  spine,  just  above  and  parallel  with  Poupart's  liga- 
ment and  the  iliac  crest  to  about  its  middle,  the  internal  iliac  artery  is  exposed 
extra-peritoneally  and  ligated.  (2)  The  long  internal  flap  is  now  made. 
The  incision  is  made  just  external  to  the  center  of  Poupart's  ligament,  in  order 
to  preserve  the  femoral  vessels — passing  thence  vertically  down  the  anterior 
aspect  of  the  thigh  to  just  below  its  middle — where  it  rounds  horizontally 
outward  to  the  mid -posterior  aspect — and  thence  vertically  upward  to  the 
posterior  end  of  the  horizontal  incision.  Having  outlined  this  incision  through 
skin  and  fascia,  it  is  deepened  to  the  bone.  At  the  transversely  divided  mus- 
cles, the  femoral  vessels  are  tied.  This  long  internal  flap,  when  turned  upward 
and  outward,  will  form  the  outer  wall  of  the  pelvis  and  will  be  the  barrier 
against  intestinal  hernia.  (3)  Division  of  the  muscles  inserted  into  the  crest 
of  the  Ilium;— Having  continued  the  first  part  of  the  iliac  incision  nearly  to 
the  posterior  superior  iliac  spine,  all  of  the  muscles  of  the  anterior,  lateral, 


INTERILIO-ABDOMINAL    AMPUTATION. 


461 


and  posterior  abdominal  wall  lying  beneath  this  incision  are  divided  down 
to  the  peritoneum,  the  opening  of  which  is  carefully  avoided.  (4)  The 
psoas  magnus  and  iliacus  internus  are  now  separated  from  the  internal  aspect 
of  the  ilium,  to  be  left  with  the  trunk.  If  they  be  involved  in  the  tumor-mass, 
they  are  to  be  sacrificed.  (5)  Removal  of  the  bone; — The  horizontal  and 
descending  rami  of  the  pubic  bone  are  divided — instead  of  disarticulating  at 


Pig.  379. — Lines  of  Incision  for  Keen's  Interilio-abdominal  Amputation. 

the  symphysis.  The  attachment  of  the  rectus  abdominis  is  thus  preserved, 
and  consequently  the  firmness  of  support  given  thereby  to  the  abdominal 
viscera.  In  order  to  preserve  the  sexual  power  in  the  male,  the  descending 
pubic  ramus  should  be  divided  below  the  attachment  of  the  corpus  cavernosum 
of  that  side.  Much  time,  difficulty,  and  hemorrhage  are  also  saved  in  thus 
avoiding  the  separation  of  the  rectus  muscle  and  corpus  cavernosum,  and  the 
disarticulation  at  the  symphysis  pubis.  The  ilium  is  now  divided  posteriorly 
by  sawing  from  the  crest  of  the  ilium,  near  its  junction  with  the  sacrum,  down 


462  AMPUTATIONS. 

into  the  sacrosciatic  notch.  This  avoids  the  difficulty  and  time  involved  in 
disarticulating  at  the  sacro-iliac  joint.  If  indicated,  however,  the  small  remain- 
ing portion  of  ilium  thus  left  attached  could  be  removed  after  the  removal  of 
the  main  portion  of  bone — and  this  would  also  apply  to  the  small  part  of  the 
pubic  bone  at  first  left.  The  entire  lower  extremity  now  comes  away,  with 
the  detached  ilium  and  the  undisarticulated  hip-joint.  (6)  The  long  internal 
flap  is  now  brought  upward  and  sutured  so  that  its  transversely  divided  end  is 
applied  to  the  iliac  incision.  The  muscles  are  approximated  by  buried 
sutures — drainage  is  provided — and  the  skin  closed.  Pressure  is  made  in  the 
voluminous  dressings,  so  as  to  sustain  the  weight  of  the  heavy  flap  and  exercise 
a  supporting  influence  against  the  weakened  pelvic  wall. 

Comments. — Varying  portions  of  the  iliac  bone  have  been  removed — or 
the  entire  bone  has  been  disarticulated.  Where  the  bone  is  divided,  this  is 
best  accomplished  by  the  Gigli  saw.  Provision  for  infusion  should  be  made 
in  advance. 


CHAPTER  XIII. 

EXCISIONS  AND  OSTEOPLASTIC  RESECTIONS 
OF  BONES  AND  JOINTS. 

GENERAL  CONSIDERATIONS. 

Definitions. — Excision  signifies  a  cutting-out.  By  Excision  of  Joints, 
is  meant  the  removal  of  the  articular  ends  (including  cartilage  and  synovial 
membrane)  of  the  bones  entering  into  the  formation  of  the  joint,  with  a 
minimum  injury  to  the  neighboring  parts.  The  articular  extremities  of  the 
proximal  and  distal  bones  are  removed,  except  in  the  cases  of  the  shoulder- 
and  hip-joints,  where  the  articular  ends  of  the  humerus  and  femur,  respec- 
tivelv.  are  alone  removed,  the  articular  cavities  of  the  scapula  and  os  in- 
nominatum  being  gouged  or  scraped.  In  Excision  of  Bones,  the  removal  of 
a  bone  is,  signified,  with  minimum  injur}'  to  neighboring  structures.  In  the 
Total  Excision  of  a  bone,  the  entire  bone  is  removed,  including  its  articular 
ends.  In  the  Partial  Excision  of  a  bone,  a  part,  only,  of  the  bone  is  removed. 
By  Resection,  is  meant  the  removal  of  the  entire  thickness  of  a  bone  (thus,  a 
joint  is  said  to  be  excised  by  the  resection  of  the  ends  of  its  constituent  bones) 
— but  the  terms  excision  and  resection  are  generally  used  synonymously. 
Osteoplastic  Resection  signifies  the  temporary  removal  of  a  bone,  or  part 
of  a  bone,  covered  by  its  soft  parts  still  attached,  for  the  purpose  of  exposing 
more  deeply  seated  structures — the  cutaneo-muscular-osseous  flap  being  re- 
placed later. 

Object  of  Excisions. — By  the  operation  of  Excision,  in  the  case  of  the 
extremities,  limbs  are  often  now  saved  in  a  state  of  usefulness  which  formerly 
were  entirely  lost  by  amputation — thus  marking  one  of  the  greatest  advances 
of  modern  conservative  surgery. 

General  Features  of  Excisions. — (i)  Total  removal  of  all  diseased 
tissue.  (2)  Preservation  of  a  useful  limb.  The  excessive  removal  of  bone, 
or  faulty  repair  of  a  wound,  or  improper  after-treatment  may  result  in  a  flail 
limb.  A  movable  joint  is  to  be  expected  everywhere,  except  in  the  case  of 
the  knee,  where  ankylosis  is  sought.  (3)  The  removal  of  bare  bone,  free 
of  its  periosteum — with  minimum  disturbance  to  surrounding  soft  parts 
and  neighboring  bony  parts.  (4)  Division  of  bones  in  such  a  manner,  and 
at  such  an  angle  and  height,  as  to  place  them  in  a  position  favorable  to  the 
formation  of  a  new  joint — or  favorable  to  ankylosis  in  the  most  desirable 
position.  The  operation  is  rarely  undertaken  in  the  very  young  or  in  the 
very  old. 

Indications  for  Excision. — Joint  disease  (generally  tuberculosis);  dis- 
ease of  shaft  or  articular  ends  of  bones;  extensive  injury  to  bone  or  joint; 
unreduced  dislocation;  ankylosis;  deformity;  compound  dislocation  or  frac- 
ture; fracture-dislocation;  ununited  fracture. 

Preparation. — Locally,  the  part  should  be  prepared  as  for  any  extensive 
operation — the  part  should  be  shaved,  and  should  come  upon  the  table  in 
an  aseptic  dressing.  Constitutionally,  the  patient  should  be  gotten  into  a 
condition  to  stand  a  long  operation — and,  subsequently,  to  meet  the  demands 
of   a   prolonged    convalescence.     Previous   to   the   operation,    an    apparatus 

463 


464  EXCISIONS. 

should  be  provided  suitable  for  the  double  purpose  of  retaining  the  part 
immovable,  and,  when  desired,  of  enabling  passive  movement  to  be  accom- 
plished. In  no  other  class  of  operations  does  the  final  result  so  largely  depend 
upon  the  mechanical  contrivance  in  which  the  part  is  to  be  subsequently  held 
and  passively  exercised. 

Instruments. — Scalpels,  light  and  heavy;  bistouries,  sharp  and  blunt; 
excision-knives  (strong  instruments,  with  good  grasping  handles  and  stout 
blades);  scissors,  straight  and  curved,  sharp  and  blunt;  saws,  large  and  small, 
solid-bladed  and  open-bladed,  broad  and  narrow,  especially  saws  with  ad- 
justable and  revolvable  blades,  chain  and  Gigli  saws,  key-hole  saw,  Adam's 
pattern,  Hey's  pattern;  forceps,  dissecting,  toothed,  and  artery-clamp;  bone- 
holding  forceps,  of  various  sizes  and  curves;  periosteal  elevators,  an  especially 
large  variety  of  straight,  curved  and  angular,  light  and  heavy;  rugines  and 
raspatories;  retractors,  angular  and  curved,  toothed  and  smooth;  spatula?, 
metal  or  ivory;  directors,  ordinary  grooved  and  saw-directors;  probes;  chisels, 
narrow  and  broad,  straight  and  curved;  osteotomes,  various;  bone-gouges 
and  curettes,  of  various  shapes  and  sizes;  drills;  flushing-gouge;  pins,  pegs, 
and  needles;  wire;  suture  and  ligature  material  of  silk,  gut,  chromic  gut, 
silkworm-gut,  and  wire;  needles;  needle-holders;  Esmarch  rubber  bandage 
and  tourniquet. 

Varieties  of  Excision. — A  joint  or  a  bone  may  be  excised  by  either 
the  subperiosteal  or  the  open  method. 


EXCISION  BY  THE  SUBPERIOSTEAL  METHOD. 

Description. — In  this  method  it  is  sought  to  preserve  the  entire  periosteum 
— from  the  site  at  which  it  is  first  reached  in  the  operation — on  upward  or 
downward  to  the  opposite  limit  of  the  wound.  In  the  case  of  excising  a 
joint,  no  periosteum  covers  the  articular  ends  of  the  bones — the  periosteum 
becoming  merged  into  the  fibrous  tissue  of  the  capsular  ligament — and  here 
a  periosteo-capsular  covering  is  separated  continuously.  The  advantages 
of  the  subperiosteal  method  are: — (a)  Production  of  new  bone  from  the 
preserved  periosteum;  (b)  Preservation  of  the  capsule  of  the  joint,  with  the 
ligaments  attached  to  it — and  hence  a  stronger  and  more  useful  joint;  (c) 
Preservation  of  the  attachment  of  tendons  to  neighboring  periosteum — and 
hence  additional  strength  and  movement;  (d)  Less  hemorrhage,  and  less 
damage  to  surrounding  tissues,  as,  when  the  bone  is  once  reached,  the  opera- 
tion is  henceforth  conducted  in  a  comparatively  safe  area,  between  bone  and 
periosteum  (or  between  bone  and  periosteo-capsular  covering);  (e)  The 
neighboring  intermuscular  planes  (except  to  reach  the  bone)  are  not  opened 
up — the  operation-site  being  circumscribed  by  the  periosteal  or  capsulo- 
periosteal  sheath  raised.  The  disadvantages  of  the  subperiosteal  method 
are  the  following: — (a)  Possibility  of  retaining  diseased  periosteum;  (b) 
Difficulty  of  the  operation,  and  the  likelihood  of  detaching  the  periosteum 
in  shreds;  (c)  Time  necessary  for  its  performance.  To  summarize — the 
subperiosteal  method  is  excellent  in  theory,  but  is  often  difficult,  and  some- 
times contraindicated,  in  practice.  The  subperiosteal  method  should  be 
adopted  whenever  possible — and  carried  out  as  far  as  possible — where  the 
periosteum  is  healthy.  Always  aim  for  the  subperiosteal  method,  where  the 
periosteum  is  healthy  and  there  is  no  contraindication — and,  if  only  partly 
successful,  less  damage  will  have  been  done  to  the  neighboring  tissues,  and 
the   result   will   be   more   satisfactory,  than  if  the  open   method  had  been 


EXCISION    BY  THE   SUBPERIOSTEAL  METHOD.  465 

undertaken  from  the  start.  As  a  result  of  a  successful  subperiosteal  excision, 
bone  is  reproduced,  refilling  the  periosteal  cavity  to  a  greater  or  lesser  extent, 
and  assuming  a  form  largely  determined  by  the  limiting  periosteum — being 
poured  out,  so  to  speak,  into  a  mould  of  periosteum  or  capsulo-periosteum. 
Sometimes  no  new  bone  forms — sometimes  an  excess.  Some  reabsorption 
of  the  new  bone  occurs.  Exceptionally,  reproduction  of  shafts  and  joint 
surfaces  of  bones  is  remarkable — and  the  functioning  almost  normal.  As 
to  the  peculiarities  of  the  periosteum, — in  the  young,  it  is  thick  and  easily 
detachable  (and  also  more  valuable); — in  the  old  (and  in  cadavera)  it  is 
thinner  and  more  adherent; — in  chronic  inflammation,  it  is  easily  detachable 
(but  often  less  valuable  here). 

Preparation. — (liven  under  General  Considerations. 

Position. — Patient's  limb  is  placed  in  such  a  position  as  to  be  most 
accessible  to  the  surgeon,  and,  at  the  same  time,  most  relax  the  overlying 
parts.  Surgeon  stands  in  the  same  general  relation  to  the  limb  as  in  ampu- 
tating— to  the  outer  side  of  right  and  inner  side  of  left  limbs.  Assistant  so 
stands  as  to  steady  the  part  or  retract  the  lips  of  the  wound.  Special  positions 
will  be  mentioned  under  special  operations. 

Landmarks. — Will  be  mentioned  under  each  operation. 

Preliminary  Control  of  Hemorrhage. — While  the  same  need  for  the 
control  of  hemorrhage  does  not  exist  as  in  the  case  of  amputations,  as  no 
important  vessels  are  ordinarily  cut,  yet,  to  avoid  what  hemorrhage  would 
otherwise  occur,  and  for  the  sake  of  having  a  clean,  dry  field,  it  is  best  to 
apply  a  rubber  constrictor  above  the  site  of  operation.  If  its  application  be 
preceded  by  elevation  and  proximal  massage  of  the  limb,  less  regurgitant 
bleeding  will  occur.  Though  oozing  may  be  greater  after  the  removal  of 
an  Esmarch  than  might  be  the  case  had  it  not  been  used,  yet  the  advantages 
more  than  conterbalance  the  disadvantages.  The  constrictor  should  always 
be  removed  before  suturing  the  wound,  that  all  vessels  which  still  bleed  may 
be  taken  up. 

Incision. — An  incision  should  be  chosen  which  is  simple — which  passes 
to  the  joint  or  bone,  by  the  most  direct  and  safest  route — which  will  do  the 
minimum  injury  to  the  neighboring  structures  on  its  way  to  the  site — which 
will  fall  in  with  the  intermuscular  planes — and,  if  possible,  with  the  cleavage 
line  of  the  skin.  The  incision  should  be  fully  long  enough  to  admit  of  easy 
manipulation  in  the  depth  of  the  wound,  upon  which  the  subperiosteal  method 
so  largely  depends.  Generally  a  single  straight  cut  is  used.  The  incision 
usually  passes  at  first  through  only  skin  and  fascia — but,  in  some  cases, 
passes  directly  to  bone. 

Operation. — (1)  If  the  primary  incision  have  passed  only  through  skin 
and  fascia,  an  intermuscular  plane  is  now  sought,  and,  by  lateral  retraction 
of  the  lips  of  the  wound  and  the  underlying  muscles,  the  bone  is  reached — 
with  the  least  possible  damage  to  the  soft  parts  and  without  any  further 
cutting,  but  simply  by  separation  of  fascial  planes.  In  other  instances,  the 
way  may  be  partly  opened  up  by  separation  and  retraction,  and  parti}'  by 
cutting  muscular  tissue  and  less  important  vessels  and  nerves.  In  still  other 
cases,  the  original  incision  passes  directly  to  the  joint  or  bone.  In  any  event, 
the  final  incision  passes  down  through  the  periosteum  of  the  lower  end  of 
the  proximal  bone — through  the  capsule  of  the  joint — and  through  the  perios- 
teum of  the  upper  end  of  the  distal  bone — all  in  one  continuous  sweep  of  a 
stout  excision  knife.  (2)  Having  once  gotten  within  the  periosteum  and 
capsule,  the  knife  is  laid  aside  and  this  capsulo-periosteal  covering  of  the 
joint  and  articular  ends  of  the  bones — or  the  periosteum  alone  where  only 
3° 


466  EXCISIONS. 

the  interarticular  portion  of  the  bone  is  involved — is  separated  by  means  of 
periostea]  elevators,  which  work  constantly  toward  the  bone,  hugging  it 
always.  Where  the  tendons  and  muscles  are  inserted  into  the  periosteum, 
these  are  levered  off  the  bone  by  means  of  periosteal  elevators  and  rugines — 
retaining  their  attachments  continuous  with  the  periosteum.  In  other  words, 
in  an  ideal  case,  the  osseous  tissue  is  decorticated,  or  shelled  out  of  its  capsulo- 
periosteal  sheath,  leaving  the  periosteum  and  capsule  intact  and  continuous, 
as  well  as  the  ligaments  of  the  joint  and  the  tendons  in  the  neighborhood. 
(3)  As  soon  as  the  articular  ends  have  been  sufficiently  freed  and  bared  in 
their  capsulo-periosteal  sheath,  disarticulation  is  accomplished  and  the  ends 
of  the  bones,  in  turn  or  together,  are  protruded  through  the  incision,  or  in- 
cisions, and  are  excised  just  above  their  articular  cartilages — the  soft  parts 
being  protected  during  the  sawing.  (4)  The  sawed  ends  of  the  bones  are 
now  drawn  back  within  their  capsulo-periosteal  covering.  The  tourniquet 
is  then  loosened  and  the  vessels  not  tied  during  the  steps  of  the  operation 
which  bleed  are  now  tied.  The  edges  of  the  capsulo-periosteal  sheath  are 
sutured  together  with  catgut.  But  where  muscles  have  been  cut  along  the 
original  incision,  these  are  quilted  with  catgut.  Even  where  no  muscle- 
fibers  are  laid  bare,  but  only  the  rounded  borders  uncut,  it  is  well  to  quilt 
together  such  separated  muscles,  as  the  fascia  covering  them  unites  and  fills 
the  dead  spaces  and  hastens  repair  of  the  wound  as  a  whole.  Temporary 
drainage  is  indicated  in  the  larger  excisions.  The  suturing  of  the  skin  should 
be  done  with  silk  or  silkworm-gut — which  is  usually  removed  about  the  tenth 
day. 

Application  of  Retentive  Apparatus,  and  After-treatment. — The 
future  usefulness  of  the  limb  depends  almost  more  upon  the  after-treatment 
than  upon  the  manner  of  operation.  There  is  hardly  any  set  of  operations 
in  which  the  ultimate  outcome  is  more  dependent  upon  the  care  and  manage- 
ment subsequent  to  operation.  The  usefulness  of  the  limb  also  largely 
depends  upon  non-suppuration,  or  but  limited  and  brief  suppuration.  While 
temporary  drainage  is  at  first  indicated,  the  dressings  should  be  dry  and 
infrequent.  In  applying  the  first  dressing,  the  limb  may  be  immobilized 
upon  almost  any  splint — often  the  permanent  position,  or  method  of  treatment, 
cannot  be  adopted  immediately.  Or  the  limb,  on  the  other  hand,  may  be 
put  up  in  its  permanent  and  special  splint  from  the  first.  This  latter  course 
is  preferable  when  possible.  In  still  another  class  of  cases,  as  in  operating 
for  deformity,  it  may  take  some  time  to  bring  the  limb  into  its  permanent 
position.  The  kind  of  splint  or  retentive  apparatus  adopted  is  extremely 
important.  It  should  be  selected  to  do  the  special  work  in  hand — and  be 
very  precisely  applied.  Its  features  are, — (a)  that  it  should  firmly  grasp 
the  limb  above  and  below  the  excised  joint — and  (b)  that  it  should  be  hinged, 
the  hinge  corresponding  with  the  joint,  so  that  from  time  to  time  the  angle 
of  the  joint  can  be  changed,  while  still  retaining  the  relative  relations  of  the 
ends  of  the  bones.  If  mobility  is  to  be  expected,  the  ends  of  the  bones  should 
not  be  put  up  in  direct  contact — the  amount  of  separation  varying  with 
circumstances — the  separation  being  less  in  adults,  and  where  much  perios- 
teum has  been  saved,  than  in  the  reverse  conditions.  If  ankylosis  be  desired, 
the  ends  of  the  bones  should  be  put  up  in  close  contact  in  the  position  desired 
— and  should  be  kept  rigidly  in  contact  until  union  is  solid.  As  to  passive 
movement,  there  is  no  fixed  time  at  which  it  should  begin.  It  should  com- 
mence just  as  soon  as  acute  inflammation  and  sensitiveness  subside  (generally 
in  from  one  to  three  weeks).  General  good  health,  massage,  and  electricity 
all  aid  the  favorable  course  of  the  traumatism  and  the  final  functioning. 


EXCISION   BY  THE  OPEX   METHOD.  467 

What  has  been  said  of  apparatus  and  after-treatment  in  connection  with 
the  subperiosteal  method  of  excision,  also  applies  equally  to  the  open  method. 
Comment. — (I)  No  vessels  of  importance  are  ordinarily  injured  in  the 
operations  of  excision — but,  if  injured,  should  be  ligated.  (2)  All  synovial 
membrane,  and  even  extra-articular  tissue,  must  be  removed  if  diseased. 
(3)  Where  muscles  or  tendons  must  be  divided,  their  oblique  division  is 
preferable.  In  any  event,  they  should  be  sutured  with  gut.  (4)  Extensive 
gouging,  or  curettage,  is  a  legitimate  substitute  for  typical  excision,  where 
the  latter  is  impracticable — as  where  an  epiphyseal  cartilage  might  be  de- 
stroyed. (5)  Where  ankylosis  is  sought,  the  synovial  membrane  should  be 
thoroughly  dissected  away.  (6)  Retention  of  the  periosteum  gives  firmness 
to  the  cicatrix,  even  where  the  amount  of  bone  deposited  is  little  or  none — 
lessens  the  shortening  of  the  limb — and  helps  retain  the  proper  relational 
attachment  of  the  muscles.  A  periosteo-capsular  covering  favors  the  repro- 
duction of  a  joint  with  articular  cartilages,  and  gives  support  to  ligaments. 
(7)  Tendons  often  have  to  be  removed  with  knife,  cutting  close  to  the  bone — 
or  may  be  chiseled  away  with  a  thin  shell  of  bone.  (8)  The  removal  of 
tissue  must  not,  ordinarily,  be  stopped  short  of  the  removal  of  the  entire 
diseased  structures.  (9)  The  destruction  of  the  epiphyses  in  young  children 
should  be  avoided.  (10)  When  the  saw-section  does  not  remove  all  of  the 
involved  bone,  it  is  better  to  remove  the  balance  with  a  gouge  than  to  saw 
another  section,  (n)  The  gap  of  an  excised  bone  may  be  filled  by  bone- 
grafting.  (12)  The  periosteum  is  easily  removable  in  chronic  osteitis  and 
synovitis — and  hard  to  remove  in  acute  periosteitis. 


EXCISION  BY  THE  OPEN  METHOD. 

Description. — No  attempt  is  here  made  to  preserve  the  periosteum.  The 
continuous  attachment,  therefore,  of  periosteum  and  capsule  is  sacrificed — 
though  the  capsule  is  preserved.  The  tendons  are  peeled  from  their  attach- 
ment to  the  periosteum — and  some  of  the  ligaments  of  the  joints  are  sacrificed. 
The  open  method  is  more  rapid,  but  more  damage  is  done  to  the  neighboring 
structures,  and  less  satisfactory  functioning  of  the  joint  is  apt  to  follow. 
The  chief  indication  for  adopting  the  open  method  is  found  in  those  cases 
where,  from  disease,  or  other  cause,  the  preservation  of  the  periosteum  is 
contraindicated.  For  further  comparison,  see  under  Description  of  the 
Subperiosteal  Method,  page  464.  A  reckless  and  careless  sacrifice  of  capsule, 
tendons,  and  ligaments  in  the  open  method  is  distinctly  unjustifiable.  In 
undertaking  the  open  method,  even  in  disease,  the  operation  should  be  carried 
out  with  the  underlying  idea  of  a  "modified  subperiosteal  method  as  far  as 
consistent." 

Preparation — Position — Landmarks. — As  in  the  subperiosteal  method. 

Preliminary  Control  of  Hemorrhage. — The  use  of  a  constrictor  is  here 
indicated  even  more  than  in  the  subperiosteal  method — as  hemorrhage  will, 
usually,  be  greater,  from  the  greater  damage  to  the  involved  parts. 

Incision. — The  line  of  incision  for  the  open  method  is  generally  the 
same  as  that  for  the  subperiosteal  method.  Sometimes,  however,  the  sub- 
periosteal excision  of  a  joint  is  done  through  one  incision — and  the  open 
excision  through  another.  Whether  the  position  of  the  line  of  incision  be 
the  same  or  not,  the  manner  of  making  it  and  of  reaching  the  level  of  the 
bone,  or  joint,  are  the  same. 

Operation.— Up  to  the  point  of  reaching  the  level  of  the  joint,  or  bone, 


468  EXCISIONS. 

there  is  no  difference  between  the  open  and  subperiosteal  methods  of  excision. 
Once  the  bone  is  reached  in  the  open  method,  however,  no  attempt  is  made 
to  preserve  the  periosteum — although  the  soft  parts  are  disturbed  as  little 
as  possible.  The  periosteum  is  not  cut  through  over  the  bones  above  and 
below  the  joint.  The  muscles  and  tendons  are  detached — not  cut,  but 
peeled — from  the  bones  as  closely  as  possible.  While  some  of  the  ligaments 
of  the  joint  are  saved,  some  are  unavoidably  lost.  This  separation  is  accom- 
plished by  rugines,  raspatories,  and  by  stout  excision  knives,  rather  than  by 
periosteal  elevators.  The  capsule  of  the  joint  is  cut  into  as  soon  as  the 
articular  region  is  sufficiently  exposed  and  cleared.  The  bones  are  then 
disarticulated  and  their  ends  protruded  and  sawed  off,  during  which  the  soft 
parts  are  well  protected.  The  ends  of  the  bones  are  now  drawn  back  into 
their  musculo-capsular  (rather  than  periosteo-capsular)  sheath — the  con- 
strictor relaxed — the  vessels  ligated — the  cut  or  separated  muscles  quilted — 
and  the  limb  put  up  and  subsequently  treated  as  in  the  subperiosteal  method. 
Application  of  Retentive  Apparatus,  and  After-treatment — Com- 
ment.— As  in  Excision  by  the  Subperiosteal  Method  (page  464). 


EXCISION  OF  COCCYX 

BY  POSTERIOR  MEDIAN  INCISION. 

Description. — Separation  of  coccyx  at  sacrococcygeal  articulation  and 
removal  from  its  bed  of  soft  parts. 

Position. — Patient  on  side  at  edge  of  table;  thigh  flexed;  buttocks  sepa- 
rated. 

Landmarks. — Tip  and  outline  of  coccyx,  and  position  of  sacrococcygeal 
articulation.  If  necessary,  this  articulation  may  be  determined  by  means 
of  a  gloved  finger  introduced  within  the  rectum  and  the  coccyx  palpated 
between  this  finger  within  and  the  thumb  without. 

Incision. — Begins  in  middle  line,  just  above  sacrococcygeal  articulation 
— passes  vertically  downward — and  ends  just  below  the  tip  of  the  coccyx. 

Operation. — Incise  through  skin  and  fascia  to  the  bone.  Separate  the 
gluteus  maximus  from  the  posterior  surface — the  coccygeus  from  the  anterior 
surface — the  sphincter  ani  from  its  tip  in  front  and  the  levator  ani  from  its 
tip  behind — and  the  sacrococcygeal  ligaments  from  its  upper  aspect — hugging 
the  bone  closely  and  putting  the  parts  upon  the  stretch  after  freeing  the  tip 
— thus  completing  the  disarticulation.  Sometimes  the  bone  may  be  more 
easily  removed  by  freeing  its  posterior  aspect  and  lateral  borders — then  dis- 
articulating and  levering  out  its  upper  end — and,  while  this  is  being  drawn 
backward,  its  anterior  surface  is  freed  from  above  downward.  The  incised 
muscles  are  sutured  together  deeply  with  buried  gut — and  the  superficial 
wound  closed. 


OSTEOPLASTIC  RESECTIONS  OF  BONES  AND  JOINTS. 

Description. — An  osteoplastic  operation,  in  general,  consists  in  the  ap- 
proximation of  fresh  sections  of  bone  to  each  other,  for  the  purpose  of  bringing 
about  union  between  their  opposed  aspects.  The  surfaces  brought  thus 
into  contact  may  have  been  originally  in  contact,  as  the  margin  of  an  oval 
of  bone  turned  back  from  the  skull  and  afterward  dropped  into  its  old  place, 
— or  some  new  bony  contact  may  be  brought  about,  as  when,  after  total 
excision  of  the  tarsus,  the  sawed  ends  of  the  metatarsals  are  approximated 


EXCISIONS    ABOUT    THE    SUPERIOR    MAXILLA.  469 

to  the  sawed  ends  of  the  tibia  and  fibula.  Osteoplastic  Resection  of  a  Bone 
consists  in  the  resection,  or  cutting  through,  of  a  bone  in  such  a  way  as  to 
leave  its  soft  coverings  attached,  and,  in  addition,  a  hinge-like  connection 
of  soft  parts  connecting  it  with  the  neighboring  bone  from  which  cut — and 
in  then  turning,  that  is,  breaking,  back  the  portion  of  bone,  with  its  soft  cover- 
ings adherent  and  soft  hinge  intact,  in  some  convenient  direction,  thus  ad- 
mitting of  free  access  to  the  underlying  structures  sought  in  the  special  opera- 
tion— and  of  subsequently,  upon  completion  of  the  object  sought,  turning  the 
bone-flap,  or  bone  part,  with  its  connected  soft  parts,  back  into  its  original 
place — union  of  the  bony  surfaces  being  expected  and  a  reproduction  of  the 
status  ante  quo — as  in  the  osteoplastic  exposure  of  the  brain.  Osteoplastic 
Resection  of  a  Joint  is  an  operation  in  which,  after  the  ordinary  excision  of 
the  joint,  the  sawed  bony  surfaces  immediately  beyond  the  joint  are  brought 
into  contact  for  permanent  union — and,  therefore,  implies  that  no  motion  is 
to  be  expected  in  that  region.  The  excision  of  the  knee-joint,  or  of  any  other 
joint,  where  ankylosis  is  expected,  or  results,  whether  expected  or  not,  is, 
consequently,  not,  properly  speaking,  a  simple  excision,  but  an  osteoplastic 
excision  or  resection.  In  another  sense  an  osteoplastic  resection  of  a  joint 
may  consist  of  a  technic  some  part  of  which  involves  the  temporary  severing 
of  a  neighboring  part  of  bone  to  reach  the  joint,  after  accomplishing  which 
the  severed  bone  is  sutured  back  into  place — as  the  temporary  removal  of  the 
acromion  to  reach  the  shoulder-joint  by  Kocher's  method  (page  503). 

General  Surgical  Considerations. — (i)  The  osteoplastic  resection  of  a 
bone,  as  to  the  manner  of  its  performance,  is  done,  in  all  practical  respects, 
in  the  same  way  as  an  excision  of  a  bone — except  that  the  soft  parts  are  not 
cleared  from  the  surface  of  the  bone  entering  into  the  osteoplastic  flap,  and 
that  the  hinge-like  connection  of  soft  parts  between  the  bone-flap  and  the 
main  bone,  or  bony  surroundings,  is  disturbed  as  little  as  possible.  (2)  The 
osteoplastic  resection  of  a  joint  is  performed,  as  far  as  the  excision  itself  is 
concerned,  in  precisely  the  same  manner  as  an  ordinary  excision  of  a  joint — 
except  that  after  the  removal,  or  excision  of  the  joint  surfaces,  the  cut  surfaces 
of  the  bones  beyond  are  brought  into  permanent  contact — and  solid  bony 
union  sought,  or  a  neighboring  process  of  bone  may  be  temporarily  removed 
to  reach  the  joint,  as  described  above. 

SURGICAL  ANATOMY   INVOLVED   IN  EXCISIONS   ABOUT  THE 
SUPERIOR  MAXILLA. 

Articulations  of  Superior  Maxilla. — With  frontal;  ethmoid;  nasal; 
lachrymal;  malar;  inferior  turbinated;  palate;  vomer;  and  its  fellow. 

Muscles  Attached  to  Superior  Maxilla. — Orbicularis  palpebrarum; 
inferior  oblique;  levator  labii  superioris  akeque  nasi;  levator  labii  superioris; 
levator  anguli  oris;  compressor  nasi;  depressor  alae  nasi;  dilator  naris  poste- 
rior; masseter;  buccinator;  internal  pterygoid;  orbicularis  oris. 

Arteries  in  Neighborhood  of  Superior  Maxilla. — Facial  and  its  follow- 
ing branches: — superior  coronary,  arteria  septi  nasi,  lateralis  nasi,  angular, 
muscular  (masseter  and  buccinator).  From  temporal: — transverse  facial. 
From  internal  maxillary: — anterior  dental,  alveolar  or  posterior  dental, 
descending  or  posterior  palatine,  pterygopalatine,  sphenopalatine,  infra- 
orbital.    From  ophthalmic: — inferior  palpebral. 

Veins  in  Neighborhood  of  Superior  Maxilla. — (1)  Superficial:— Facial, 
with  its  following  tributaries,— angular,  superior  and  inferior  lateral  nasal, 
inferior    palpebral,    infraorbital,    anterior    internal    maxillary    (deep    facial, 


47° 


EXCISIONS. 


between  buccinator  and  masseter  muscles),  superior  coronary,  transverse 
facial,  and  muscular  branches  (masseter  and  buccinator).  (2)  Deep: — 
veins  corresponding  to  branches  of  internal  maxillary  artery,  forming  the 
pterygoid  plexus  (situated  on  the  inner  surface  of  the  internal  pterygoid  and 
partly  around  the  external  pterygoid) — ending,  anteriorly,  in  the  anterior 
internal  maxillary  (or  deep  facial),  joining  the  facial  vein — and  ending, 
posteriorly,  in  the  internal  maxillary  vein,  which  unites  with  the  common 
temporal  vein  to  form  the  temporomaxillary  vein 

Chief  Nerves  in  Neighborhood  of  Superior  Maxilla. — (1)  From  facial: 
— malar;  supraorbital  branches  of  temporofacial  division;  and  buccal  branch 
of  cervicofacial  division.  (2)  From  superior  maxillary  division  of  fifth  nerve: 
— malar;  posterior  superior,  middle  superior,  and  anterior  superior  dental; 


Fig.  380. — Skin  Incisions  in  Excisions  about  the  Maxill.k: — A,  Excision  of  superior  max- 
illa, by  median  incision  (Fergusson's  operation);  B,  Excision  of  inferior  maxilla. 

palpebral;  nasal;  labial.  (3)  From  sphenopalatine  ganglion — anterior  (large) 
palatine;  middle  (external)  palatine;  posterior  (small)  palatine;  superior 
nasal  branches;  nasopalatine;  upper  posterior  nasal. 

Other  Structures  in  Neighborhood  of  Superior  Maxilla. — Eye; 
nasal  duct;  antrum  of  Highmore. 

Surface  Form  and  Landmarks  of  Superior  Maxilla. — The  superior 
maxilla  forms  the  largest  part  of  the  face — the  outer  wall  and  larger  part  of 
floor  of  nose — the  larger  part  of  roof  and  part  of  outer  wall  of  mouth — and 
part  of  floor  of  orbit. 

General  Surgical  Considerations  in  Operations  upon  Superior 
Maxilla. — See  under  Description  and  Comment,  in  Excision  of  the  upper 
jaw,  pages  471  and  473. 


EXCISION    OF    SUPERIOR    MAXILLA.  47 1 


EXCISION  OF  SUPERIOR  MAXILLA 

BY  MEDIAN  INCISION  — FERGUSSON'S  OPERATION. 

Description. — Ordinarily  refers  to  removal  of  superior  maxilla  of  one 
side,  as  herein  described — more  rarely,  to  the  removal  of  both  superior  maxilla-. 
The  entire  bone  is  removed — except  the  upper  part  of  the  nasal  process.  In 
addition  to  the  removal  of  the  entire  bone,  the  following  additional  bones 
are  removed,  in  whole  or  in  part: — lower  part  of  malar;  part  or  whole  of 
palate  bone;  whole  inferior  turbinated. 

Preliminary  Steps  to  Excision. — Preliminary  tracheotomy  is  often  per 
formed,  with  plugging  of  the  larynx,  or  the  use  of  a  tampon-cannula.  Pre- 
liminary exposure  of  the  external  carotid,  with  temporary  ligation  of 
the  vessel  during  the  operation,  is  also  often  performed.  Both  of  these 
steps  are  indicated  in  difficult  cases  where  especial  trouble  is  antici- 
pated. 

Position. — Patient  supine;  head  and  shoulders  well  elevated;  face 
turned  to  sound  side;  region  shaved;  posterior  nares  plugged  (for  earlier 
part  of  operation).  Surgeon  to  right  side  in  either  case.  Assistant  oppo- 
site surgeon. 

Landmarks. — General  contour  and  boundaries  of  superior  maxilla. 

Incisions. — Median  Incision — begins  about  1.3  cm.  (\  inch)  below 
the  inner  canthus — passes  down  in  the  naso-facial  groove- — curves  around 
convexity  of  ala  nasi — passes  along  margin  of  nostril,  in  naso-labial 
groove,  to  mid-line  of  lip — and  thence  downward  through  the  center 
of  the  upper  lip.  Horizontal  Incision — passes  from  the  beginning  of  the 
median  incision  along  the  lower  border  of  the  orbit,  to  end  over  the  malar 
bone  beyond  the  outer  canthus  (Figs.  380,  A,  and  381,  A,  B,  C). 

Operation. — (1)  The  above  incision  passes  everywhere  to  the  bone. 
While  incising  from  the  inner  canthus  to  the  septum  nasi,  and  from  the  inner 
canthus  to  the  malar,  the  facial  artery  is  compressed  over  the  inferior  maxilla. 
Just  before  dividing  the  upper  lip,  the  lip  is  compressed  on  either  side  of  the 
median  line,  between  thumb  and  finger,  and,  when  severed,  the  superior 
coronary  arteries  are  tied  while  still  compressed.  In  this  median  incision 
are  cut  the  following  arteries  and  corresponding  veins — angular,  lateralis 
nasi,  superior  coronary,  arteria  septi  nasi,  and  branches  of  the  infraorbital. 
In  the  horizontal  incision,  branches  of  the  infraorbital  and  transverse  facial 
are  cut.  (2)  Dissect  up  the  flap  included  in  the  above  incisions — clearing 
the  surface  of  the  superior  maxilla  as  completely  as  possible,  though  not 
subperiosteal!}'.  The  infraorbital  artery  is  divided  during  this  stage.  (3) 
Detach  the  nasal  cartilages  from  the  bone.  Divide  the  nasal  process  of  the 
superior  maxilla  with  a  fine  saw,  from  the  junction  of  the  nasal  process  with 
the  lower  border  of  the  nasal  bone,  to  the  margin  of  the  orbit  just  below  the 
canal  for  the  nasal  duct.  (4)  Raise  the  periosteum  from  the  floor  of  the 
orbit,  including  the  origin  of  the  inferior  oblique,  and  retract  them  upward, 
carefully  protecting  the  eye-structures.  With  a  fine,  narrow  chisel,  chisel 
obliquely  across  the  orbital  plate,  from  the  end  of  the  saw-cut  dividing  the 
nasal  process,  to  the  anterior  end  of  the  sphenomaxillary  fissure.  (5)  The 
orbital  and  external  surfaces  of  the  malar  bone  are  now  cleared,  the  former 
subperiosteallv,  preparatory  to  sawing.     A  chain  or  Gigli  saw  is  then  guided 


472 


EXCISIONS. 


into  position  through  the  sphenomaxillary  fissure  and  zygomatic   fossa,  upon 

a  curved  carrier,  or  aneurism- 
needle,  closely  hugging  the  bone 
— and  the  malar  bone  divided  ob- 
liquely through  its  middle,  from  the 
anterior  end  of  the  sphenomaxil- 
lary fissure  downward  and  out- 
ward to  the  center  of  its  lower 
free  border.  (6)  Extract  the  cen- 
tral incisor  tooth  of  the  involved 
side.  Divide  the  muco-periosteal 
covering  of  the  hard  palate  in  the 
median  line  along  the  intermax- 
illary and  interpalatal  sutures, 
from  the  alveolar  process  to  the 
posterior  nasal  spine.  Similarly 
divide  the  muco-periosteal  cover- 
ing of  the  floor  of  the  nose,  with 
a  long  knife,  cutting  as  near  the 
septum  as  possible,  from  the  pos- 
terior nasal  spine  to  the  anterior 
nasal  spine.  Make  a  transverse 
incision  across  the  roof  of  the 
mouth,  at  the  junction  of  the  hard 
and  soft  palates,  and  separate  the 
latter  from  the  former.  Pass  a 
long,  narrow  saw  in  through  the 
nose,  seeing  that  its  tip  passes 
through  the  interval  between  the 
separated  hard  and  soft  palates  (not 
injuring  the  latter),  and  divide  the 
horizontal  plate  of  the  palate  and  palatal  and  alveolar  portions  of  the  superior 
maxillary  bone  as  nearly  in  the  central  line  as  the  septum  nasi  will  allow.  The 
descending  palatine  and  nasopalatine  arteries  are  cut  here  and  bleed  freely. 
(7)  Grasp  the  superior  maxilla  with  large  bone-forceps,  catching  the  orbital 
and  alveolar  aspects  of  the  bone,  and  gently  wrench  it  from  side  to  side  to 
determine  the  position  and  extent  of  the  remaining  connections  which  still 
hold  it  in  place.  The  two  remaining  bony  connections  are,  part  of  the  orbital 
plate,  and  the  union  between  the  pterygoid  processes  and  superior  maxilla. 
These  are  generally  severed  with  cutting  forceps.  The  former  is  more 
accessible.  The  latter,  after  depressing  the  inferior  maxilla,  and  freeing  the 
outer  and  posterior  surfaces  of  the  superior  maxilla,  is  separated  by  means  of 
angular  bone-cutting  forceps  introduced  within  the  mouth  and  passed  up 
behind  the  maxillary  tuberosity — being  sure  that  the  soft  palate  has  been 
entirely  separated  and  held  out  of  the  way.  Or,  after  depressing  the  inferior 
maxilla,  a  chisel  may  be  used  between  the  superior  maxilla  and  pterygoid 
process.  The  superior  maxilla  is  thus  drawn  away  in  the  hold  of  the  large 
forceps,  after  all  bony  connections  have  been  divided.  The  posterior  dental, 
pterygopalatine,  and  infraorbital  arteries  are  here  severed.  (8)  All  bleeding 
vessels  are  now  secured,  and  remaining  hemorrhage  controlled  by  temporary 
gauze  packing.  The  wound  is  sutured  throughout — and  with  especial  care* 
through  the  upper  lip,  to  avoid  disfigurement.  Drainage  is  established 
through  the  mouth.  Feeding  is  done  by  a  tube  for  a  time.  An  artificial 
palate  is  generally  worn  after  the  operation. 


Fig.  381. — Bone  Sections  in  Excisions 
about  the  Maxill/E: — A,  B,  C,  Lines  of 
bone-division  in  excision  of  right  superior 
maxilla,  by  Fergusson's  method;  D,  Line  of 
division  of  inferior  maxilla,  in  excision  of  left 
inferior  maxilla,  or  in  the  osteoplastic  resec- 
tion of  the  lower  jaw,  by  median  section. 


CHOXDROPLASTIC    RESECTION    OF    NASAL    CARTILAGES.  473 

Comment. — (I)  No  attempt  is  made  to  remove  the  superior  maxilla 
subperiosteal!}'  in 'the  above  operation.  (2)  Preservation  of  branches  of  the 
facial  nerve  is  important.  (3)  While  the  above  method  of  freeing  the  bone 
from  its  final  attachments  is  to  be  preferred,  yet  if  difficulty  be  experienced 
in  severing  the  ptervgomaxillary  connections  by  cutting  forceps,  the  superior 
maxilla  may  be  separated  from  the  pterygoid  processes  by  a  quick  downward 
wrench,  tearing  it  away  from  its  bony  attachments.  (4)  The  upper  jaw  may 
also  be  excised  by  the  methods  of  Velpeau,  Langenbeck,  Liston,  Gensoul, 
Nelaton,  Boeckel,  Oilier,  and  others. 

Partial  Excisions  of  the  Superior  Maxilla. — The  following  parts  of 
the  upper  jaw  may  be  done  through  special  incisions, — (a)  Alveolar  and 
palate  processes, — (b)  Orbital  and  nasal  portions, — (c)  All  the  superior 
maxilla  below  the  infraorbital  foramen, — (d)  All  the  superior  maxilla  except 
the  orbital  plate. 

OSTEOPLASTIC  RESECTION  OF  SUPERIOR  MAXILLA 

BY  VERTICAL  AND  HORIZONTAL  INCISIONS. 

Description. — Having  made  the  same  incisions,  preceded  by  the  same 
preliminaries,  as  in  the  ordinary  excision  of  the  upper  jaw  by  Fergusson's 
method  (page  471),  and  carried  them  everywhere  to  the  bone — the  soft  parts 
are  carefully  guarded,  and  are  nowhere  freed  from  the  bones,  except  in  so 
far  as  necessary  to  reach  the  bones  in  making  the  original  incisions.  The 
bones  are  now  divided  just  as  in  that  operation,  everywhere  along  the  line 
of  skin  incision — except  that  no  division  of  the  bone  is  made  from  the  anterior 
end  of  the  sphenomaxillary  fissure  through  the  malar — this  portion  of  bone 
being  preserved  for  the  "hinge."  When  all  other  connections  have  been 
divided,  the  bone,  with  its  soft  parts  adherent,  is  broken  outward  and  back- 
ward through  the  above  indicated  undivided  portion  as  a  hinge — by  putting 
pressure  from  without  over  the  region  where  the  bone  is  to  be  broken  back, 
and  then  prizing  it  outward  and  backward  in  that  direction.  At  the  end 
r>f  the  operation,  the  flap  of  bone  and  soft  parts  is  turned  back  into  place — 
and,  if  necessary,  the  bone  wired. 

Comment. — It  is  better  to  previously  divide  the  frontal  process  of  the 
malar,  making  a  limited  incision  for  that  purpose,  prior  to  turning  back  the 
bone — thus  avoiding  the  uncertainty  of  the  line  of  breakage  and  possible 
harm  that  might  result  to  neighboring  structures  through  the  rougher 
manoeuvre. 

CHONDROPLASTIC  RESECTION  OF  NASAL  CARTILAGES 

TO  EXPOSE  NOSE  AND  ANTERIOR  NASOPHARYNX  PA*  NASAL  ROUTE,  BY  TRANS- 
VERSE INCISION  — ROUGE'S  OPERATION. 

Description. — The  cartilaginous  portion  of  the  nose  is  temporarily 
separated  from  the  bony  nares  and  turned  upward. 

Position. — Patient  supine,  with  head  elevated  and  thrown  back. 

Landmarks. — Line  of  reflection  of  mucous  membrane  of  upper  lip. 

Incision  and  Operation. — An  assistant  stands  behind  the  head  and 
draws  the  upper  lip  well  upward,  holding  it  opposite  the  angles  of  the  mouth. 
The  surgeon,  standing  in  front,  with  scissors  curved  on  the  flat,  cuts  the 
mucous  membrane  in  the  line  of  its  reflection  from  the  superior  maxilla,  from 
one  bicuspid  tooth  to  the  opposite  one,  hugging  the  bone  throughout.  Simi- 
larly separate  the  cartilaginous  septum  from  the  anterior  nasal  spine,  and 
alar  cartilages  from  the  lateral  borders  of  the  maxilla.     Having  retracted 


474  EXCISIONS. 

the  cheeks  well,  the  anterior  naris  is  now  turned  upward  and  backward 
toward  the  forehead.  At  the  end  of  the  operation,  the  nose  is  dropped  back 
into  place  and  the  cut  edges  of  the  mucous  membrane  sutured,  if  sufficient 
free  margin  exist — but  suturing  is  not  necessary. 

Comment. — This  operation  gives  imperfect  access  to  the  nasopharynx — ■ 
but  satisfactory  access  to  the  nose.  The  cheeks  must  be  sufficiently  separated 
from  the  underlying  bones  to  enable  the  nose  to  be  turned  back. 

OSTEOPLASTIC  RESECTION  OF  SUPERIOR  MAXILLA 

TO  EXPOSE  NASOPHARYNX  BY  PALATINE  ROUTE,  BY  TRANSVERSE   AND 
Ml  MIAN  INCISIONS  — ANN ANDALE'S  OPERATION. 

Description. — After  having  exposed  the  bony  anterior  nares  as  in  Rouge's 
operation,  the  alveolar  and  palatal  processes  of  the  superior  maxilla  are 
divided  in  the  median  line,  and  the  septum  nasi  also  divided.  The  two 
halves  of  the  superior  maxilla  can  then  be  separated  from  1.3  to  2.5  cm. 
(J  to  1  inch). 

Position. — Patient  supine,  head  elevated  and  thrown  back.  Surgeon 
faces  patient. 

Landmarks. — Anterior  and  posterior  nasal  spines;  septum  nasi;  two 
central  incisors. 

Incisions. — Transverse  Incision — through  mucous  membrane  of  upper 
lip  (this  portion  of  the  operation  being  similar  to  Rouge's).  Median  Incision 
— follows  the  base  of  the  septum  nasi,  as  near  to  the  middle  line  as  possible, 
and  extending  along  the  floor  of  the  nose  from  the  margin  of  the  posterior 
bonv  nares  to  the  anterior  bony  nares,  and  along  the  alveolar  process  of  the 
superior  maxilla  between  the  two  central  incisors,  possibly  extracting  one. 

Operation. — Expose  the  bony  anterior  nares  as  in  Rouge's  operation 
(page  473).  Divide  the  septum  nasi  just  above  the  maxillary  attachment, 
from  before  backward,  with  a  fine  narrow  saw,  or  with  cutting  pliers.  Having 
gagged  the  mouth  open,  separate  the  soft  from  the  hard  palate  by  a  short 
transverse  incision  crossing  the  median  line.  If  necessary,  the  soft  palate 
may  be  divided.  Drill  holes  in  the  alveolar  process  for  future  wiring. 
By  means  of  a  fine,  narrow  saw,  introduced  through  the  nose,  divide  the  entire 
length  of  hard  palate  and  alveolar  process  of  superior  maxilla,  in  the  median 
line.  The  two  halves  of  the  superior  maxillae  are  now  prized  apart  and  the 
nasopharynx  reached  with  instruments.  Upon  the  completion  of  the  opera- 
tion, the  alveolar  process  is  wired  and  the  soft  palate  sutured  back  to  the 
soft  tissues  of  the  hard  palate  (and  together,  if  divided).  The  nose-flap  of 
Rouge's  operation  is  dropped  back  into  place  and  the  mucous  lips  of  the 
wound  closed. 

Comment. — The  room  thus  furnished  is  not  great.  The  above  operation 
may  be  considered  the  first  step  of  an  osteoplastic  resection  of  the  entire 
superior  maxilla. 

OSTEOPLASTIC  RESECTION  OF  SUPERIOR  MAXILLA 

TO  EXPOSE  NASOPHARYNX  BY  MAXILLARY  ROUTE,  BY  TWO   SEMILUNAR 
INCISIONS  —  LANGENBECK'S  OPERATION. 

Description. — A  tongue-shaped  flap,  having  its  base  over  the  nose  and 
its  apex  over  the  malar  bone  is  turned  forward  and  inward  upon  the  nasal 
bone  and  nasal  process  of  superior  maxilla  as  a  hinge. 

Position. — Patient  supine;  head  elevated  and  turned  to  opposite  side 
Surgeon  on  side  of  operation. 


EXCISIONS    ABOUT    THE    INFERIOR    MAXILLA.  475 

Landmarks. — Naso-frontal  suture;  ala  nasi;  malo-zygomatic  arch. 

Incisions. — Upper  Incision — begins  at  root  of  nose  and  passes  down- 
ward and  outward  just  below  the  lower  border  of  the  orbit,  ending  a  short 
distance  posterior  to  the  center  of  the  malar.  Lower  Incision — begins  at 
ala  nasi  and  passes  upward  and  outward  across  the  cheek,  joining  the  outer 
end  of  the  upper  incision.  These  united  incisions  may  extend  further  out- 
ward as  a  single  incision  along  the  zygoma,  if  necessary. 

Operation. — (1)  Incise  everywhere  through  skin,  fascia,  and  muscles, 
and  through  periosteum  to  bone.  Separate  the  periosteum  for  only  a  wide 
enough  interval  along  the  lines  of  incision  for  a  saw  to  travel — except  along 
the  floor  of  the  orbit,  where  it  is  stripped  to  the  anterior  end  of  the  spheno- 
maxillary fissure.  The  masseter  is  detached  from  the  malar  where  exposed. 
The  soft  parts  are  not  otherwise  raised  from  the  bone.  (2)  Depress  the 
inferior  maxilla  and  pass  a  sharp  periosteal  elevator,  or  pointed  director, 
below  the  inferior  border  of  the  zygoma,  opposite  its  junction  with  the  malar, 
and  thrust  it  horizontally  through  the  pterygomaxillary  fissure  to  the  outer 
wall  of  the  nasal  cavity,  which  is  recognized  by  a  finger  in  the  mouth.  Upon 
this  guide,  introduce  a  fine  key-hole  saw  and  divide  the  zygomatic  arch 
upward — continuing  the  section  so  as  to  enter  the  sphenomaxillary  fissure, 
cutting  the  posterior  wall  of  the  superior  maxilla  and  following  the  floor  of 
the  orbit  nearly  to  the  lachrymal  bone.  If  possible,  however,  it  is  better  to 
make  the  saw  section  follow  the  line  of  the  upper  semilunar  incision,  thus 
avoiding  the  orbital  plate.  (3)  The  saw  is  again  passed  into  the  pterygo- 
maxillary fissure  and  made  to  cut  forward  and  downward,  passing  through 
the  walls  of  the  antrum  and  into  the  anterior  nasal  cavity  near  its  floor — 
following,  approximately,  the  line  of  the  inferior  semilunar  incision.  (4)  Pass 
the  periosteal  elevator  into  the  pterygomaxillary  fissure  and  prize  the  severed 
portion  of  the  superior  maxilla  upward  and  inward — bending  it  over  the  nasal 
bone  and  nasal  process  of  the  superior  maxilla  (which  fracture  in  the  act) 
as  a  hinge.  (5)  At  the  end  of  the  operation,  turn  the  displaced  bone,  with 
its  soft  coverings  attached,  back  into  place — and  suture  the  wound. 

Comment. — Next  to  the  osteoplastic  resection  of  the  entire  bone,  the 
above  operation  gives  freer  access  to  the  nasopharynx  than  does  any  of  the 
other  partial  osteoplastic  resections  mentioned. 

SURGICAL   ANATOMY   INVOLVED   IN    EXCISIONS  ABOUT  THE 
INFERIOR   MAXILLA. 

Ligaments  of  Temporomaxillary  Articulation. — External  lateral; 
internal  lateral;  stylomaxillary;  capsular;  interarticular  fibrocartilage.  Two 
svnovial  membranes. 

Muscles  Attached  to  Inferior  Maxilla.— To  Outer  Aspect; — levator 
labii  inferioris;  orbicularis  oris;  depressor  labii  inferioris;  depressor  anguli 
oris;  platvsma  myoides;  buccinator;  masseter.  To  Inner  Aspect; — Genio- 
hyoglossus;  geniohyoid;  mylohyoid;  digastric;  superior  constrictor  of  pharynx; 
temporal;  internal  pterygoid;  external  pterygoid. 

Arteries  in  Neighborhood  of  Inferior  Maxilla. — Facial  and  following 
branches: — submaxillary,  submental,  muscular  (pterygoid,  masseter,  buc- 
cinator), inferior  labial,  inferior  coronary.  Internal  maxillary  and  following 
branches: — tympanitic,  middle  meningeal,  inferior  dental,  pterygoid,  masse- 
teric, buccal.  From  temporal: — transverse  facial.  (The  internal  carotid 
lies  considerablv  to  the  inner  side  of  the  lower  jaw.) 

Veins    in    Neighborhood    of    Inferior    Maxilla. — Superficial; — facial, 


476  EXCISIONS. 

with  its  following  tributaries;  transverse  facial,  inferior  coronary,  inferior 
labial,  submental,  submaxillary,  muscular  (pterygoid,  masseter,  buccinator). 
Superficial  and  Deep; — external  jugular  and  its  tributaries;  common  tem- 
poral, internal  maxillary,  communicating  branch  from  the  facial  to  external 
jugular.  Deep; — veins  corresponding  to  the  above  branches  of  the  internal 
maxillary  artery.  (The  internal  jugular  vein  lies  considerably  to  the  inner 
side  of  the  lower  jaw.) 

Chief  Nerves  in  Neighborhood  of  Inferior  Maxilla. — From  facial; — 
buccal,  supramaxillary  and  inframaxillary  branches  of  cervicofacial  division. 
From  inferior  maxillary  division  of  fifth  nerve; — internal  pterygoid,  masse- 
teric, temporal,  buccal,  external  pterygoid,  auriculotemporal,  lingual,  inferior 
dental.  (The  glossopharyngeal  and  hypoglossal  are  considerably  to  the 
inner  side  of  the  inferior  maxilla.) 

Other  Structures  in  Neighborhood  of  Inferior  Maxilla. — Parotid 
gland;  submaxillary  gland;  sublingual  gland. 

Surface  Form  and  Landmarks  of  Inferior  Maxillary  Region. — (i) 
Steno's  duct  of  the  parotid  gland  crosses  the  ascending  ramus  of  the  inferior 
maxilla  horizontally,  about  2  cm.  (f  inch)  below  and  parallel  with  the  zygo- 
matic arch — the  transverse  facial  artery  lying  above  and  the  facial  nerve 
below  it.  (2)  The  facial  nerve  crosses  the  parotid  gland  forward  and  slightly 
downward,  from  the  junction  of  the  anterior  border  of  the  mastoid  process 
and  the  ear.  (3)  The  facial  artery  crosses  the  inferior  maxilla  at  the  anterior 
border  of  the  masseter  muscle — the  facial  vein  lying  just  behind. 

EXCISION  OF  TEMPOROMAXILLARY  ARTICULATION 

BY  ANGULAR  INCISION. 

Description. — Consists  in  removal  of  condyle  of  inferior  maxilla.  The 
interarticular  fibro-cartilage  of  the  joint  and  the  glenoid  cavity  are,  ordinarily, 
not  disturbed. 

Position. — Patient's  head  and  shoulders  elevated;  faced  turned  to  oppo- 
site side.     Surgeon  on  side  of  operation.     Assistant  opposite. 

Landmarks. — Ascending  ramus  and  condyle  of  inferior  maxilla. 

Incision. — Vertical  portion — begins  at  lower  border  of  zygoma  and 
passes  vertically  downward  anterior  to  the  temporal  artery  (which  is  about 
2  cm.,  f  inch,  in  front  of  the  tragus),  ending  just  above  the  transverse  facial 
artery  (which  is  from  1.3  to  2  cm.,  ^  to  -|  inch,  below  the  zygoma).  Horizontal 
portion — passes  forward  along  the  lower  border  of  the  zygoma  for  about 
4  cm.  (i£  inches).     (Fig.  382.) 

Operation. — Incise  through  skin  and  fascia  and  turn  the  triangular  flap 
thus  raised  downward  and  forward.  Be  on  the  lookout  for  the  transverse 
facial  artery,  Steno's  duct,  and  facial  nerve,  all  crossing  parallel  with  the 
zygoma  from  behind  forward,  and  in  the  above  order  from  above  downward. 
Retract  the  lower  border  of  the  wound  downward  to  avoid  these — and  the 
vertical  border  backward,  with  the  anterior  margin  of  the  parotid  gland. 
Incise  whatever  portion  of  the  masseter  fibers  are  encountered  along  the 
lower  border  of  the  zygoma — and  along  the  ascending  ramus,  if  any  extend 
into  the  field.  Incise  the  capsule  of  the  joint  vertically  and  expose  the  condyle. 
Clear  the  circumference  of  the  neck  of  the  condyle,  as  near  the  condyle  itself 
as  possible,  closely  hugging  the  bone — leaving  some  of  the  lower  fibers  of 
the  external  pterygoid,  if  feasible.  Conduct  a  Gigli  saw  around  the  neck 
of  the  bone  and  divide  it  just  below  the  condyle.  This  is  better  than  dividing 
it  by  chisel  or  pliers.     Seize  the  condyle  with  bone-forceps  and  divide  any 


EXCISION    OF    INFERIOR    MAXILLA. 


477 


remaining  connections,  while  putting  traction  upon  the  end  of  the  bone — 
preserving  the  capsule  as  intact  as  possible.  Suture  the  capsule  with  buried 
gut.  If  the  masseter  have  been  extensively  removed  from  the  zygoma,  suture 
it  back  to  the  periosteum.  Establish  temporary  drainage.  Close  the  angular 
wound — and  dress  the  jaw  closed. 

Comment. — (I)  Both  temporomaxillary  articulations  may  require  simul- 
taneous excision.  (2)  The  joint  may  be  less  satisfactorily  excised  from  within 
the  mouth. 


Fig.  382. — Incisions  about  the  Inferior  Maxilla: — A,  Skin  incision  in  excision  of 
temporomaxillary  articulation  by  angular  incision;  B,  Bone  section  in  osteoplastic  resection  of 
lower  jaw  by  lateral  section. 


EXCISION  OF  INFERIOR  MAXILLA 

BY  SINGLE  INCISION  ALONG  INFERIOR  AND  POSTERIOR  BORDERS. 

Description. — Ordinarily  refers  to  the  removal  of  the  inferior  maxilla  of 
one  side.  Both  sides  may  be  removed.  The  bone  is  removed  subperiosteally, 
when  the  preservation  of  the  periosteum  is  not  contraindicated. 

Position. — Patient  supine;  head  and  shoulders  elevated;  head  to  opposite 
side;  face  shaved.     Surgeon  on  side  of  operation.     Assistant  stands  opposite. 

Landmarks. — General  contour  of  bone,  especially  its  inferior  and  poste- 
rior borders. 

Incision. — Begins  in  the  midline  of  the  chin,  just  below  the  free  portion 
of  the  lip — passes  down  the  front  of  the  chin  well  around  its  prominent  border 
— thence  follows  the  lower  border  of  the  inferior  maxilla,  passing  a  little 
nearer  the  posterior  than  the  anterior  aspect  of  the  border  (in  order  to  hide 
the  scar)  to  the  angle — thence  upward  along  the  posterior  border  of  the 
ascending  ramus — ending  about  opposite  the  center  of  the  ascending  ramus 
(about  opposite  the  lobule  of  the  ear).     (Fig.  380,  B,  and  381,  D.) 

Operation. — (1)  This  incision  is  everywhere  carried  through  skin,  fascia, 
platysma,  and  periosteum  to  bone — except  over  the  facial  artery,  where  the 


478  EXCISIONS. 

skin  alone  is  incised.  The  facial  artery  is  then  regularly  exposed,  doubly 
ligated  and  cut  between  the  ligatures.  (2)  All  the  structures  (see  Surgical 
Anatomy,  page  475)  covering  the  outer  surface  of  the  inferior  maxilla  are  now 
raised  subperiosteally,  working  from  the  free  border  of  the  bone  toward  the 
alveolar  margin,  and  from  the  symphysis  toward  the  angle  and  upward  along 
the  ascending  ramus.  The  mental  vessels  and  nerve  are  divided  at  the 
mental  foramen.  The  strong  attachment  of  the  masseter  muscle  is  difficult 
to  free  from  the  margin  of  the  angle,  except  with  a  sharp  rugine,  after  having 
cut  through  the  periosteum  to  the  bone.  The  bone  is  closely  hugged  every- 
where. The  clearing  is  continued  as  high  up  the  ascending  ramus  as  can  be 
reached  with  the  bone  in  situ.  (3)  The  structures  along  the  inner  aspect 
of  the  horizontal  ramus  of  the  jaw  are  now  similarly  separated  subperiosteally, 
in  the  same  order  as  upon  the  outer  surface,  as  far  as  they  can  be  reached. 
Guard  against  injuring  the  submaxillary  and  sublingual  glands.  (4)  The 
mucous  membrane  is  then  divided  along  the  alveolar  margin,  on  the  outer 
and  inner  sides — all  the  muscles  having  been  freed  from  both  aspects  of  the 
bone.  The  lower  lateral  incisor  tooth  is  extracted  and  a  chain  or  Gigli  saw 
conducted  around  the  bone  at  the  site  of  the  empty  socket.  As  much  of 
the  attachments  of  the  digastric,  geniohyoid,  and  geniohyoglossus  of  the 
involved  side  as  possible  are  saved  (for  their  future  action).  (5)  Seizing 
the  anterior  end  of  the  severed  jaw,  and  drawing  it  outward,  the  remaining 
structures  are  detached  from  the  inner  aspect — internal  pterygoid  muscle, 
inferior  dental  artery  and  nerve  at  the  inferior  dental  foramen,  superior  con- 
strictor of  the  pharynx,  internal  lateral  ligament,  stylomaxillary  ligament. 
If  not  already  divided,  the  mylohyoid  and  posterior  part  of  the  mucous  mem- 
brane of  the  mouth  are  now  separated.  (6)  Firmly  depress  the  anterior 
portion  of  the  inferior  maxilla,  thereby  bringing  the  coronoid  process  further 
forward  and  downward — and  then  cut  from  it  the  temporal  muscle  with 
blunt  curved  scissors,  following  the  anterior  border  of  the  coronoid  process 
upward.  (7)  Still  further  depress  the  inferior  maxilla,  until  the  coronoid 
process  is  more  accessible.  This  is  especially  necessary,  as  the  original  in- 
cision ceases  about  the  center  of  the  posterior  border  of  the  ascending  ramus, 
in  order  to  avoid  the  danger  of  cutting  the  important  structures  near  the 
upper  half  of  the  posterior  border  of  the  ascending  ramus  (parotid  gland, 
facial  nerve,  transverse  facial  and  internal  maxillary  arteries,  Steno's  duct, 
and  temporomaxillary  vein) — hence  the  coronoid  process  is  thus  approached 
from  before  rather  than  from  behind.  The  inferior  maxilla  should  be  de- 
pressed only,  and  not  rotated  outward — in  doing  the  latter,  the  internal 
maxillary  artery  is  apt  to  be  hooked  around  the  inner  portion  of  the  condyloid 
process  and  dragged  out  into  the  wound,  and  even  ruptured.  (8)  Following 
the  upper  inner  aspect  of  the  condyloid  process,  free  the  insertion  of  the 
external  pterygoid  with  elevator,  or  cut  with  blunt  curved  scissors.  Divide 
the  capsule  and  disarticulate  the  head  of  the  bone  forward.  If  not  already 
divided,  sever  the  internal  lateral,  stylomaxillary,  and  pterygomaxillary 
ligaments,  and  any  binding  bands  of  fascia,  or  fibers  of  the  external  pterygoid 
muscle.  (9)  The  wound  is  temporarily  drained  through  the  posterior  portion 
of  the  incision.     The  skin  wound  is  carefully  sutured  to  avoid  scar. 

Comment— (1)  Excision,  where  large  growths  complicate,  may  require 
a  preliminary  ligation  of  the  external  carotid — and  a  preliminary  tracheotomy, 
with  tamponing  of  the  larynx — as  well  as  division  of  the  entire  thickness  of 
the  lower  lip.  (2)  If  the  median  portion  of  the  inferior  maxilla,  and  therefore 
the  genial  tubercles,  be  removed,  the  tongue  must  be  stitched  forward  to 
keep  it  from  falling  backward.     (3)  The  coronoid  and  condyloid  processes 


EXCISION    OF    RIBS,    IN    GENERAL.  479 

may  require  to  be  first  divided  with  forceps  or  chisel,  and  then  withdrawn. 
(4)  Only  healthy  periosteum  is  to  be  saved — otherwise  an  open  operation  is 
indicated.  (5)  Any  portion  of  the  alveolar  process,  or  of  the  body,  may  be 
removed.  (6)  Both  inferior  maxillae  may  be  simultaneously  removed,  by 
a  repetition  of  the  above  procedure.  (7)  Feeding  through  a  tube  is,  at  first, 
indicated  after  the  operation. 

OSTEOPLASTIC  RESECTION  OF  THE   LOWER   JAW 

TO    EXPOSE    STRUCTURES    IN    PHARYNX    AND    UPON    FLOOR    OF    MOUTH. 

Description. — The  inferior  maxilla  is  divided  either  in  the  middle  line, 
or  just  in  front  of  its  ascending  ramus — the  former,  for  the  exposure  of  the 
structures  in  the  floor  of  the  mouth,  the  fauces,  and  the  anterior  pharyngeal 
structures — the  latter,  for  the  exposure  of  the  fauces  and  the  posterior  pharyn- 
geal structures.  At  the  completion  of  the  operation,  the  severed  bone  is 
brought  together  with  silk  or  metallic  suture. 

Preparation ; — Position. — As  in  the  simple  excision  of  the  lower  jaw 
(page  477)- 

Landmarks. — The  median  line,  for  the  anterior  operation, — and  the  angle 
of  the  jaw  and  the  attachment  of  the  masseter,  for  the  lateral  operation. 

Incisions. — (A)  For  the  division  in  the  middle  line; — the  incision  is  made 
in  the  median  line,  through  the  lower  lip,  extending  thence  down  to  the  hyoid 
bone  (Fig.  381,  D).  (B)  For  the  division  in  front  of  the  ascending  ramus 
of  the  jaw,  at  the  anterior  margin  of  the  masseter; — an  incision  passing  from 
the  tip  of  the  mastoid  process  toward  the  hyoid  bone  (Fig.  380,  B). 

Operation. — (A)  In  the  middle  line; — The  upper  part  of  the  median 
incision  is  carried  directly  to  the  bone — the  lower  part  is  carefully  deepened 
and  extended  as  far  as  the  hyoid  bone.  The  arteries  in  the  lips  are 
clamped.  The  entire  circumference  of  the  jaw  is  cleared  subperiosteally — a 
central  incisor  tooth  is  drawn — a  Gigli  saw  is  conducted  beneath  that  site  of 
the  bone — and  the  jaw  divided  so  as  to  be  bevelled  at  the  expense  of  its  inner 
surface  and  lower  border,  and  so  as  to  spare  the  genial  tubercles  (thus  prevent- 
ing over-riding  of  the  bone,  and  keeping  the  genio-hyo-glossi  and  genio-hyoids 
intact).  The  two  sides  of  the  jaw  are  now  widely  drawn  apart  by  hooks — 
and  the  tongue  forward  by  a  silk  ligature  passed  through  its  substance.  The 
special  object  of  the  operation  is  now  accomplished.  Holes  should  have  been 
drilled  on  each  side  of  the  site  to  be  divided — through  which  kangaroo-tendon 
is  now  carried  and  tied.  The  skin  wound  is  then  closed — and  the  vermillion 
border  of  the  lip  carefully  sutured.  (B)  In  front  of  the  ascending  ramus  of 
the  jaw; — Ligate  the  facial  artery  and  expose  the  inferior  border  of  the  lower 
jaw  at  the  anterior  border  of  the  masseter  muscle — raising  the  periosteum  and 
inching  the  mucous  membrane  upon  both  aspects  of  the  jaw.  Having  drilled 
holes  for  future  suturing,  at  the  site  of  intended  division,  a  Gigli  saw  is  con- 
ducted around  the  bone  behind  the  molar  teeth,  and  the  section  made  obliquely 
— the  limit  of  section  being  farther  forward  upon  the  external  and  inferior 
than  upon  the  internal  and  superior  aspect.  The  ascending  ramus  is  drawn 
upward  and  the  body  of  the  jaw  forward — thus  securing  the  requisite  exposure. 
At  the  completion  of  the  operation,  the  parts  of  the  bone  are  sutured  and  the 
wound  closed. 

EXCISION  OF  RIBS,   IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
the  Thorax,  pages  733,  734. 


480  EXCISIONS. 

General  Surgical  Considerations. — (1)  The  following  extents  of  rib 
may  be  removed; — (a)  An  entire  rib,  from  and  including  its  chondrosternal 
articulation,  to  and  including  its  costovertebral  articulation; — (b)  Part  of  a 
rib  (the  rib  proper),  from  and  including  the  chondrocostal,  to  and  including 
the  costovertebral  articulation; — (c)  Part  of  a  rib,  from  and  including  the 
chondrocostal,  up  to  the  costotransverse  articulation; — (d)  Any  limited  por- 
tion of  a  rib; — (e)  Two  or  more  adjacent  ribs,  in  whole  or  in  part.  (2) 
Unless  contraindicated,  the  portion  of  rib  covered  by  periosteum  should  be 
removed  subperiosteal!}'  (that  is,  the  rib  proper). 

Best  Methods  of  Excision. — By  parallel  incision  over  center  of  rib — 
for  one  rib,  or  part  of  a  rib.  Parallel  incision  midway  between  ribs — for 
two  adjacent  ribs. 

EXCISION  OF  ENTIRE  RIB  AND  COSTAL  CARTILAGE 

BV  PARALLEL  INCISION  OVER  CENTER  OF  RIB. 

Position. — Patient  near  edge  of  table,  in  such  a  position  as  to  render 
site  of  operation  accessible,  and  resting  upon  pad  so  as  to  render  the  part 
prominent.  Surgeon  on  side  of  operation,  or  behind,  if  patient  be  upon 
side.     Assistant  stands  opposite. 

Landmarks. — Tipper  and  lower  border  of  rib;  chondrosternal  articula- 
tion; costovertebral  articulation. 

Incision. — The  long  parallel  incision  begins  over  the  center  of  the  chondro- 
sternal articulation — passes  directly  over  center  of  costal  cartilage  and  rib — 
ending  over  costovertebral  articulation.  The  posterior  end  of  this  incision 
will  be  over  the  center  of  the  vertebral  ends  of  the  ribs,  in  the  case  of  the  lower 
ribs — but  will  run  along  their  upper  border,  just  above  the  transverse  pro- 
cesses of  the  vertebra?,  in  the  case  of  the  upper  ribs. 

Operation. — Incise  directly  through  skin,  fascia,  overlying  muscle,  and 
periosteum,  down  to  bone.  Over  the  costal  cartilages  there  is  no  periosteum, 
as  such.  The  treatment  of  the  overlying  muscles  will  be  modified  by  the 
part  of  the  chest  involved — where  unimportant,  they  are  cut  through — where 
important  and  capable  of  retraction  after  being  cut,  they  are  divided  in  their 
cleavage  line  as  far  as  this  is  possible — otherwise  their  fibers  must  be  cut. 
Important  vessels,  and  especially  important  nerves,  coursing  downward 
from  the  axillary  region,  are  to  be  avoided,  if  possible.  The  rib  is  freed 
subperiosteally — and  with  especial  care  along  the  groove  upon  the  lower, 
inner  aspect,  where  the  intercostal  vessels  and  nerve  run — using  fully  curved 
periosteal  elevator  and  rugine.  Guard  the  pleura  behind  the  posterior 
surfaces  of  the  ribs — intrathoracic  fascia  alone  here  intervening.  Having 
freed  the  center  of  the  rib  around  its  entire  circumference,  a  chain  or  Gigli 
saw  is  carried  between  bone  and  periosteum  and  the  rib  divided.  First  one 
and  then  the  other  cut  end  of  the  rib  is  seized  with  bone-forceps  and  drawn 
outward — and,  while  held  in  this  position,  is  freed  toward  either  end  and 
disarticulated.  The  musculo-periosteal  sheath  is  sutured  with  gut — and  the 
wound  closed. 

Comment. — For  excision  of  two  or  more  consecutive  ribs,  in  whole  or 
in  part,  see  Estlaender's  and  Schede's  operations,  pages  765  and  768. 

EXCISION  OF  CLAVICLE,  IN  GENERAL. 

Surgical  Anatomy. — Anteriorly; — supraclavicular  nerves  and  vein  con- 
necting cephalic  and  external  jugular  veins  cross  the  antero-superior  surface 
of  the  clavicle.     Interiorly; — axillary  vessels  and  brachial  plexus  rest  upon 


EXCISION    OF    SCAPULA,    IN    GENERAL.  481 

the  first  rib,  under  the  clavicle,  the  subclavius  muscle  and  dense  fascia  inter- 
vening Posteriorlv; — omohyoid,  scalenus  anticus,  scalenus  medius,  scalenus 
posticus,  sternohyoid,  and  sternothyroid  muscles;  subclavian,  suprascapular, 
and  internal  mammary  arteries;  innominate,  subclavian,  and  external  jugular 
veins;  brachial  plexus,  phrenic  and  posterior  thoracic  nerves;  pleura,  apex 
of  lung,  and  thoracic  duct. 

General  Surgical  Considerations. — The  clavicle  may  be  removed  in 
whole  or  in  part — or  the  sternoclavicular  or  acromioclavicular  joints  may  be 
separately  excised. 

TOTAL  EXCISION  OF  CLAVICLE 

BY  LONG  AXIAL  INCISION. 

Position. — As  for  ligation  of  third  part  of  subclavian  artery,  page  53. 

Landmarks. — Clavicle;  acromioclavicular  joint;  sternoclavicular  joint. 

Incision. — Along  the  antero-superior  surface,  following  the  curve  of  the 
bone  and  extending  beyond  both  sternoclavicular  and  acromioclavicular 
joints  (Fig.  383,  C). 

Operation. — The  incision  passes  directly  through  skin,  platysma,  supra- 
clavicular nerves,  fascia,  and  periosteum  to  bone.  Once  within  the  perios- 
teum, this  membrane  is  completely  detached  with  a  fairly  sharp,  curved 
periosteal  elevator,  together  with  the  attached  muscles  and  coracoclavicular 
ligament.  The  clearing  is  first  completed  entirely  around  the  center  of  the 
bone,  and  at  this  point  the  bone  is  divided  with  a  chain  or  Gigli  saw  conducted 
between  bone  and  periosteum.  Each  end  is  then  grasped  in  turn  with  bone- 
forceps  and  drawn  outward — the  remaining  portions  of  periosteum  being 
freed  to  the  articular  ends  while  the  bone  is  thus  held.  The  outer  end  is 
first  removed  and  then  the  inner — especially  guarding  the  important  struc- 
tures near  the  latter.  The  knife  and  periosteal  elevator,  or  rugine,  hug  the 
bone  throughout  the  entire  operation,  the  soft  and  important  parts  being 
protected  by  spatula'.  The  musculo-periosteal  sheath  is  closed  as  usual,  and 
the  wound  closed.     The  arm  is  put  up  as  in  the  case  of  fractured  clavicle. 

Comment. — The  safety  of  the  operation  and  the  freedom  from  hemor- 
rhage will  depend  upon  the  nearness  with  which  the  subperiosteal  method  is 
followed  out.  The  chief  dangers  are  the  wounding  of  the  structures  beneath 
and  behind  the  clavicle  (v.  Surgical  Anatomy,  page  480).  Any  portion  of  the 
clavicle  may  be  removed  through  a  corresponding  part  of  this  incision. 

Excision  of  Sternoclavicular  or  Acromioclavicular  Joints. — In  ex- 
cising the  sternoclavicular  or  acromioclavicular  articulations,  disarticulation 
is  first  accomplished — the  inner  or  outer  end  of  the  clavicle,  as  may  be,  is 
then  elevated  sufficiently  to  slip  the  Gigli  saw  beneath — it  is  then  removed, 
and  the  sternum  or  acromion  gouged.  The  bone  is  closely  hugged  in  these 
operations,  especially  when  working  near  its  inner  end. 

EXCISION  OF  SCAPULA,  IN  GENERAL. 

Surgical  Anatomy. — The  chief  arteries  in  the  neighborhood  of  the 
scapula  are  the  following: — suprascapular,  crossing  the  ligament  of  the 
suprascapular  notch;  posterior  scapular,  along  the  vertebral  border;  sub- 
scapular branch  of  axillary,  along  the  inferior  border  of  the  subscapularis; 
dorsalis  scapulae  branch  of  subscapular,  crossing  the  axillary  border;  acromial 
branches  of  acromial  thoracic,  about  the  acromial  process.  The  surgical  neck 
of  the  bone  is  marked  off  by  a  line  from  the  suprascapular  notch  through 
the  great  scapular  notch. 
31 


482 


EXCISIONS. 


General  Surgical  Considerations. — (1)  The  scapula  may  be  removed 
in  whole  or  in  part.  The  parts  usually  separately  removed  are,  the  acromion, 
part  of  the  spine,  and  part  of  the  lower  angle.  (2)  The  glenoid,  acromion 
and  coracoid  processes  are  to  be  saved  when  possible.  (3)  The  chief  danger 
is  from  hemorrhage.  The  chief  difficulty  is  in  the  detachment  of  the  muscles. 
(4)  Temporary  drainage  is  indicated.  (5)  The  excision  is  generally  by  the 
open  method.  The  subperiosteal  method  is  scarcely  practicable,  and  is 
generally  not  indicated,  as  well. 

After-treatment. — A  pad  is  placed  in  the  axilla  to  keep  the  head  of  the 
humerus  out.  The  arm  is  pushed  up  so  that  the  head  is  in  its  natural  position 
and  steadied  against  the  chest — and  held  there  by  a  sling  for  three  or  four 
months.     Passive  movement  is  used  in  about  three  weeks. 

Results. — A  very  useful  limb  often  results — capable  of  all  underhand, 
but  no  overhand,  movements,  and  of  lifting  weights. 


TOTAL  EXCISION  OF  SCAPULA 

BY  STRAIGHT  INCISIONS  ALONG  SPINE  AND  VERTEBRAL  BORDER,  FORMING 
SUPERIOR  AND    INFERIOR   FLAPS. 

Position. — Patient  on  sound  side,  near  edge  of  table,  with  back  to  opera- 
tor.    Surgeon  behind  both  scap- 
ula?.    One  assistant   compresses 
subclavian  artery.     Another  as- 
sistant retracts  flaps. 

Landmarks.  —  Bony  promi- 
nences and  outlines  of  scapula. 

Incisions.  —  Vertebral  Inci- 
sion— passes  parallel  with  and 
just  to  outer  side  of  vertebral 
border,  from  superior  to  interior 
angle.  Spinal  Incision —  begins 
over  acromioclavicular  joint  and 
passes  thence  along  acromion 
and  spine  to  junction  with  ver- 
tebral incision,  meeting  it  at 
almost  a  right  angle.  (Fig.  383, 
C,  C,  and  B,  B'.) 

Operation.  —  (1)    These  in 
cisions   pass   through   skin    and 
fascia.     Raise  the  superior  flap, 
dividing  the  trapezius  along  the 
upper  border  of  the  spine.     (2) 
Raise    the    inferior   flap,    divid- 
ing the  deltoid  along  the  lower 
border  of  the  spine.     (3)  Render 
the  vertebral  border  prominent 
by  drawing    the    patient's    arm 
across  his  chest  and   divide  the 
muscles  along  that  border  (leva- 
tor anguli   scapulae,  rhomboidei   minor  and  major) — then  further  drawing 
the  vertebral  border  outward,  divide  the  serratus  magnus.     Ligate  the  pos- 
terior scapular  artery  near  the  superior  angle.     (4)  Clear  the  superior  border, 
severing  the  omohyoid  and  ligating  the  suprascapular  artery  near  the  supra- 


Fig.  383.— Excisions  about  the  Shoulder  and 
Scapula  : — A,  Excision  of  shoulder-joint,  by  posterior 
vertical  incision  ;  B,  B',  Vertebral  incision,  in  total 
excision  of  scapula  by  vertebral  and  spinal  incisions  ; 
C,  C'i  Spinal  incision,  in  total  excision  of  scapula  by 
vertebral  and  spinal  incisions  ;  D,  V-shaped  incision, 
for  excision  of  superior  angle  of  scapula  ;  E,  V-shaped 
incision,  for  excision  of  inferior  angle  of  scapula. 


EXCISIONS    ABOUT    THE    FINGERS.  483 

scapular  notch — the  arm  still  being  held  across  the  chest.  (5)  Render  the 
angle  of  the  shoulder  prominent  by  drawing  the  arm  downward — open  the 
acromioclavicular  joint — sever  any  remaining  portions  of  the  deltoid  and 
trapezius — and  cut  the  conoid  and  trapezoid  ligaments  as  near  the  clavicle 
as  possible.  (6)  Manipulate  the  arm  so  as  to  bring  the  coracoid  process 
as  far  as  possible  into  the  wound  made  by  separating  the  acromion  from 
the  clavicle,  and  sever  the  insertion  of  the  biceps,  coracobrachialis  and  pec- 
toralis  minor.  (7)  Divide  the  capsule  and  the  muscles  surrounding  it  (supra- 
spinatus,  infraspinatus,  and  subscapularis) — and  also  the  scapular  head  of  the 
biceps  at  the  upper  part  of  the  glenoid  fossa,  and  the  scapular  head  of  the 
triceps  at  the  lower  part  of  the  glenoid  fossa.  (8)  Divide  the  remaining 
muscles  connecting  the  axillary  border  of  the  scapula  to  the  arm,  the  teres 
major  and  minor,  cutting  these  muscles  from  in  front — seizing  and  tying  the 
subscapular  artery  proximal  to  the  origin  of  the  dorsalis  scapula?.  (9)  The 
deeper  muscles,  the  supraspinatus,  infraspinatus,  and  subscapularis,  are  re- 
moved with  the  bone — except  that  their  tendons  of  insertion  into  the  humerus 
are  left.  Drop  the  flaps  into  place  and  suture  their  margins.  Temporary 
drainage  should  be  used,  as  oozing  is  apt  to  be  marked. 

Comment. — If  necessary,  the  subclavian  may  be  compressed  through  an 
incision.  The  chief  vessels,  however,  may  be  ligated  in  advance  of  incisions 
for  the  flaps,  that  is,  before  the  beginning  of  the  operation  proper — but  can 
generally  be  taken  up  during  the  operation,  before  actually  cutting  them. 

Partial  Excisions  of  the  Scapula. — The  acromion  process  may  be 
excised  through  an  incision  placed  centrally  over  its  prominent  contour  (Fig. 
383,  B).  The  angles  of  the  bone  may  be  removed  by  V-shaped  incisions 
(Fig.  383,  D  and  E).  The  body  of  the  scapula  is  excised  through  practically 
the  same  incisions  as  are  used  for  the  total  excision. 


EXCISIONS  ABOUT  THE  FINGERS. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — See  under  Am- 
putations of  the  Fingers,  pages  323  and  324. 

General   Surgical    Considerations. — (i)    Typical   excisions   about   the 


Fig.384  —Excisions  about  the  Fingers  :— A,  Excision  of  terminal  phalanx,  by  U-shaped  pal- 
mar incision  ;  B,  Excision  of  second  phalanx  of  index,  by  dorso-external  incision  ;  C,  Excision  of  first 
interphalangeal  joint,  by  two  lateral  incisions. 

fingers  are  unusual.  Incomplete  excisions  for  dead  bone  are  more  common. 
(2)  Excision  of  the  terminal  phalanx  is  better  than  disarticulation  at  the 
last  interphalangeal  joint.  (3)  Excision  of  the  interphalangeal  joints  is  very 
satisfactory.     (4)  Excision  of  the  metacarpo-phalangeal  joints  often  leaves  a 


484  EXCISIONS. 

useless  joint — except  in  the  case  of  the  thumb.  It  should  n<  t  be  clone  in  the 
young,  as  it  destroys  the  epiphyses  of  the  metacarpal  and  phalanx.  It  is 
satisfactory  in  the  case  of  the  thumb,  especially  if  the  phalangeal  epiphysis 
be  left  (there  is  no  lower  metacarpal  epiphysis).  (5)  In  excisions  of  the 
phalanges  and  metacarpals,  the  subperiosteal  method  is  particularly  indicated, 
although  its  execution  is  not  very  satisfactory.  (6)  Partial  excision  of  the 
phalanges  and  metacarpals  is  more  satisfactory  than  total  excision.  (7) 
About  the  only  phalanges  one  usually  attempts  to  excise  are  the  last  of  all 
the  fingers,  the  second  of  the  index,  and  the  first  of  the  thumb. 

Methods  of  Excision  about  the  Fingers. — (a)  For  Terminal  Phalanx 
of  Finger  or  Thumb: — Best  Method;  U-shaped  Palmar  Incision,  (b)  For 
Second  Interphalangeal  Joint: — Be>t  Methods;  Two  Lateral  Incisions  (for 
lingers  in  general);  Dorso-external  Incision  (for  index);  Dorso-internal  Inci- 
sion (for  little  finger) ; — Other  Methods;  Dorsolateral  Incision;  Single  Lateral 
Incision,  (c)  For  Second  Phalanx: — Dorso-lateral  Incision  (for  ringers  in 
general — if  done  at  all);  U-shaped  Palmar  Incision  (for  thumb);  Dorso- 
external  Incision  (for  index) ;  Dorso-internal  Incision  (for  little  finger — if 
done  at  all); — Other  Methods;  Two  Lateral  Incision-,  (d)  For  First  Inter- 
phalangeal Joints: — Two  Lateral  Incisions  (for  fingers  in  general);  Dorso- 
external  Incision  (for  index  and  thumb);  Dorso-internal  Incision  (for  little 
finger); — Other  Methods;  Single  Lateral  Incision,  (e)  For  First  Phalanx: — 
Dorso-lateral  Incision  (for  fingers  in  general — if  done  at  all);  Dorso-internal 
Incision  (for  thumb — and  for  index,  if  done  in  the  latter  case  at  all) ;  Dorso- 
internal  (for  little  finger — if  done  at  all; ; — Other  Method;  Two  Lateral 
Incisions. 

EXCISION  OF  TERMINAL  PHALANGES  OF  FINGERS 

BY  I'-SHAPED  PALMAR.' IXCISIOX. 

Position. — As  for  Amputations  about  the  Fingers  (page  327). 

Landmarks. — Terminal  interphalangeal  joint. 

Incision. — U -shaped  incision — beginning  opposite  the  terminal  inter- 
phalangeal joint-line,  with  the  two  limbs  about  three-fourths  of  the  width 
of  the  linger  apart,  and  with  the  convexity  extending  downward  nearly  to 
the  nail-tip  (Fig.  384,  A). 

Operation. — The  incision  passes  directly  to  the  bone — the  soft  parts  are 
dissected  up  in  the  form  of  a  palmar  flap — and  the  terminal  phalanx  grasped 
with  forceps,  disarticulated,  and  enucleated.  The  palmar  flap  is  then  sutured 
back  into  position  and  the  digit  dressed  upon  a  palmar  splint. 

Comment. — Is  is  better  to  make  a  partial  excision,  if  possible,  leaving 
the  base  of  the  phalanx — which  insures  the  retention  of  the  epiphvsis  and 
the  attachment  of  the  flexor  profundus  digitorum.  If  a  total  excision  be 
done,  suture  the  flexor  tendon  into  the  stump  and  close  the  beginning  of  the 
flexor  sheath,  if  demonstrable. 

EXCISION   OF   SECOND   INTERPHALANGEAL   JOINTS  OF   FINGERS 

BY  TWO  LATERAL  [NCISK  INS. 

Position. — As  for  Amputations  about  the  fingers  (page  327). 

Landmarks. — Second  Interphalangeal  joint-line. 

Incisions. — Two  straight  incisions  in  the  mid-lateral  aspects  of  the 
fingers,  with  their  center  over  the  joint-line  (Fig.  385  A.  A'). 

Operation. — The  incisions  pass  directly  through  skin,  fascia,  lateral 
ligaments,  periosteum,  and  capsule  into  joint.     By  hugging  the  bones  and 


EXCISION    OF    SECOND    1XTERPHALAXGEAL    JOINTS    OF    FIXGERS.        485 

working  between  them  and  the  soft  parts  with  a  sharp,  fully  curved  small 
periosteal  elevator,  the  bones  are  everywhere  freed.  The  articular  ends  are 
then  disarticulated — thrust  out  of  the  wounds — cut  off  with  saw — and  the 


Fig.385.— Excisions  about  the  Hand  and  Wrist  :— A.  A'.  Excision  of  second  interphalangeal 
joint  by  two  lateral  incisions  :  B.  Of  second  interphalangeal  joint  of  index,  by  dorso-external  incision  ; 
C.  Of  second  interphalangeal  joint  of  little  ringer,  by  dorso-internal  incision  :  D.  Of  second  phalanx  of 
finger,  by  dorso-lateral  incision  :  E.  E'.  Of  first  interphalangeal  joint,  by  two  lateral  incisions  ;  F.  Of 
first  phalanx  of  thumb,  by  dorso-external  incision  :  G.  Ofmetacarpo-phalangeal  joint,  by  dorso-latera) 
(dorso-external'  incision:  H.  Of  metacarpophalangeal  joint,  by  dorso-lateral  .dorso-internal)  inci- 
sion ;  I.  Of  metacarpal,  by  dorsal  incision  ;  J.  Of  metacarpal,  by  dorsal  incision,  with  added  angular 
incision  :  K.  Of  metacarpal  of  little  finger,  by  dorso-internal  incision;  L.  Of  metacarpal  of  thumb,  by 
dorso-extenial  incision:  M,  M',  Of  wrist-joint,  by  radial  incision,  and  N,  ulnar  incision  lOllier's 
operation);  O,  O,  Of  wrist  joint,  by  dorso-radial  incision  (Boeckel-Langenbeck operation);  P,  P, 
of  wrist-joint,  by  dorso-ulnar  incision  (.Kocher's  method). 


sawed  ends  drawn  back.  The  musculo-periosteo-capstilar  sheath  is  then 
closed  on  either  side  with  buried  gut  sutures.  The  skin  wounds  are  sutured 
and  the  parts  dressed  on  a  palmar  splint. 


4  86  EXCISIONS. 

EXCISION  OF  SECOND  INTERPHALANGEAL  JOINT  OF  INDEX 

BY  DORSO-EXTERNAL  INCISION. 

Position — Landmarks. — As  in  the  above  operation. 

Incision. — A  straight  incision  placed  over  the  dorsal  aspect  of  the  second 
interphalangeal  joint,  just  to  the  outer  side  of  the  extensor  tendon — with  its 
center  over  the  joint-line. 

Operation. — The  incision  passes  directly  through  skin,  fascia,  capsule, 
and  periosteum — going  through  the  last  over  the  ends  of  the  phalanges  just 
above  and  below  the  joint.  The  soft  parts  are  subperiosteally  elevated  from 
the  joint  and  ends  of  the  bones.  The  bones  are  then  disarticulated — pro- 
truded— and  their  ends  sawed  off  just  beyond  their  articular  surfaces.  The 
sawed  ends  are  now  drawn  back  into  position — the  musculo-periosteo- 
capsular  sheath  is  closed,  on  either  side,  with  buried  gut  sutures — the  lips 
of  the  skin  wounds  sutured — and  the  digit  dressed  upon  a  palmar  splint. 
(For  principle,  see  Fig.  384,  C,  and  Fig.  385,  B.) 

EXCISION  OF  SECOND  INTERPHALANGEAL  JOINT  OF  LITTLE  FINGER 

BY  DORSO-INTERNAL  INCISION. 

Description. — The  operation  is,  in  every  respect,  similar  to  the  above 
— except  that  the  incision  is  placed  over  the  dorsal  aspect  of  the  second  inter- 
phalangeal joint  of  the  little  finger,  just  to  the  inner  side  of  the  extensor 
tendon,  with  its  center  over  the  joint-line  (Fig.  385,  C). 

EXCISION  OF  SECOND  PHALANGES  OF  FINGERS 

BY  DORSO-LATERAL  INCISION. 

Position. — As  for  Amputations  (page  327). 

Landmarks. — Second  phalanx,  and  first  and  second  interphalangeal 
joints. 

Incision. — Straight  incision  placed  over  the  dorsal  aspect  of  the  second 
phalanx,  just  to  the  outer  or  inner  side  of  the  extensor  tendon — beginning 
just  above  the  first  interphalangeal  joint  and  ending  just  below  the  second 
interphalangeal  joint.  In  the  index-finger  the  incision  would  be  dorso- 
external  (that  is,  to  the  outer  side  of  the  extensor  tendon).  In  the  little 
finger,  if  performed  at  all,  it  would  be  dorso-internal.  In  the  thumb,  it 
would  be  by  a  U-shaped  palmar  incision  (Fig.  384,  B,  and  Fig.  385,  D). 

Operation. — The  incision  passes  directly  through  skin,  fascia,  perios- 
teum, and  capsules  of  the  first  and  second  interphalangeal  joints.  The  soft 
parts  are  subperiosteally  elevated  from  the  bone  and  the  bone  isolated  and 
disarticulated.  The  lips  of  the  periosteo-capsular  sheath  are  carefully  sutured 
with  buried  gut  sutures.  The  margins  of  the  skin  wound  are  closed  in  the 
usual  manner.  The  finger  is  dressed  upon  a  palmar  splint  until  new  bone 
has  been  thrown  out. 

Comment. — In  the  case  of  the  thumb,  the  operation  is  the  same  as  for 
the  terminal  phalanx  of  the  fingers  in  general. 

EXCISION  OF  SECOND  PHALANX  OF  INDEX 

P.Y  DORSO-EXTERNAL  INCISION. 

Position. — As  for  Amputations  of  Fingers  (page  327). 

Landmarks. — Second  phalanx. 

Incision. — Straight  incision  over  dorsal  aspect  of  index,  placed  just  to 
the  outer  side  of  the  extensor  tendon — beginning  just  above  the  first  inter- 
phalangeal joint  and  ending  just  below  the  second  interphalangeal  joint 
(Fig.  384,  B). 


EXCISION  OF  METACARPOPHALANGEAL    JOINTS    OF    FINGERS.      487 

Operation. — As  for  excision  of  the  second  phalanges  of  the  fingers  in 
general. 

EXCISION  OF  SECOND  PHALANX  OF  LITTLE  FINGER 

BY  DORSO-INTERNAL  INCISION". 

Position — Landmarks. — As  in  the  last  operation. 

Incision. — Straight  incision  over  dorsal  aspect  of  little  finger,  just  to  the 
inner  side  of  the  extensor  tendon — beginning  just  above  the  first  and  ending 
just  below  the  second  interphalangeal  joint. 

Operation. — As  for  excision  of  the  second  phalanges  in  general. 


EXCISION  OF  FIRST  INTERPHALANGEAL  JOINTS  OF  FINGERS. 

Description. — The  best  method  of  excising  the  first  interphalangeal 
joints  is  the  same  as  adopted  in  the  case  of  the  second  interphalangeal  joints 
— namely,  by  two  lateral  incisions  for  the  fingers  in  general  (Fig.  385,  E,  E'), 
■ — dorso-external  incision,  for  the  index  or  thumb, — and  dorso-internal  in- 
cision, for  the  little  finger.  (For  principle,  see  Fig.  385,  G  and  C.)  These 
operations  are  described  at  pages  4S4  and  486. 


EXCISION  OF  FIRST  PHALANGES  OF  FINGERS. 

Description. — The  excision  of  the  first  phalanx  of  a  finger  is,  ordinarily, 
not  admissible — except  in  the  case  of  the  thumb.  If  performed  at  all,  the 
best  methods  would  be  the  same  as  those  adopted  in  the  case  of  excision 
of  the  second  phalanges — namely,  by  the  dorsodateral  incision,  for  the  fingers 
in  general  (on  either  inner  or  outer  side  of  the  extensor  tendon), — dorso- 
external  for  thumb  or  index, — and  dorso-internal  for  little  finger. 

EXCISIONS  ABOUT  THE  HAND. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — See  under  Am- 
putations about  the  Hand,  pages  323,  324,  and  325. 

General  Surgical  Considerations. — (i)  Partial  excisions  about  the  hand 
are  successful  operations.  (2)  Total  excisions,  if  subperiosteal,  will  some- 
times yield  a  firm  cicatrix  that  will  render  the  finger  useful.  But  sometimes 
the  finger  is  drawn  up  and  useless.  (3)  Operations  for  the  partial  excision 
of  the  metacarpals  are  the  same  in  principle  as  those  for  the  excision  of  the 
entire  bone,  except  more  limited — and  hence  will  not  be  given  separately. 
If  a  chain  or  Gigli  saw  can  be  passed  around  the  bone  in  these  operations 
of  partial  excision,  this  is  preferable  to  cutting  the  metacarpal  with  pliers. 
If  this  cannot  be  done,  one  can  cut  through  the  center  of  that  part  which  is 
to  be  removed  with  pliers,  and  then  slip  a  chain  or  Gigli  saw  under  either 
end  and  remove  the  requisite  amount,  thus  avoiding  the  crushing  effect  of 
the  bone  pliers.  (4)  Operations  for  the  removal  of  individual  carpal  bones 
are  uncommon.  Their  removal  in  the  course  of  excision  of  the  wrist  is  dealt 
with  under  that  operation. 

EXCISION    OF    METACARPOPHALANGEAL    JOINTS    OF    FINGERS 

BY  DORS' )-LATERAL  INCISION. 

Position. — As  for  Disarticulations  at  the  Metacarpophalangeal  joints 
(page  332). 


488  EXCISIONS. 

Landmarks. — Metacarpophalangeal  joints. 

Incision. — Straight  incision  over  the  dorsal  aspect  of  the  joint,  just 
to  the  outer  or  inner  side  of  the  extensor  tendon,  with  its  center  over  the 
joint-line  (Fig.  385,  H  and  G). 

Operation. — The  incision  passes  through  skin,  fascia,  capsule  of  the 
joint,  and  the  periosteum  of  the  ends  of  the  metacarpal  and  phalangeal 
bones.  The  bones  are  closely  hugged  and  the  soft  parts  are  freed  from  the 
articular  ends  and  shafts.  The  articular  ends  of  the  bones  are  disarticulated 
and  the  base  of  the  phalanx  first  protruded  and  sawed  off.  The  parts  are 
then  retracted  from  about  the  head  of  the  metacarpal,  which  is  thus  made 
prominent  and  removed  with  a  small  saw,  or  chain  or  Gigli  saw,  while  steady- 
ing the  end  of  the  bone  with  bone-forceps.  The  bones  are  then  drawn  back 
in  place — the  periosteo-capsular  sheath  sutured  with  buried  gut  stitches — 
the  skin  wound  closed — and  the  part  dressed  upon  a  palmar  splint. 

Comment. — In  excising  the  metacarpophalangeal  joint  of  the  thumb  or 
index,  a  dorso-external  incision  is  used — and,  in  the  case  of  the  little  finger, 
a  dorso-internal  incision.  Otherwise  the  operations  at  these  sites  are  similar 
to  the  one  just  described. 


EXCISION  OF  THE   METACARPALS 

BY  DORSAL  INCISION. 

Position. — As  for  Disarticulation  of  the  Metacarpals,  page  332. 

Landmarks. — Carpo-metacarpal  and  metacarpophalangeal  joints. 

Incision. — Straight  incision  over  the  dorsal  aspect,  immediately  to  the 
outer  or  inner  side  of  the  extensor  tendon,  beginning  just  above  the  carpo- 
metacarpal and  ending  just  below  the  metacarpo-phalangeal  joint.  If  neces- 
sary, the  upper  and  lower  ends  of  the  incision  may  have  two  short  diverging 
arms  continuing  from  them,  to  better  expose  the  joints.  The  incision  may 
be  placed  directly  in  the  mid-dorsal  line,  the  extensor  tendon  being  carefully 
drawn  to  one  side,  out  of  harm's  way,  as  soon  as  the  skin  is  incised  (Fig.  ^85, 
I  and  J). 

Operation. — After  guarding  the  extensor  tendon,  the  incision  passes 
through  periosteum  of  the  metacarpal  and  the  capsules  of  the  two  joints 
directly  to  the  bone.  The  central  portion  of  the  metacarpal  is  first  cleared 
subperiosteal]}7-  around  its  entire  circumference  by  a  fully  curved  periosteal 
elevator,  the  interossei  being  separated  with  the  periosteum.  Unless  a  Gigli 
saw  can  be  conducted  around  the  shaft  of  the  metacarpal,  the  center  of  the 
bone  is  divided  with  cutting  pliers  (for  although  they  crush  the  bone,  no  part 
of  it  is  to  be  saved).  Each  end  of  the  divided  bone  is  then  seized  in  turn 
with  bone-forceps  and  forcibly  drawn  backward  and  manipulated  from  side 
to  side — during  which  manipulation  the  lateral  and  palmar  surfaces  are  freed 
and  the  ligaments  at  the  carpo-metacarpal  and  metacarpo-phalangeal  joints 
are  put  upon  the  stretch  and  divided.  The  musculo-periosteal  sheath  is 
then  sutured  with  buried  catgut  stitches  and  the  skin  wound  closed. 

Comment. — (1)  The  metacarpal  may  be  first  disarticulated  at  the  meta- 
carpo-phalangeal joint  and  then  drawn  backward — but  the  above  method  is 
easier.  (2)  The  extensor  tendons  and  the  structures  in  the  palm  of  the 
hand  are  always  especially  guarded. 


EXCISION    OF    THE    WRIST-JOINT,    IN    GENERAL.  489 

EXCISION  OF  METACARPAL  OF  THUMB 

BY  DORSO-EXTERNAL  INCISION. 

Position. — The  ulnar  side  of  the  hand  is  held  against  the  table,  the  radial 
side  presenting. 

Landmarks. — The  metacarpal  bone  and  carpometacarpal  and  meta- 
carpophalangeal joints. 

Incision. — Straight  incision  over  the  dorso-external  aspect  of  the  meta- 
carpal, just  to  the  outer  side  of  the  extensor  brevis  pollicis  tendon — beginning 
above  the  trapezio-metacarpal  and  ending  just  below  the  metacarpo-phalan- 
geal  joints.  If  necessary  an  angular  incision  may  be  added  to  the  ends  of 
the  straight  incision  (Fig.  385,  L). 

Operation. — Having  incised  skin,  avoid  the  external  branch  of  the  radial 
nerve — and  then  cut  directly  through  periosteum  and  capsules  onto  bone  and 
into  joints.  The  operation  is  then  completed  as  in  the  case  of  an  ordinary 
finger.  The  extensor  ossis  metacarpi  pollicis  is  separated  from  the  base  of 
the  metacarpal.  The  subperiosteal  method  is  here  especially  to  be  carried 
out,  if  possible. 

EXCISION  OF  METACARPAL  OF  LITTLE  FINGER 

BY  DORSO-INTERNAL  INCISION. 

Description. — The  operation  is  the  same  as  that  for  the  fingers  in  general, 
except  that  the  incision  is  placed  upon  the  inner  side  of  the  extensor  tendon 
(Fig.  385,  K). 

EXCISION  OF  THE  WRIST- JOINT,  IN  GENERAL. 

Surgical  Anatomy — Surface  Forms  and  Landmarks. — Given  under 
Disarticulation  at  the  Wrist,  page  348. 

Position. — See  each  operation. 

General  Surgical  Considerations.— In  complete  excision  of  the  wrist- 
joint,  all  of  the  carpals,  the  lower  ends  of  the  radius  and  ulna,  and  the  articular 
ends  of  the  metacarpals  are  removed.  When  not  diseased,  it  is  well,  however, 
to  leave  the  pisiform,  unciform  process  of  the  unciform  and  trapezium,  as  the 
two  former  give  attachment  to  man}-  muscles  and  the  latter  forms  part  of  the 
important  thumb-joint. 

After-treatment. — A  splint  is  indicated  which  will  support  the  palm; 
keep  the  wrist  slightlv  extended;  the  fingers  slightly  flexed  and  the  thumb 
slightly  separated  from  the  hand.  The  fingers  should  be  passively  moved 
within  three  or  four  days.  The  wrist  should  be  kept  still  until  fairly  solid 
and  then  passively  moved,  still  being  held  upon  a  splint,  which  is  generally 
retained  for  from  three  to  six  months. 

Results. — Usually  not  altogether  satisfactory.  The  hand  may  become 
rigid,  adducted,  and  useless.  Speedy  healing  without  suppuration,  a  good 
splint,  and  faithful  passive  movement  aid  largely  in  the  production  of  a 
satisfactory  result. 

Best  Methods.— Radial  and  Ulnar  Dorsal  Incisions  (Ollier's  operation). 
Single  Dorso-radial  Incision  (Boeckei-Langenbeck  operation) .  Single  Dorso- 
ulnar  Incision  (Kocher's  method). 

Other  Methods. — Bilateral  Incisions  (Lister's  method).  Dorso-ulnar 
Incision.  Median  Dorsal  Incision  (Mayo  Robson's  method).  Single  Ulnar 
Lateral  Incision  (Heron  Watson's  method). 


49©  EXCISIONS. 

Comparison. — The  carpal  bones  are  removed  with  greater  ease,  and  less 
damage  is  done  to  the  tendons,  bv  the  method  of  the  radial  and  ulnar  dorsal 


EXCISION  OF  WRIST 

BV  RADIAL  AND  ULNAR  DORSAL  INCISION  —  OLLIKR'S  OPERATION. 

Description. — The  articular  ends  of  the  radius  and  ulnar  are  removed. 
The  articular  ends  of  the  metacarpal  bono  are  gouged  only,  unless  exten- 
sivelv  diseased,  and,  if  so,  are  removed.  The  pisiform  bone,  the  unciform 
processes  of  the  unciform  bone,  and  the  trapezium  are  preserved,  if  possible — 
for  the  reasons  given  below. 

Position. — Patient's  hand,  prone,  rests  by  his  side,  or,  preferably,  upon 
a  small  table  at  the  patient's  side,  supported  upon  a  firm  cushion.  Surgeon 
sits  in  front  of  the  hand.     Assistant  steadies  patient's  forearm  and  fingers. 

Landmarks. — See  Incision. 

Incisions. — (i)  Radial  Incision — begins  opposite  the  center  of  the  dorsal 
surface  of  the  second  metacarpal — passes  obliqued}'  upward,  just  to  the  outer 
border  of  the  extensor  indicis  tendon,  to  the  center  of  a  line  connecting  the 
two  stvloid  processes — thence  changes  its  course  slightly  and  passes  vertically 
upward  in  the  long  axis  of  the  limn  for  about  7.5  cm.  (3  inches)  above  the 
radial  styloid  process.  (2)  Ulnar  Incision — begins  opposite  the  center  of  the 
dorsal  surface  of  the  fifth  metacarpal — and  passes  upward  $.2  cm.  (i\  inches) 
above  the  tip  of  the  ulnar  styloid  process,  lying  to  the  inner  side  of  the  extensor 
carpi  ulnaris  (Fig.  385,  MM'  and  X). 

Operation. — (1)  The  radial  incision  is  at  first  superficial.  The  internal 
branch  of  the  dorsal  division  of  the  radial  nerve  is  avoided,  if  possible.  The 
extensor  indicis  tendon  is  exposed  and  is  retracted  outward,  with  its  sheath. 
The  tendon  of  the  extensor  carpi  radialis  brevior  is  crossed  by  the  incision — 
is  followed  down  to  the  insertion  into  the  base  of  the  third  metacarpal  and 
is  drawn  outward,  but  not  cut.  The  upper  part  of  the  incision  passes  down 
between  the  extensor  indicis  (which,  with  the  extensor  communis  digitorum, 
is  drawn  inward)  and  the  extensor  longus  pollicis  (which  is  drawn  outward). 
This  incision  is  now,  after  retraction  of  the  muscles  and  tendons,  carried 
through  the  posterior  annular  ligament,  capsule  of  the  joint,  and  periosteum 
of  the  carpal,  radial,  and  metacarpal  bones.  (2)  The  ulnar  incision  is  also 
at  first  superficial.  The  dorsal  cutaneous  branch  of  the  ulnar  nerve  is  avoided, 
if  possible.  The  incision  is  carried  down  along  the  inner  border  of  the  ex- 
tensor carpi  ulnaris — upon  the  ulna,  cuneiform,  unciform,  and  fifth  meta- 
carpal— going  through  the  posterior  annular  ligament,  capsule,  and  peri- 
osteum of  the  ulna,  carpal  and  metacarpal  bones.  (3)  Decortication  is 
begun  upon  the  radial  side.  The  periosteum  and  ligaments  are  stripped  up 
from  the  dorsal  surface  of  the  carpal  bones  as  far  as  can  be  done  through 
the  radial  incision.  All  the  tendons  are  raised  with  their  periosteum  bodily 
from  their  grooves,  with  their  sheaths  unopened.  The  same  steps  are  re- 
peated through  the  ulnar  incision — hugging  the  bones  closely  and  elevating 
off  all  the  overlying  tissues,  working  entirely  between  these  tissues  and  the 
bones.  (4)  Removal  of  the  carpal  bones.  As  each  carpal  bone  is  outlined 
and  partially  separated,  it  is  seized  from  the  dorsum  of  the  hand  with  strong 
bone-forceps,  and,  while  being  twisted  from  side  to  side,  its  lateral  attach- 
ments are  severed  as  close  to  the  bone  as  possible,  and  its  palmar  attachments 
as  subperiosteal!}'  as  possible,  and  removed.     The  most  convenient  order  in 


EXCISION    OF    THE    WRIST- JOINT.  49 1 

which  to  remove  the  carpal  bones  is,  scaphoid,  semilunar,  cuneiform,  os 
magnum,  trapezoid,  and  body  of  unciform.  All  are  thus  freed  and  removed 
— except  that  the  pisiform  (which  is  deeply  seated  and  has  the  attachments 
of  the  flexor  carpi  ulnaris  and  abductor  minimi  digiti)  is  left; — and  the  unci- 
form process  of  the  unciform  bone  (which  is  also  deeply  seated  and  has  the 
attachments  of  the  flexor  brevis  minimi  digiti,  flexor  ossis  metacarpi  minimi 
digiti,  and  anterior  annular  ligament)  should  be  cut  through  with  bone-pliers 
and  left — and  the  trapezium  (which  is  rarely  diseased  and  which  enters  into 
the  important  metacarpo-trapezial  joint  of  the  thumb,  and  has  the  attach- 
ments of  the  abductor  pollicis,  flexor  ossis  metacarpi  pollicis,  flexor  brevis 
pollicis,  and  anterior  annular  ligament)  should  also  be  left.  If  any  of  these 
be  diseased,  however,  they  should  be  removed.  (5)  The  lower  ends  of  the 
radius  and  ulna  are  now  freed  of  periosteum,  by  following  them  around  from 
the  upper  part  of  the  vertical  incisions.  The  soft  parts  are  all  then  retracted 
and  the  ends  of  the  bones  protruded  through  the  wound  and  removed  just 
above  the  articular  cartilages — or,  if  but  little  diseased,  may  be  simply  gouged 
without  being  extensively  freed.  (6)  The  articular  ends  of  the  metacarpals 
should  be  gouged,  if  not  much  involved — or.  if  extensively  diseased,  removed, 
by  being  protruded  into  the  wound  and  a  thin  slice  of  bone  taken  off  with  a 
narrow  saw.  (7)  Temporary  drainage  is  used — the  wound  sutured  and 
dressed — and  a  special  splint  applied. 

Comment. —  (1)  The  subperiosteal  method  is  difficult,  but  if  carefully 
carried  out,  no  tendons  are  cut.  In  the  open  method  the  tendons  of  the 
extensores  carpi  radialis  longior  et  brevior  are  cut — and  tendons  of  the  flexor 
carpi  radialis,  flexor  carpi  ulnaris,  and  extensor  carpi  ulnaris  are  in  danger 
of  being  cut.  (2)  The  ends  of  the  radius  and  ulna  may  be  first  disarticulated 
and  sawed,  and  then  the  carpal  bones  removed,  if  such  a  course  seem  more 
convenient.  (3)  The  radial  artery  and  the  palmar  structures  are  to  be 
specially  guarded. 


EXCISION  OF  THE  WRIST- JOINT 

BY  SINGLE  DORSO-RADIAL  INCISION  — BOECKEL-LANGENBECK  OPERATION. 

Description. — Same  as  for  the  last  operation,  as  to  the  bones  removed — 
but  different  in  incision  of  approach. 

Position. — As  in  preceding  operation. 

Landmarks. — See  Incision. 

Incision. — Straight  incision,  between  the  extensor  communis  digitorum 
and  extensor  indicis,  on  the  inner  side,  and  extensor  longus  pollicis  (extensor 
secundi  internodii  pollicis)  on  the  outer  side,  running  close  to  the  outer  border 
of  the  former — extending  from  the  ulnar  border  of  the  dorsal  surface  of  the 
lower  third  (or  half)  of  the  second  metacarpal  up  over  the  radius  for  about 
5  cm.  (2  inches)  above  the  joint-line  (Fig.  385,  O,  O'). 

Operation. — The  incision  is  made  carefully,  and  branches  of  the  radial 
nerve  to  the  middle  finger  avoided,  if  possible.  The  incision  is  now  deepened 
toward  the  second  metacarpal,  trapezoid,  scaphoid,  capsule,  posterior  annular 
ligament,  and  radius.  In  this  deeper  incision,  however,  the  tendons  of  the 
extensor  indicis  and  extensor  communis  digitorum  are  retracted  when  exposed 
— and  the  tendons  of  the  extensor  radialis  longior  and  extensor  radialis  brevior 
are  not  cut.  These  latter  tendons  are  isolated  and  are  then  freed  down  to 
their  attachment  into  the  bases  of  the  second  and  third  metacarpals  respec- 
tively.    If  the  trapezium  is  to  be  left,  together  with  the  pisiform  and  unciform 


492 


EXCISIONS. 


process  of  the  unciform,  it  is  possible,  though  difficult,  to  complete  the  exci- 
sion without  severing  these  tendons.  Otherwise,  however,  and  where  the 
tissues  are  much  infiltrated  and  bound  down  especially,  these  two  tendons 
are  detached  subperiosteal!;/  at  their  insertion.  If  not  divided,  these  tendons 
are  shifted  from  side  to  side  in  the  subsequent  manipulations.  If  divided, 
they  are  sutured  back  as  nearly  in  their  normal  positions  as  possible,  at  the 
end  of  the  operation.     The  remaining  steps  of  the  operation — decortication — • 

freeing  and  excising  of  the  ends  of  the  radius 
and  ulna — removal  of  the  carpal  bones — 
freeing  and  excising,  or  gouging,  of  the 
ends  of  the  metacarpals — together  with  the 
closure  of  the  wound — are  all  carried  out 
through  this  single  opening,  aided  by  good 
lateral  retraction,  just  as  in  Ollier's  opera- 
tion by  the  double  dorsal  incisions. 

Comment. — The  chief  objections  to  the 
operation  are  the  difficulty  of  dealing  with 
the  bones  to  lie  excised  without  division  of 
the  extensores  carpi  radialis  longior  et  bre- 
vior — and  damage  done  to  the  extensor 
muscles  of  the  hand,  dorsifiexion  some- 
times being  seriously  impaired  subsequently. 

EXCISION  OF   THE  WRIST- JOINT 

BY    SINGLE    DORSO-ULNAR    INCISION 

kocher's   METHOD. 

Description. — The  joint  is  approached 
from  its  ulnar  aspect — the  important  radial 
extensor  tendons  are  not  severed- — and  by 
completely  dislocating  the  joint,  it  is  pos- 
sible to  inspect  it  in  its  entirety. 

Position. — As  in  Ollier's  method  (page 
490). 

Landmarks. — Fifth  metacarpal  bone; 
wrist-joint. 

Incision.— Is  from  7  to  8  cm.  (about  3 
inches)  in  length — -extending  from  the  cen- 
ter of  the  wrist-joint — and  thence  upward 
along  the  middle  of  the  back  of  the  fore- 
arm (Fig.  385,  P,  P). 

Operation. — Deepen  this  incision — 
avoiding  dorsal  branch  of  the  ulnar  nerve 
and  the  posterior  ulnar  vein  in  the  lower  part 
of  the  incision.  Divide  the  fascia  and  the  pos- 
terior annular  ligament  and  open  the  sheaths 
of  the  extensor  minimi  digiti  and  extensor  communis  tendons  and  draw  them  to 
the  radial  side.  Under  the  retracted  tendons  the  ligaments  connecting  the  fifth 
metacarpal,  the  unciform,  cuneiform,  and  ulna  are  divided.  The  capsule 
together  with  the  tendon  of  the  extensor  carpi  ulnaris  is  separated  and  retracted 
toward  the  ulnar  aspect.  (The  separation  of  the  extensor  carpi  ulnaris  in 
this  operation  is  not  as  serious  as  the  separation  of  the  two  radial  extensors 
in  the  Dorso-radial  operation.)     The  tendon  of  the  extensor  carpi  ulnaris  is 


Fig.  386. —  Excisions  about  the 
Long  Bones  of  the  Upper  Extrem- 
ity:— A,  Excision  of  ulna,  by  long  pos- 
terior incision  ;  B,  Excision  of  radius, 
by  long  externo-dorsal  incision  ;  C,  Ex- 
cision of  part  of  diaphysis  of  humerus, 
by  external  vertical  incision. 


TOTAL    EXCISION    OF    THE    ULNA 


493 


removed  from  its  osseous  groove  on  the  dorsal  surface  of  the  ulna.  The  cap- 
sule is  incised  and  removed  from  around  the  lower  end  of  the  ulna.  The 
meniscus  is  to  be  removed  if  the  inferior  radio-ulnar  articulation  is  involved. 
The  joint  between  the  cuneiform  and  pisiform  is  opened  up — leaving  the 
tendon  of  the  flexor  carpi  ulnaris  attached  to  the  pisiform.  The  unciform 
process  of  the  unciform  is  exposed  and  cut  off  with  bone-cutting  pliers.  The 
mass  of  common  flexor  tendons  is  lifted  out  of  their  groove.  The  ligamentous 
connections  between  the  three  innermost  metacarpals  are  separated  upon 
the  palmar  aspect  of  the  hand — preserving  the  insertion  of  the  flexor  carpi 
radialis  into  the  second  metacarpal.  Detach  the  anterior  ligament  of  the 
wrist  from  anterior  aspect  of  the  lower  end  of  the  radius.  Dorsally,  the 
posterior  ligament  is  detached  from  the  inferior  end  of  the  radius  as  far  as  the 
extensors  of  the  radius  and  thumb,  and  the  tendons  are  elevated  from  their 
grooves — the  insertions  of  the  radial  extensor  tendons  into  the  third  and 
second  metacarpals  being  preserved.  The  hand  is  now  forcibly  flexed  toward 
the  forearm  and  completely  dislocated  toward  the  radio-flexor  aspect — bringing 
the  thumb  into  touch  with  the  radial  border  of  the  forearm,  and  displacing 
the  extensor  tendons  to  the  radial  side  of  the  radius.  If  necessary,  further 
detach  the  capsule  from  the  outer  aspect  of  the  radius  up  to  the  insertion  of 
the  supinator  longus.  The  carpal  bones  are  now  dissected  out  in  turn — the 
trapezium  and  trapezoid  being  the  most  difficult  to  remove.  A  thin  slice  of 
the  articular  aspect  of  the  bones  of  the  forearm  and  the  heads  of  the  metacarpals 
is  removed  with  an  appropriate  saw.  These  bones  should  be  sawn  so  as  to 
give  surfaces  curved  on  a  transverse  axis — to  aid  in  subsequent  dorsal  and 
palmar  flexion  and  extension.  The  hand  is  brought  back  into  line  with  the 
forearm — and  the  limb  put  up  in  a  splint  which  will  secure  dorsi-flexion  of 
the  hand,  while  leaving  the  fingers  free  for  passive  movement. 

Comment. — (i)  Apart  from  the  advantages  mentioned  under  Description, 
this  form  of  approach  is  especially  indicated  where  the  involvement  is  chiefly 
of  the  ulnar  aspect  of  the  hand.  (2)  Avoid  the  radial  artery  in  its  course 
upon  the  dorsum  between  the  trapezium  and  trapezoid  and  passing  to  the 
palm  between  the  first  and  second  metacarpals. 

EXCISION  OF  THE  ULNA,   IN  GENERAL. 

Surgical  Anatomy  Surface  Form  and  Landmarks. — Given  under 
Amputations  about  the  Forearm,  pages  353  and  354. 

General  Surgical  Considerations. — The  entire  ulna,  or  any  portion  of 
its  diaphysis,  may  be  removed. 

After-treatment. — A  long  supporting  splint  for  the  forearm,  with  pas- 
sive movement  at  the  elbow  and  wrist. 

Results. — Satisfactory  results  have  followed  the  subperiosteal  method. 

TOTAL  EXCISION  OF  ULNA 

BY    LONG    POSTERIOR    INCISION. 

Position. — Patient's  forearm  is  pronated  and  outstretched  upon  a  small 
table. 

Landmarks. — Ulna;  elbow-  and  wrist-joints. 

Incision. — In  the  long  axis  of  the  ulna,  and  placed  so  as  to  fall  upon  its 
posterior  border  in  the  interval  between  the  anconeus  and  flexor  carpi  ulnaris 
above,  and  between  the  flexor  carpi  ulnaris  and  extensor  carpi  ulnaris  below 
(Fig.  386,  A). 

Operation. — Having  incised  the  skin  and  fascia,  the  above  intermuscular 


494  EXCISIONS. 

spaces  are  recognized  and  followed  to  the  bone — after  having  sought  the 
dorsal  branch  of  the  ulnar  nerve  beneath  the  flexor  carpi  ulnaris,  about  5 
cm.  (2  inches)  above  the  wrist-joint,  and  henceforth  guarded  it.  The  perios- 
teum is  incised  to  the  bone  throughout  along  the  line  of  incision.  The  center 
of  bone  is  then  freed  of  periosteum  entirely  around  its  circumference,  using 
a  well-curved  periosteal  elevator.  A  chain  or  Gigli  saw  is  now  carried  between 
bone  and  periosteum  and  the  former  divided  at  its  center.  Each  end  of  the 
bone  is  then  seized  with  bone-forceps  and,  while  manipulated,  is  further 
freed  of  periosteum  up  to  and  into  the  capsules  of  the  elbow-  and  wrist-joints 
— thus  raising  a  periosteo-capsular  covering.  Both  articular  ends  are  dis- 
articulated— the  periosteo-capsular  sheath  sutured  with  buried  gut  stitches — 
the  muscles  quilted — the  skin-wound  closed,  except  for  temporary  drainage 
of  the  elbow  and  wrist  articulations — and  the  limb  put  up  upon  a  long  splint. 
Comment. — If  it  be  possible  to  leave  one  or  both  articular  ends  of  the 
bone,  it  is  desirable. 

EXCISION  OF  THE  RADIUS,  IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks  General  Sur- 
gical Considerations — After-treatment — Results. — As  in  the  case  of  the 
Ulna,  page  493- 

TOTAL  EXCISION  OF  RADIUS 

BY  LONG  EXTERXO-DORSAL  INCISION. 

Position. — Patient's  forearm  lies  outstretched  and  upon  its  ulnar  border, 
resting  on  a  small  table. 

Landmarks. — Radius;  elbow-  and  wrist-joints. 

Incision. — In  long  axis  of  radius,  and  placed  so  as  to  fall  upon  its  ex- 
terno-dorsal  aspect,  in  the  groove  between  the  supinator  longus  and  extensor 
carpi  radialis  longior  (Fig.  386,  B). 

Operation. — Having  incised  the  skin  and  fascia,  this  intermuscular  space 
is  identified  and  followed  to  the  bone — after  having  sought  the  radial  nerve 
beneath  the  supinator  longus  and  henceforth  guarded  it.  The  periosteum 
is  incised  to  the  bone  throughout.  The  insertion  of  the  pronator  radii  teres 
is  raised  from  the  bone  with  the  periosteum  and  turned  forward.  The 
supinator  brevis  is  bisected  vertically,  the  anterior  half  being  displaced  forward 
with  the  radial  nerve,  the  posterior  half  backward  with  the  posterior  inter- 
osseous nerve.  The  bone  is  now  freed  of  its  periosteum  entirely  around  its 
circumference  at  its  center,  using  a  fully  curved  periosteal  elevator.  A  chain 
or  Gigli  saw  is  passed  between  bone  and  periosteum  and  the  former  divided. 
Each  end  of  the  bone  is  then  seized  with  bone-forceps — and  the  operation 
completed  as  in  the  corresponding  operation  upon  the  ulna  (page  492)- 

Comment. — Same  as  for  the  Ulna  (page  494)  • 


EXCISION  OF  ELBOW- JOINT,  IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
Disarticulation  at  the  Elbow,  pages  359  and  360. 

General  Surgical  Considerations. — (1)  Excision  of  the  elbow-joint 
consists  in  the  removal  of  the  lower  end  of  the  humerus  and  the  upper  ends 
of  the  radius  and  ulna.  (2)  It  is  difficult,  if  not  impossible,  to  save  the  peri- 
osteo-capsular sheath  intact.  (3)  Partial  excisions  may  be  done — of  the 
articular  ends  of  either  humerus,  radius,  or  ulna.     (4)  The  brachialis  anticus 


EXCISION    OF    ELBOW- JOINT.  495 

is  inserted  into  the  ulna  beyond  the  coronoid  process, — and  the  triceps  into 
the  sides  as  well  as  the  tip  of  the  olecranon,  and  thence  into  the  deep  fascia 
of  both  sides  of  the  forearm,  especially  on  the  inner  side.  Therefore  as  little 
of  these  parts  is  to  be  sacrificed  as  possible.  The  preservation  of  the  bands 
of  fibers  continued  from  the  triceps  to  the  fascia  of  the  forearm  is  important 
in  excising  the  elbow,  as  the  power  to  extend  the  limb  is  thereby  preserved 
in  part.  For  the  relation  of  the  triceps  and  brachialis  anticus  to  the  move- 
ments of  the  forearm,  see  Movements  of  the  Elbow-joint,  page  360.  (5) 
The  ulnar  and  posterior  interosseous  nerves  are  to  be  especially  guarded 
in  these  operations. 

After-treatment. — A  special  jointed  splint  is  indicated  that  will  hold  the 
forearm  and  arm  at  any  angle  to  each  other,  with  the  power  to  change  the  angle 
without  removing  the  splint.  The  limb  is  at  first  put  up  at  an  angle  of  135 
degrees,  with  the  forearm  midway  between  pronation  and  supination,  the 
ends  of  the  bones  being  about  1.3  cm.  (h  inch)  apart,  and  the  fingers  free. 
Where  ankylosis  is  feared  (as  in  children  and  after  the  subperiosteal  method), 
or  where  much  bone  has  been  removed,  the  limb  may  be  put  up  at  a  right 
angle  from  the  start. 

Results. — Satisfactory,  as  a  rule.  Ankylosis  is  likely  to  follow  if  the 
sawed  ends  are  kept  in  contact — and  a  flail  limb,  if  kept  too  far  apart.  There 
is  generally  a  tendency  to  the  posterior  displacement  of  the  bones  of  the 
forearm. 

Best  Methods. — Posterior  Median  Incision  (Langenbeck).  Posterior 
Bayonet-shaped  Incision,  with  or  without  an  additional  Ulnar  Incision 
(Oilier).  Vertically  Curved  Dorso-external  Incision  (Kocher).  The  Radio- 
ulnar Articulation  may  be  excised  by  a  Posterior  Vertical  Incision. 

Other  Methods. — Dorso-radial  Angular  Incision  (Kocher).  Lateral 
Radial  and  Ulnar  Incisions  (Hueter).  H -shaped  Incision  (Moreau).  Pos- 
terior Angular  Incision  (Nelaton). 

EXCISION  OF  ELBOW- JOINT 

BV  POSTERIOR  MEDIAN  INCISION  —  LAN GENBECK'S  OPERATION. 

Position. — Patient  supine,  near  edge  of  table.  Assistant  on  side  of 
table  opposite  to  surgeon,  holding  the  operated  limb  by  the  wrist  and  forearm, 
with  patient's  forearm  across  his  (the  patient's)  chest,  so  that  the  arm  is 
vertical  and  the  forearm  horizontal  (nearly  at  a  right  angle  to  the  arm) — 
thus  throwing  the  flexed  elbow  prominently  out  toward  the  surgeon,  with  the 
ulna  and  olecranon  uppermost.  Surgeon  stands  to  outer  side  of  elbow,  on 
the  involved  side,  and  cuts  from  the  forearm  toward  the  arm. 

Landmarks. — Lower  end  of  humerus;  elbow-joint;  upper  ends  of  radius 
and  ulna. 

Incision. — About  10  cm.  (4  inches)  in  length,  in  the  long  axis  of  the 
limb,  passing  directly  over  the  center  of  the  humerus,  olecranon  fossa,  olec- 
ranon process,  and  posterior  crest  of  ulna — half  of  the  incision  being  above 
the  tip  of  the  olecranon  and  half  below  (Fig.  387,  A). 

Operation. — (i)  This  incision  is  made  at  once  directly  through  soft 
parts,  periosteum,  and  capsule  to  the  bone — and,  in  the  above  position,  will 
pass  from  above  downward,  from  the  forearm  over  the  olecranon  and  onto 
the  arm — bisecting  the  triceps  tendon,  incising  the  capsule  and  passing 
through  the  muscular  portion  of  the  triceps  onto  the  humerus.  (2)  The 
incision  is  at  once  deepened  to  the  bone  throughout — efficient  retraction  of 


496 


EXCISIONS. 


the  lips  of  the  wound  being  very  important  for  the  ease  of  the  subsequent 
steps.  The  periosteal  elevator,  of  various  curves,  and  the  rugine,  should 
closely  hug  the  many  irregularities  about  the  joint-structure — raising  up 
the  periosteum  and  the  periosteo-capsular  sheath  with  the  attachments  of 
the  ligaments  undisturbed.  The  surgeon's  left  thumb  aids  in  the  separation, 
while  the  knife  is  used  as  sparingly  as  possible — the  object  being  to  peel 
the  bones  bare  of  all  soft  parts,  including  periosteum.  (3)  The  inner  aspect 
of  the  wound  is  first  freed.  The  inner  half  of  the  triceps  tendon  is  freed 
from  the  olecranon — especial  care  being  observed  and  the  bone  being  very 
closely  hugged  in   freeing  the  groove  between  the  olecranon  and  internal 

condyle,  that  the  ulnar  nerve  may  not 
be  wounded.  The  internal  lateral  liga- 
ment is  freed  from  the  humerus  and  ulna, 
and,  with  it,  the  common  origin  of  the 
flexor  muscles,  together  with  the  perios- 
teum. (4)  The  outer  aspect  of  the  wound 
is  next  freed.  The  outer  half  of  the  tri- 
ceps tendon  is  separated  from  the  olecra- 
non, with  especial  care  that  its  expansion 
into  the  deep  fascia  of  the  forearm  be  not 
severed.  The  anconeus,  the  continua- 
tion of  the  outer  portion  of  the  triceps,  is 
similarly  separated.  The  external .  lat- 
eral ligament,  and,  with  it,  the  common 
origin  of  the  extensor  muscles,  are  sepa- 
rated from  the  external  condyle,  together 
with  the  periosteum.  The  supinator 
brevis  is  freed  from  the  external  condyle 
and  ulna  and  turned  forward,  especially 
guarding  the  interosseous  nerve  between 
its  superficial  and  deep  portions.  (5) 
The  bones  are  now  everywhere  free  ex- 
cept upon  their  anterior  surfaces  (Fig. 
388).  The  articular  end  of  the  humerus 
is  generally  first  removed.  The  patient's 
hand,  of  the  involved  side,  is  placed  prone 
upon  the  table  near  his  head,  and  firmly 
held  there,  while  steadying  the  forearm  in 
an  upright  position — while  an  assistant 
steadies  the  arm  midway  between  a  ver- 
tical and  horizontal.  By  firmly  drawing  the  soft  parts  downward  (toward  the 
shoulder)  the  assistant  protrudes  the  lower  end  of  the  humerus  upward.  Its 
anterior  surface  is  now  sufficiently  cleared— and,  while  the  articular  end  is 
steadied  with  lion-jaw  forceps,  'and  the  soft  parts  retracted  with  spatula? 
or  retractors,  the  bone  is  sawed  at  a  right  angle  to  its  axis  and  generally  on 
a  level  just  below  the  tips  of  the  condyles,  or  at  whatever  height  may  be  in- 
dicated. (6)  The  articular  ends  of  the  radius  and  ulna  are  now  removed. 
By  drawing  down  (toward  the  wrist)  the  soft  parts  from  the  radius  and 
ulna,  while  held  in  the  above  almost  vertical  position,  their  articular  ends 
are  made  to  protrude,  and  are  freed  as  far  as  necessary  on  their  anterior 
surfaces,  care  being  taken  that  the  attachment  of  the  brachials  anticus  is 
not  entirely  freed  from  the  coronoid  process.     The  olecranon  is  seized  and 


Fig.  3S7.— Excisions  about  Elbow  : 
— A,  Excision  of  elbo\v-joint,by  posterior 
median  incision  (Langenbeck's  operation); 
B,  B',  Excision  of  elbow-joint,  by  radial 
and  ulnar  lateral  incisions  ;  C,  Excision  of 
superior  radio-ulnar  articulation,  by  pos- 
terior vertical  incision. 


EXCISION    OF    ELBOW-JOINT. 


497 


steadied  with  forceps,  the  soft  parts  well  re- 
tracted, and  the  articular  end  of  the  olecra- 
non sawed  off  horizontally  to  its  base,  the 
section  including  a  thin  slice  from  the  articu- 
lar end  of  the  radius.  (7)  The  wound  in 
the  periosteo-capsule  is  sutured  with  buried 
gut  stitches.  The  muscles  are  quilted,  also 
by  buried  gut  sutures.  The  wound  is  closed, 
with  temporary  drainage  provided — and 
dressed  upon  a  special  splint  previously  pro- 
vided.    (See  After-treatment,  page  495 . ) 

Comment. —  (1)  Avoid  injury  to  the  ul- 
nar and  posterior  interosseous  nerves.  (2) 
Do  not  completely  detach  the  insertions  of 
the  brachialis  anticus  and  triceps  from  all 
their  neighboring  attachments,  as  such  at- 
tachments preserved  greatly  aid  flexion  and 
extension.  (3)  The  biceps  insertion  is  also 
to  be  strictly  guarded,  but  is  not  so  much  in 
danger  as  the  others  mentioned.  (4)  Freer 
access  may  be  given  to  the  articulation  by 
an  earlier  division  of  the  olecranon.  (5)  Par- 
tial excision  of  the  articular  end  of  the  ulna 
may  he  readily  done  through  the  posterior 
median  incision. 


Fig.  388.— Te 
of  the  Elbow-, 
terior  Aspect. 


Articul 
ixt  CPOX 


ar  Line 
its  Ax- 


Fig.  389. — Excisions  about  El- 
bow:— A,  Excision  of  elbow -joint, 
by  bayonet-shaped  incision  (Ot- 
her's operation);  B,  Ulnar  incision, 
added  to  bayonet-shaped  incision, 
if  needed. 


32 


EXCISION  OF  ELBOW- JOINT 

BY     POSTERIOR      BAYONET-SHAPED      INCISION, 

WITH     OR     WITHOUT     AN    ADDITIONAL 

SHORT  VERTICAL  ULNAR  INCISION 

— OLLIER'S   OPERATION. 

Description. — The  operation  can  usually 
be  completed  through  the  bayonet-shaped  in- 
cision alone.  Where  insufficient  access  is 
thereby  given,  a  short  vertical  ulnar  incision 
may  be  added. 

Position — Landmarks. — As  in  the  above 
operation. 

Incisions. — (1)  Bayonet-shaped  incision 
— the  upper  part  of  the  incision  is  vertical, 
practically  parallel  with  the  axis  of  the  hu- 
merus, placed  in  the  groove  between  the  tri- 
ceps and  supinator  longus,  and  extends  from 
about  5  cm.  (2^  inches)  above  the  joint-line 
to  the  tip  of  the  outer  condyle, — the  middle 
portion  is  oblique,  placed  between  the  outer 
head  of  the  triceps  and  anconeus,  and  ex- 
tends from  the  tip  of  the  outer  condyle 
obliquely  downward  and  inward  to  the  base 
of  the  olecranon, — the  lower  portion  is  again 
vertical,  placed  over  the  posterior  border  of  the 
olecranon  and  extends  from  the  base  of  the 


498  EXCISIONS. 

olecranon  down  the  forearm  for  about  4  to  5  cm.  (i£  to  2  inches).  (2)  Ulnar 
incision  (when  used) — is  a  vertical  incision  of  about  5  cm.  (2  inches)  and  is 
placed  over  the  lateral  aspect  of  the  internal  condyle.  It  is  resorted  to  in 
order  to  secure  more  working-room,  especially  in  cases  of  disease  (Fig.  389, 
A  and  B). 

Operation. — (1)  The  above  incision  is  at  first  only  superficial.  The 
intermuscular  planes  above  indicated  are  identified  and  in  these  planes  the 
incision  is  carried  to  the  bones,  through  the  periosteum  and  periosteo-capsulai 
sheath.  (2)  Through  this  wound,  by  means  of  rugine  and  periosteal  elevator, 
are  detached,  subperiosteal^,  the  triceps  insertion,  external  lateral  ligament, 
common  origin  of  extensor  muscles  and  insertion  of  brachialis  anticus,  and 
the  olecranon  and  border  of  the  sigmoid  cavity  are  decorticated  and  the  head 
of  the  radius  exposed.  (3)  Through  the  same  wound — or  through  the  addi- 
tional ulnar  incision,  if  necessary — the  internal  lateral  ligament  and  common 
origin  of  flexor  tendons  are  freed,  and  the  internal  condyle  decorticated, 
special  care  being  taken  of  the  ulnar  nerve  in  the  groove  between  the  olecranon 
and  internal  condyle.  (4)  Disarticulation  is  now  accomplished.  The 
articular  ends  of  ulna  and  radius  are  thrust  outward,  freed  to  the  desired 
extent,  if  not  already  so  (being  careful  to  preserve  the  greater  part  of  the 
attachment  of  the  brachialis  anticus),  steadied  with  forceps  and  sawed  hori- 
zontally through  at  the  base  of  the  olecranon,  including  a  slice  of  the  radius. 
The  articular  end  of  the  humerus  is  similarly  treated.  (5)  The  periosteo- 
capsular  sheath  is  sutured — the  muscles  quilted— temporary  drainage  estab- 
lished— the  wound  closed — and  the  part  dressed  upon  a  special  splint. 

Comment. — (1)  The  disadvantages  of  this  method  are,  that  the  external 
expansion  of  the  triceps  tendon  is  cut;  the  anconeus  atrophies  (for  the  nerve 
to  it  comes  from  that  branch  of  the  musculospiral  which  supplies  the  outer 
head  of  the  triceps  and  is  cut  in  the  oblique  portion  of  the  incision);  and 
the  ulnar  nerve  is  less  easily  kept  from  harm.  (2)  Partial  excision  (of  the 
articular  ends  of  humerus,  ulna,  or  radius)  may  be  done  through  part  of 
Ollier's  incision. 

EXCISION  OF  THE  ELBOW- JOINT 

BY    VERTICALLY    CURVED    DORSO-EXTERNAL    INCISION KOCHER'S    METHOD. 

Description. — The  special  object  of  the  present  operation  is  to  preserve 
all  the  muscles  and  their  attachments,  of  the  region  involved,  as  well  as  the 
nerves  which  supply  them.  The  nerve  which  supplies  the  anconeus  (descend- 
ing from  the  branch  of  the  musculo-spiral  which  supplies  the  outer  head  of 
the  triceps)  is  here  preserved — while  it  is  divided  (with  consequent  atrophy 
of  the  anconeus)  in  the  excision  of  the  elbow  by  Ollier's  bayonet-shaped 
incision) . 

Position. — As  in  excision  of  the  elbow  by  Langenbeck's  method  (page  495) . 

Landmarks. — Supracondyloid  ridge; — line  of  elbow-joint;  head  of  radius; 
— anconeus; — posterior  border  of  ulna; — olecranon. 

Incision. — Having  flexed  the  elbow  to  an  angle  of  150  degrees,  the  incision 
begins  from  3  to  5  cm.  (i|  to  2  inches)  above  the  line  of  the  elbow-joint,  at 
the  supracondyloid  ridge — passes  thence  downward  vertically  in  the  axis  of 
the  limb  to  the  head  of  the  radius — thence  along  the  external  border  of  the 
anconeus  to  the  posterior  border  of  the  ulna,  to  a  point  about  7.5  cm.  (3  inches) 
below  the  tip  of  olecranon — and  then,  curving  slightly  inward,  ends  over  the 
inner  surface  of  the  ulna  (Fig.  390) . 

Operation. — Passing  from   above  downward,   this  incision  is  deepened 


EXCISION    OF    ELBOW-JOINT. 


499 


to  the  external  border  and  outer  condyle  of  the  humerus,  having  the  radial 
extensors  and  supinator  longus  in  front,  and  the  margin  of  the  triceps  pos- 
teriorly— and,  in  the  forearm,  it  passes  to  the  bone  between  the  extensor  carpi 
ulnaris  and  the  external  border  of  the  anconeus — dividing  the  capsule  over 
the  radial  head  and  the  annular  ligament  at  its  attachment  to  the  ulna.  The 
lowermost  end  of  the  incision  severs  the  lower  fibers  of  the  anconeus  nearly 
transversely  at  their  ulnar  attachment — these  fibers  extending  quite  far  down 
the  forearm.     It  will  be  seen  that  this  incision  passes  along  the  interval  between 


Fig.  390. — Excisions  about  Elbow  and  Shoulder: — Excision  of  elbow  by  vertically 
curved  dorso-external  incision  (Kocher);  osteoplastic  exckion  of  shoulder  by  posterior  curved 
incision  (Kocher). 


the  muscles  supplied  by  the  musculo-spiral  and  those  supplied  by  the  posterior 
interosseous,  thereby  avoiding  atrophy  of  the  anconeus,  which  tenses  and  fixes 
the  capsule  of  the  joint.  Having  exposed  the  bones  of  the  region  and  incised 
the  capsule,  detach  the  external  head  of  the  triceps  subperiosteally,  and  the 
capsule  subcapsularis-  from  the  humerus — and  the  triceps  and  anconeus 
subperiosteally  from  the  ulna.  The  flap  thus  formed  of  the  triceps  and 
anconeus  is  now  retracted  from  the  olecranon  and  displaced  to  the  ulnar  side. 


500  EXCISIONS. 

The  external  lateral  ligament  and  the  attachment  of  extensor  tendons  are 
chiselled  from  the  external  condyle  subcortically  and  displaced  forward. 
The  forearm  can  now  be  readily  and  completely  dislocated  inward,  which 
is  done.  The  extensor  structures  and  their  nerves  are  thus  preserved.  If 
the  object  of  the  operation  is  to  gain  free  access  to  the  interior  of  the  joint, 
this  is  now  readily  accomplished.  If  it  be  desired  to  make  a  complete  excision, 
the  internal  lateral  ligament  and  adjacent  muscles  are  separated  subperios- 
teal^ from  the  internal  humeral  condyle  and  the  inner  border  of  the  ulna — 
accomplishing  the  separation  subcortically,  as  in  the  case  of  the  external 
condyle.  The  sawing  off  of  the  articular  ends  of  the  bones  is  next  accom- 
plished— and  this  should  be  done  in  such  a  way  as  to  leave  surfaces  of  humerus 
above,  and  radius  and  ulna  below,  curved  on  a  transverse  axis,  in  order  to 
aid  in  subsequent  flexion  and  extension,  and  also  to  prevent  displacement. 
This  method  of  sawing  reproduces  the  curve  of  the  olecranon.  The  capsule 
is  now  closed — the  musculo-aponeurotic  tissue  brought  together  with  buried 
sutures — and  the  wound  closed  with  or  without  drainage,  as  indicated — and 
the  limb  immobilized. 


EXCISION  OF  SUPERIOR  RADIO-ULNAR  ARTICULATION 

BY  POSTERIOR  VERTICAL  INCISION. 

Description. — An  operation  sometimes  done  for  unreduced  dislocation 
of  the  head  of  the  radius. 

Position. — As  in  excision  of  the  elbow-joint  by  the  posterior  median 
incision. 

Landmarks. — Elbow  and  radio-ulnar  articulations. 

Incision. — Vertical,  about  5  cm.  (2  inches)  in  length,  with  its  center 
over  the  radio-ulnar  articulation,  and  placed  behind  and  over  the  posterior 
part  of  the  supinator  longus  (Fig.  387,  C). 

Operation. — Incision  passes  through  skin  and  fascia.  The  supinator 
longus  is  recognized  and  is  either  slightly  displaced,  the  incision  passing 
along  its  posterior  border — or  the  incision  passes  directly  through  its  posterior 
fibers  and  upon  the  supinator  brevis.  This  latter  muscle  is  then  carefully 
divided  over  the  head  of  the  radius,  preferably  in  the  direction  of  its  fibers 
(guarding  the  posterior  interosseous  nerve  between  its  two  layers,  and  also 
the  musculospiral  nerve  and  the  biceps  tendon).  The  orbicular  ligament 
is  now  severed — the  parts  well  retracted — the  head  exposed  and  removed 
with  a  Gigli  or  other  saw.  The  musculo-periosteo-capsular  structures  are 
sutured  with  buried  gut  stitches — the  muscles  quilted — the  wound  closed — 
and  the  elbow  dressed  upon  a  special  splint. 


EXCISION  OF  HUMERUS,  IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
Amputations  about  the  Arm,  pages  365  and  366. 

General  Surgical  Considerations. — The  entire  humerus  has  been  ex- 
cised subperiosteallv,  followed  by  a  useful  arm.  Generally,  however,  only 
portions  of  the  shaft  are  excised.  The  operation  for  its  entire  removal  will 
be  described — any  portion  of  the  incision  being  available  for  the  removal  of 
special  portions  of  the  bone.  The  result  of  the  operation,  even  of  a  portion 
of  the  bone,  is  often  a  tlail  and  useless  limb. 


EXCISION    OF    SHOULDER-JOINT,    IN    GENERAL.  501 

EXCISION  OF  HUMERUS 

BY  LONG   EXTERNAL   INCISION. 

Position. — Patient  is  turned  partly  upon  his  side  and  the  arm  sc  placed 
as  to  expose  its  external  aspect. 

Landmarks. — Pectoro-deltoid  groove;  external  bicipital  sulcus. 

Incision. — So  placed  as  to  lie  between  the  deltoid  and  pectoralis  major 
above — and  along  the  external  bicipital  sulcus  below  (Fig.  386,  C,  where 
incision  for  partial  excision  is  given). 

Operation. — The  incision  is  carried  through  skin  and  superficial  fascia, 
and  is  then  carefully  deepened  between  the  soft  parts,  through  the  periosteum, 
to  the  bone  throughout.  The  deltoid  fascia  is  incised  and  the  groove  between 
the  deltoid  and  pectoralis  major  opened  up  by  retraction — the  bicipital  fascia 
incised — and  the  humerus  reached  along  the  outer  border  of  the  coraco- 
brachialis  and  brachialis  anticus.  Avoid,  by  retraction,  the  acromial  thoracic 
and  cephalic  vessels  in  the  pectoro-deltoid  groove — the  circumflex  vessels 
and  nerve  at  the  surgical  neck — the  musculospiral  nerve  and  superior  pro- 
funda artery  to  the  outer  side  of  the  middle  of  the  shaft — and  the  musculo- 
cutaneous nerve  between  the  biceps  and  brachialis  anticus  in  the  lower  third 
of  the  arm.  The  bone  is  freed  subperiosteally,  the  insertions  of  the  tendons 
being  raised  with  the  periosteum.  The  entire  circumference  of  the  bone 
is  freed  at  its  center.  A  chain  or  Gigli  saw  is  then  passed  between  periosteum 
and  center  of  humerus  and  the  bone  divided — after  which  either  end  is  grasped 
by  bone-forceps  and  cleared  toward  either  articulation.  The  articular  ends 
are  disarticulated  in  a  manner  similar  to  the  disarticulation  in  the  excision 
of  a  joint — except  that  the  ends  of  the  bones  are  approached  from  the  shaft. 
The  long  musculo-periosteal  sheath  of  the  diaphysis,  and  the  musculo- 
periosteo-capsular  sheaths  of  the  articular  ends,  are  united  with  buried  gut 
sutures — the  muscles  quilted — temporary  drainage  established  at  the  joint- 
ends — and  the  wound  closed.  The  limb  is  dressed  in  a  long  rigid  splint, 
which  includes  both  shoulder  and  elbow.     (See  end  of  preceding  page.) 


EXCISION  OF  SHOULDER- JOINT,  IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
Disarticulation  at  the  Shoulder-joint,  pages  372  and  373. 

General  Surgical  Considerations. — Excision  of  the  shoulder-joint  con- 
sists in  the  removal  of  the  articular  end  of  the  humerus,  with  gouging,  only, 
of  the  glenoid  fossa — no  part  of  the  scapula  being  removed  with  a  saw.  The 
subperiosteal  method  is  especially  desirable,  the  best  results  attained  having 
followed  this  method. 

After-treatment. — The  sawed  end  of  the  humerus  is  held  in  contact  with 
the  glenoid  fossa,  the  arm  being  bound  to  the  side,  an  axillary  pad  inter- 
vening, and  the  weight  of  the  extremity  being  supported  by  a  sling.  The 
axillary  pad  is  important  in  keeping  the  head  of  the  bone  from  being  drawn 
under  the  coracoid  process,  which  is  more  likely  when  the  external  rotators 
have  been  cut  and  the  pectoralis  major  and  latissimus  dorsi  act  unopposedly. 
Passive  movements  should  begin  as  soon  as  acute  inflammation  subsides — 
abduction  being  the  last  movement,  as  it  displaces  the  head  inward. 

Results. — All  movements  are  to  be  expected,  except  abduction  beyond 
a  right  angle.     Weights  may  also  be  lifted. 


502  EXCISIONS. 

Best  Methods. — Anterior  Oblique  Incision  (Baudens,  Hueter,  and 
Oilier).     Posterior  Curved  Incision  (Kocher's  Osteoplastic  Method). 

Other  Methods. — Anterior  Vertical  Incision  (Langenbeck) .  Posterior 
Vertical  Incision.  Deltoid  Flap.  Anterior  Curved  Incision.  Posterior 
Curved  Incision.     External  Curved  Incision  (Senn's  Osteoplastic  Method) . 

Comparison  of  Methods. — The  anterior  oblique  method  involves  the 
minimum  damage  to  the  deltoid  muscle,  the  chief  muscle  of  the  shoulder- 
joint. 


Fig. 39 1. —Excisions  about  the  Shoulder  : — A,  Excision  of  shoulder-joint,  by  anterior  oblique 
incision  ;  B,  Excision  of  shoulder-joint,  by  anterior  vertical  incision  ;  C,  Excision  of  clavicle,  by  long 
axial  incision. 


EXCISION  OF  SHOULDER- JOINT 

BY  ANTERIOR  OBLIQUE  INCISION. 

Position. — Patient  supine,  near  edge  of  table,  shoulders  raised,  arm 
slightly  abducted.  Surgeon  to  outer  side  of  both  shoulders.  Assistant 
supports  limb. 

Landmarks. — Coracoid   process;  pectoro-deltoid   groove;  shoulder-joint. 

Incision. — Begins  just  to  outer  side  of  tip  of  coracoid  process  and  passes 
obliquely  downward  and  outward  along  the  anterior  border  of  the  deltoid 
for  9  to  10  cm.  (3J  to  4  inches)  (Fig.  391,  A). 


OSTEOPLASTIC    RESECTION    OF    THE    SHOULDER- JOINT.  503 

Operation. — (I)  This  incision  passes,  at  first  through  skin  and  fascia, 
from  the  coraco-acromial  arch  to  its  lower  end.  The  pectoro-deltoid  groove 
is  then  demonstrated.  The  cephalic  vein  and  pectoral  muscle  are  drawn 
inward — the  deltoid  outward.  The  biceps  tendon  is  identified,  its  sheath 
opened,  and  the  contained  tendon  drawn  inward.  The  incision  is  continued 
in  the  original  line  through  the  capsule  into  the  joint  just  to  the  outer  side  of 
this  tendon,  and  through  the  periosteum  onto  the  humerus.  (2)  The  outer 
lip  of  the  wound  is  now  cleared.  The  periosteum,  capsule,  muscular  and 
tendinous  insertions  are  separated  by  rugine  and  periosteal  elevator  as  one 
continuous  layer.  An  assistant  depressing  the  elbow  and  rotating  the  humerus 
inward,  brings  the  greater  tuberosity  into  the  wound,  and  the  insertions  of 
the  supraspinatus,  infraspinatus,  and  teres  minor  are  cleared.  (3)  The 
inner  lip  of  the  wound  is  similarly  cleared.  By  depressing  the  elbow  and 
rotating  the  humerus  outward,  the  lesser  tuberosity  is  brought  into  the  wound. 
The  biceps  tendon  is  now  drawn  out  and  the  insertion  of  the  subscapularis  is 
separated.  (4)  The  head  of  the  humerus  is  then  disarticulated  by  depressing 
the  elbow  and  thrusting  the  head  forward  through  the  retracted  wound,  while 
the  biceps  tendon  is  drawn  inward.  The  neck  of  the  bone  is  now  cleared 
posteriorly,  hugging  the  bone  carefully  to  avoid  damage  to  the  circumflex 
vessels  and  nerve.  After  disarticulation,  the  head  of  the  humerus  is  steadied 
by  lion-jaw  forceps  and  sawed,  the  section  passing  from  without  and  slightly 
downward  and  inward,  the  surgeon  so  standing,  on  both  sides,  as  to  grasp 
the  limb  with  his  left  hand  distally  to  the  saw-cut,  while  the  soft  parts  are  well 
retracted  by  an  assistant.  Following  the  section,  the  margins  of  the  sawed 
bone  may  be  rounded  slightly.  The  humerus  is  sawed  between  the  attach- 
ments of  the  pectoralis  major,  latissimus  dorsi  and  teres  major  below,  and 
the  muscles  of  the  tuberosities  above — the  section  being  as  high  as  possible. 
(5)  The  glenoid  cavity  is  gouged  thoroughly  with  a  sharp  spoon,  and  the 
capsule  of  the  joint  is  scraped,  if  indicated.  (6)  Temporary  drainage  is 
provided  through  a  posterior  opening.  The  head  of  the  bone  is  drawn  into 
place — the  periosteo-capsular  wound  is  sutured  with  buried  gut  stitches — the 
muscles  quilted — and  the  wound  closed. 

Comment. — (1)  The  capsule  should  not  be  cut  transversely,  if  avoidable. 
(2)  All  the  muscles,  tendons,  and  ligaments  should  be  raised  attached  to  the 
periosteo-capsular  covering.  (3)  The  head  of  the  bone  may  be,  less  advis- 
ably, divided  in  situ  by  means  of  a  chain  or  Gigli  saw. 


OSTEOPLASTIC  RESECTION  OF  THE  SHOULDER- JOINT 

BY    POSTERIOR    CURVED    INCISION KOCHER'S    METHOD. 

Description. — The  essential  features  of  this  operation  are  that  the  posterior 
joint  structures  are  more  fully  exposed — while  no  serious  damage  is  done 
to  muscle  or  nerve  structure.     The  acromion  process  is  temporarily  displaced. 

Position. — The  patient  lies  partly  upon  the  opposite  chest,  rendering  the 
externo-posterior  aspect  of  the  shoulder  region  prominent. 

Landmarks. — Acromio-clavicular  articulation; — acromion; — spine  of  the 
scapula; — posterior  fold  of  axilla. 

Incision. — Begins  at  the  acromio-clavicular  articulation — passes  over 
the  upper  part  of  the  shoulder,  along  the  superior  border  of  the  acromion  to 
the  outer  aspect  of  the  spine  of  the  scapula — thence  curves  downward  to  end 
about  3  cm.  (i|  inches)  above  the  posterior  fold  of  the  axilla  (Fig.  392). 


5°4 


EXCISIONS. 


Operation. — This  incision  is  carried  directly  into  the  acromio-clavicular 
joint — and  separates  the  attachment  of  the  trapezius  from  the  superior  border 
of  the  spine  of  the  scapula — the  lower  portion  of  the  incision  exposing  the 
posterior  border  of  the  deltoid.  By  a  finger  inserted  beneath  it  the  deltoid 
is  separated  from  the  posterior  scapular  muscles  up  to  its  insertion  into  the 
acromion.  Its  posterior  fibers  are  incised.  The  upper  border  of  the  infra- 
spinatus muscle  is  similarly  freed  with  a  finger  opposite  the  outer  border  of  the 
spine  and  the  root  of  the  acromion.  The  supraspinatus  is  similarly  detached 
with  a  blunt  dissector  from  the  superior  border  of  the  scapular  spine — so  that 
a  passage  may  be  made  beneath  the  root  of  the  acromion,  which  is  chiselled 
off  obliquely — and,  together  with  the  deltoid,  is  retracted  over  the  head  of 
the  humerus.     Prior  to  this  chiselling,  holes  should  be  drilled  for  subsequent 


Fig.  392. — Osteoplastic  Resection  of  the  Shoulder  joint  by  Curved  External  Inci- 
sion (Senn's  Method). 


suturing  of  the  acromion.  The  suprascapular  nerve  is  guarded  at  this  stage 
of  the  operation.  With  the  reflection  of  the  acromio-deltoid  flap,  the  head  of 
the  humerus  is  freely  exposed  superiorly,  externally,  and  posteriorly,  together 
with  the  attachments  of  the  supraspinatus,  infraspinatus,  and  teres  minor 
muscles,  as  well  as  the  posterior  aspect  of  these  muscles.  The  capsule  is  now 
incised.  Having  rotated  the  arm  outward,  the  capsular  incision  begins  at 
the  upper  part  of  the  posterior  lip  of  the  bicipital  groove — extends  thence 
upward  through  the  thickness  of  the  capsule  along  the  anterior  border  of  the 
insertions  of  the  external  rotator  muscles^to  the  highest  part  of  the  humeral 
head — thus  exposing  the  tendon  of  the  biceps  up  to  its  attachment  to  the 
glenoid  cavity.     Detach   the  supraspinatus,   infraspinatus,   and  teres  minor 


EXCISIONS    OF    BONES    AND    JOINTS    ABOUT    TOES.  505 

muscles  from  the  great  tuberosity  and  retract  them  backward.  Lift  the 
biceps  tendon  from  its  groove  and  displace  it  forward,  exposing  its  sheath. 
Thus  the  whole  head  of  the  humerus  and  the  entire  glenoid  fossa  are  freely 
accessible.  If  a  complete  exposure  of  the  joint  be  sought,  this  is  now  accom- 
plished, allowing  the  preservation  of  the  anterior  portion  of  the  capsule  and 
the  anterior  muscles.  If,  however,  an  excision  be  intended,  the  subscapularis 
is  detached  from  the  lesser  tuberosity — the  cora-humeral  head  of  the  biceps 
displaced — and  the  head  of  the  humerus  thrown  outward.  The  division  of 
the  bone  is  accomplished  as  in  the  preceding  operation.  The  capsule  is 
sutured.  The  repair  of  the  neighboring  soft  parts  is  carried  out  as  far  as 
indicated.  The  chiselled  acromion  is  sutured  back  into  position  through 
the  previously  drilled  holes — and  the  skin  incision  closed,  with  temporary 
drainage.     The  shoulder  and  arm  are  immobilized. 


Fig.  393. — Excisions  about  Shoulder  and  Scapula: — A,  Excision  of  shoulder-joint, 
by  deltoid  flap  (or  less  desirable  form  of  exposure);  B,  Incision  for  excision  of  acromion  and 
spinous  process  of  scapula. 

Comment. — (i)  Instead  of  chiselling  off  the  acromion,  the  posterior  flap 
may  be  formed  by  detaching  the  scapular  origin  of  the  deltoid  subcortically, 
which  subsequently  unites  firmly.  (2)  The  circumflex  vessels  and  nerves, 
coming  out  from  under  the  teres  minor,  can  be  preserved  from  injur}'. 


EXCISIONS   OF  BONES   AND    JOINTS   ABOUT   THE   TOES. 

Surgical  Anatomy — Surface   Form  and   Landmarks. — Given    under 
Amputations  about  the  Toes,  pages  385  and  386. 


506 


EXCISIONS. 


General  Surgical  Considerations. — The  same  general  principles  apply 
in  excisions   about   the   toes   as  in  excisions  about    the  fingers.     The  details 

of  the  various  excisions  about  the 
toes  will,  therefore,  not  be  separately 
given.  Besides,  excision  of  the 
parts  of  the  toes  is  quite  rare — am- 
putations generally  being  done  in- 
stead. This  applies  to  all  the  toes 
except  the  great  toe — with  reference 
to  which  it  may  be  understood  that 
most  of  the  following  operations 
apply. 

EXCISION   OF   TERMINAL   PHA- 
LANGES OF  TOES. 

Best    Method.  — U-Shaped 

Plantar  Incision. 

Description. — As  for  the  termi- 
nal phalanx  of  finger,  page  484. 


EXCISION    OF    SECOND    INTER- 
PHALANGEAL  JOINTS  OF  TOES. 

Best  Method. — Two  Dorso-lat- 
eral  Incisions. 

Description. — As  for  the  second 
interphalangeal  joint  of  the  fingers 
(page  484) — except  that  the  inci- 
sions are  here  more  dorsal  than  lat- 
eral.    (Fig.  394,  A,  A'.) 


EXCISION  OF  SECOND  PHA- 
LANGES OF  TOES. 

Best  Methods.  —  Two  Dorso- 
lateral Incisions — for  toes  in  general. 
U-shaped  Palmar  Incision  — •  for 
great  toe. 

Description. — As  for  the  sec- 
ond phalanx  of  the  fingers  (page 
486) — or  of  the  thumb  (page  484). 
(Fig.  394,  B,  B'.) 


Fig-.  394. — Excisions  about  the  Foot  : — A, 
A',  Excision  of  second  phalangeal  joint  by  two  dor- 
sal incisions  ;  B,  B',  Excision  of  second  phalanx, 
by  two  dorsal  incisions;  C,  C,  Excision  of  first 
phalang  :al  joint,  by  two  dorsal  incisions  ;  D,  Exci- 
sion of  first  phalangeal  joint  of  great  toe  by  dorso- 
internal  incision  ;  E,  E',  Excision  of  metatarso- 
phalangeal joint  by  two  dorso-lateral  incisions  ;  F, 

Excision  of  metatarsal,  by  dorsal  incision;  G,  Ex-       _,vr,TCT__T   ~_  _TT;)CT   T     __     ^^ 
cisionof  metatarsal  bv  dorsal  incision,  with  addi-       r-AClblUlN   Ur   riK.^1    liNinxmA- 
tional  angular  incision;  H,  H',  Osteoplastic  resec-  LANGEAL    JOINTS   OF    TOES. 

tion  of  anterior  tarsus  and  tarso-metatarsus,  by  in- 

ternal  and  external  dorso-lateral  incisions.  Best  Method. — T WO,  Dorsolat- 

eral Incisions — for  toes  in  general. 
Dorso-internal  Incision — for  great  toe. 

Description. — As  for  the  first  interphalangeal  joint  of  the  fingers  (page 
487) — or  of  the  thumb  (also  page  487).     (Fig.  394,  C,  C.) 


EXCISION    OF    ASTRAGALUS.  507 


EXCISION  OF  FIRST  PHALANGES  OF  TOES. 

Best  Methods. — Dorso-internal  Incision — for  great  toe.  Two  Dorso- 
lateral Incisions — for  toes  in  general,  if  done  at  all. 

Description. — As  for  the  first  phalanx  of  the  fingers  in  general,  if  done 
at  all  (page  487) — or  for  the  thumb  (also  page  487). 


EXCISIONS  OF  BONES  AND  JOINTS  ABOUT  THE  FOOT. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
Amputations  and  Disarticulations  about  the  Foot  (pages  385  and  386). 

General  Surgical  Considerations. — (i)  The  general  features  of  ex- 
cisions of  the  metatarsals  are  the  same  as  of  excisions  of  the  metacarpals. 
(2)  Individual  metatarsal  bones  are  not  frequently  excised.  That  of  the 
great  toe  is  the  one  most  often  excised.  (3)  The  sesamoid  bones  are  left 
in  situ,  as  in  the  hand.  (4)  The  chief  tarsal  bones  systematically  excised 
are  the  os  calcis  and  astragalus.  Other  portions  of  the  tarsus  are  excised 
as  indicated.  And  other  tarsal  bones  are  wholly  or  partially  excised  in  such 
operations  as  those  for  the  deformities  about  the  foot. 


EXCISION  OF  METATARSO-PHALANGEAL  JOINTS. 

Best  Methods. — Two  Dorso-lateral  Incisions — for  the  toes  in  general. 
Dorso-internal  Incision — for  the  great  toe. 

Description. — As  for  the  metacarpophalangeal  joint  of  the  fingers,  in 
general  (page  487) — or  of  the  thumb.    (Fig.  394,  E,  E'.) 


EXCISION  OF  THE  METATARSAL  BONES. 

Best  Methods. — Dorsal  Incision — for  toes  in  general.  Dorso-internal 
Incision — for  great  toe. 

Other  Methods. — Interno-plantar  Flap — for  great  toe. 

Description. — As  for  the  metacarpal  bones  by  dorsal  incision  (page  488) 
— or  of  the  metacarpal  of  the  thumb  by  dorso-external  incision  (page  489). 
(Fig.  394.) 

EXCISION  OF  ASTRAGALUS 

BY  EXTERNAL  CURVED  INCISION. 

Position. — Patient  supine,  foot  resting  on  inner  side.  Surgeon  on  side 
of  operation.     Assistant  steadies  foot  and  leg. 

Landmarks. — Fibula;  astragalus;  base  of  fifth  metatarsal. 

Incision. — Begins  about  7.5  cm.  (3  inches)  above  ankle,  at  anterior 
border  of  fibula — passes  vertically  downward  external  to  peroneus  tertius 
and  musculocutaneous  nerve — and  curves  thence  forward  over  outer  surface 
of  astragalus  to  base  of  fifth  metatarsal  (Fig.  395,  A). 

Operation. — Having  incised  skin  and  fascia,  retract  the  peroneus  tertius 
inward  and  extensor  brevis  digitorum  outward.  In  the  interval  thus  left, 
incise  the  capsule  of  the  ankle-joint  and  open  the  medio-tarsal  joint.  Free 
the  neck  of  the  astragalus  and  the  lower  ends  of  the  tibia  and  fibula.     Divide 


508  EXCISIONS. 

the  calcaneo-astragaloid  ligament  and  anterior  and  posterior  bands  .of  the 
externa]  lateral  ligament.  Run  along  the  outline  of  the  astragalus  at  its 
junction  with  the  os  calcis  and  scaphoid  with  a  stout  knife.  Invert  the  foot 
forcibly  and,  while  in  this  semidislocated  position,  free  the  inner  surface  of 
the  astragalus,  using  special  care  near  the  posterior  tibial  vessels  and  nerve. 
The  astragalus  is  now  grasped  with  bone-forceps  and  removed — severing  any 
further  binding  ligaments  which  may  hold  it,  while  under  tension.  The  leg 
then  drops  down  upon  the  upper  surface  of  the  os  calcis.  The  soft  parts  are 
brought  together  with  deep  and  superficial  sutures — the  deep  sutures  being 
of  chromic  gut  and  including  as  much  fibrous  tissue  as  possible.  Temporary 
drainage  is  used — and  the  foot  is  put  up  at  a  right  angle  to  the  leg. 

Comment. — Excision  of  the  astragalus  by  the  external  curved  incision 
is  preferable  where  the  unyielding  condition  of  the  tissues  does  not  require 
two  lateral  incisions,  as  in  the  following  operation. 


EXCISION  OF  ASTRAGALUS 

BV  EXTERNAL  ANGULAR  AND  INTERNAL  CURVED  INCISION. 

Description. — The  bone  is  most  easily  removed  from  the  outer  aspect — 
the  bone  being  approached  between  the  tendons  of  the  tibialis  anticus  and 
tibialis  posticus,  on  the  inner  side — and,  on  the  outer  side,  between  the  tendons 
of  the  peroneus  tertius  and  peroneus  brevis.  The  operation  is  done  by  the 
open  method. 

Position. — Patient  supine,  foot  extending  over  edge  of  table  and  turned 
to  face  inward  and  upward  for  inner  incision  and  outward  and  upward  for 
outer  incision.  The  surgeon  stands  facing  the  foot.  The  assistant  steadies 
leg  and  toes. 

Landmarks. — Inner  and  outer  malleoli;  articular  border  of  tibia;  as- 
tragalo-scaphoid  joint;  astragalo-calcaneal  joint. 

Incisions. — (i)  External  Angular  Incision; — The  Vertical  portion  begins 
just  above  the  level  of  the  articular  border  of  the  tibia,  on  its  antero-external 
aspect,  and  passes  downward  between  the  tendons  of  the  peroneus  tertius 
and  peroneus  brevis,  parallel  with  and  just  behind  the  former  tendon,  for 
about  6  cm.  (2 \  inches),  and  ends  over  the  cuboid  bone; — the  Horizontal 
portion,  shorter,  is  at  a  right  angle  to  the  vertical  portion,  beginning  about 
its  center  and  passing  backward  and  slightly  downward,  ending  just  below 
the  tip  of  the  external  malleolus.  (2)  Internal  Curved  Incision; — begins  just 
above  the  level  of  the  articular  surface  of  the  tibia,  on  its  antero-internal 
aspect,  and  passes  down  immediately  in  front  of  the  anterior  margin  of  the 
tibia  to  slightly  below  the  tip  of  the  internal  malleolus,  whence  it  curves 
backward  and  ends  just  below  the  center  of  the  internal  malleolus.  (Fig. 
395,  B,  and  Fig.  396,  C.) 

Operation. — (1)  These  incisions  first  pass  through  skin  and  fascia  only. 

(2)  The  outer  incision  is  then  deepened  first,  and  the  two  rectangular  flaps 
turned  back  and  the  antero-external  aspect  of  the  astragalus  exposed  between 
the  tendons  of  the  peroneus  tertius  and  peroneus  brevis.  Forcibly  extend 
and  invert  the  foot,  retracting  the  tendons,  and  divide  the  ligaments  between 
the  astragalus,  on  the  one  hand,  and  the  fibula,  os  caicis,  scaphoid,  and 
tibia,  on  the  other — as  far  as  can  be  accomplished  from  the  outer  wound. 

(3)  The  inner  incision  is  now  deepened  and  the  curved  flap  turned  back  and 
the  antero-internal  aspect  of  the  astragalus  exposed  between  the  tendons  of 
the  tibialis  anticus  and  posticus.     Forcibly  extend  and  evert  the  foot,  re- 


EXCISION    OF    ASTRAGALUS. 


5°9 


tracting  the  tendons  out  of  the  way,  and  complete  the  division  of  the  ligaments 
binding  the  astragalus  to  the  tibia,  os  calcis,  and  scaphoid — as  far  as  can  be 


Fig. 395.— Excisions  about  thk  Foot  : — A,  Excision  of  astragalus,  by  external  curved  incision  ;  B, 
External  angular  incision,  in  excision  of  astragalus  by  external  angular  and  internal  curved  incisions  ; 
C,  Excision  of  os  calcis,  by  horizontal  curved  and  vertical  incisions. 


Fig. 396.— Excisions  about  the  Foot: — A,  Excision  of  terminal  phalanx  by  U-shaped  palmar 
incision;  B,  Excision  of  metatarsal  of  great  toe,  by  dorse-internal  incision,  with  or  without  one  or 
more  additional  incisions  at  one  or  both  ends;  C,  Internal  curved  incision,  in  excision  of  astragalus 
by  external  angular  and  internal  curved  incisions  ;  D,  Internal  angular  incision,  in  excision  of  ankle- 
joint  by  external  curved  and  internal  angular  incisions. 


further  accomplished   from   the   inner  wound.      (4)    The   foot  being  again 
firmly  extended  and  inverted,  the  astragalus  is  seized  with  lion-jaw  forceps 


510  EXCISIONS. 

and  strongly  whipped  out  through  the  outer  wound — any  remaining  connec- 
tions being  severed  while  on  the  stretch.  (5)  Suture  the  flaps  into  place — 
institute  temporary  drainage — and  put  up  the  foot  at  a  right  angle  to  the 
leg.  Prior  to  suturing  the  skin-flaps,  it  is  well  to  apply  several  buried  chromic 
gut  sutures  wherever  loose  portions  of  fibrous  tissue  may  be  brought  into 
contact  to  strengthen  the  parts. 

Comment. — (1)  This  excision  may  be  made  through  simply  the  vertical 
portions  of  these  two  incisions — by  retracting  the  lips  of  the  wounds  and 
thus  reaching  the  bones.     (2)  Movement  of  the  ankle-joint  is  not  expected. 

Other  Methods  of  Excision. — External  Angular  Incision.  Transverse 
Incision.     Internal  and  External  Vertical  Incisions. 


EXCISION  OF  OS  CALCIS 

BY  HORIZONTAL  CURVED  AND  VERTICAL  INCISIONS. 

Description. — The  bone  is  removed  from  the  postero-external  aspect. 
The  operation  should  be  done  as  subperiosteally  as  possible. 

Position. — Patient  lies  on  sound  side  with  foot  supported  on  inner  side 
and  free.     Surgeon  faces  foot.     Assistant  steadies  leg. 

Landmarks. — Base  of  fifth  metatarsal;  position  of  posterior  tibial  vessels; 
tendo  Achillis;  calcaneo-cuboid  joint. 

Incisions. — Horizontal  Incision — begins  at  base  of  fifth  metatarsal — 
passes  horizontally  backward,  well  above  the  margin  of  the  sole,  around  the 
convexity  of  the  heel  to  its  inner  side,  to  a  point  about  3.2  cm.  (1^  inches) 
internal  to  the  median  line  of  the  heel — stopping  well  posterior  to  the  posterior 
tibial  vessels  and  nerve.  Vertical  Incision — begins  about  5  cm.  (2  inches) 
above  the  horizontal  incision,  on  the  outer  side  of  the  foot — and  passes  ver- 
tically downward  just  anterior  to  the  tendo  Achillis,  and  between  it  and  the 
tendons  of  the  peroneus  longus  and  brevis,  and  meets  the  horizontal  incision 
at  a  right  angle.      (Fig.  305,  C.) 

Operation. — (1)  These  incisions  are  now  deepened  and  the  two  small 
flaps  made  by  them  are  turned  forward  and  upward,  and  backward  and 
upward,  respectively.  (2)  The  os  calcis  :s  exposed  behind  the  peronei  tendons 
and  the  periosteum  incised  in  the  lines  of  the  incisions.  By  means  of  a  rugine 
everything  is  raised  from  the  bone  as  subperiosteally  as  possible — on  its 
outer,  under,  posterior,  inner,  and  upper  surfaces,  in  order.  The  tendo 
Achillis  is  severed  and  the  soft  parts  and  tendons  are  well  retracted  during 
this  decortication.  (3)  The  head  of  the  bone  is  grasped  with  lion-jaw  forceps 
and  is  drawn  outward — the  remaining  connections  being  severed  while  on 
the  stretch.  (4)  The  flaps  are  dropped  into  place  and  sutured — temporary 
drainage  being  established.  The  foot  is  put  up  at  a  right  angle,  upon  an 
anterior  splint  (so  as  not  to  exert  any  undue  pressure  upon  the  wound). 


EXCISION  OF  ANKLE-JOINT,  IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
Disarticulation  at  the  Ankle,  pages  412,  413. 

General  Surgical  Considerations. — The  operation  is  not  frequently 
performed.  Ankylosis  results  in  the  majority  of  cases.  The  medio-tarsal 
joint,  however,  generally  takes  on  considerable  compensatory  action.     Some 


EXCISION   OF   ANKLE-JOINT.  511 

shortening  results.  Sometimes  the  entire  astragalus  is  removed  at  the  same 
time. 

After-treatment. — The  foot  is  kept  at  a  right  angle  to  the  leg  in  a  fixed 
splint — and  in  the  same  straight  line  with  the  leg.  Although  ankylosis  is 
sought  by  some  surgeons,  movement  is  aimed  at  by  the  majority — and  passive 
movements  are  begun  early. 

Best  Methods. — Transversely  curved  external  incision  (Lauenstein) ; 
external  curved  and  internal  angular  incisions. 

EXCISION  OF  ANKLE-JOINT 

BY  TRANSVERSELY  CURVED  EXTERNAL  INCISION  —  LAUENSTEIN'S  OPERATION. 

Description. — The  joint  is  exposed  through  a  single  external  incision, 
and  the  articular  surfaces  of  the  bones  brought  into  the  field  by  disarticula- 
tion accomplished  by  forcible  temporary  inversion  of  the  foot. 

Position. — Patient  midway  between  supine  and  lateral  positions;  foot 
resting  upon  inner  side.  Surgeon  stands  behind  heel  to  make  incision,  and 
faces  foot  to  complete  operation.     Assistant  steadies  leg. 

Landmarks. —  Ankle  and  astragalo-scaphoid  joints;  peroneus  tertius 
tendon;  external  malleolus;  tendons  of  peroneus  longus,  brevis.  and  Achillis. 

Incision. — Begins  on  dorsum  of  foot,  midway  between  ankle-joint  and 
astragalo-scaphoid  articulation,  and  over  peroneus  tertius  tendon — passes 
nearly  horizontally  backward  below  and  beyond  the  outer  malleolus — and 
thence  upward  between  the  tendo  Achillis,  on  the  one  hand,  and  the  tendons 
of  the  peroneus  longus  and  brevis,  until  from  5  to  7.5  cm.  (2  to  3  inches) 
above  the  joint  (Fig.  397,  A). 

Operation. — (1)  The  skin  and  fascia  are  at  first  carefully  divided.  The 
musculocutaneous  nerve  is  identified  and  drawn  inward.  The  peroneus  ter- 
tius tendon  and  extensor  tendons  are  also  displaced  inward.  The  external 
saphenous  vein  and  nerve  are  not  disturbed  posteriorly.  (2)  The  incision 
is  deepened  between  the  retracted  extensor  tendons  and  fibula  down  to  the  as- 
tragalus, dividing  the  capsule  cf  the  ankle-joint  back  to  the  external  malleolus. 
The  three  bands  of  the  external  lateral  ligament  are  separated  from  the 
outer  malleolus.  The  sheath  of  the  peroneus  longus  and  brevis  is  carefully 
incised  upward  posteriorly  to  the  fibula  so  that  it  may  be  subsequently  sutured 
(the  sheaths  being  separate  below  the  tip  of  the  external  malleolus  and  common 
above  the  tip).  The  tendons  are  then  removed  from  their  sheath  and  re- 
tracted backward.  By  dividing  the  peroneal  sheath  high  up  the  leg  and 
freeing  of  the  tendons,  sufficient  room  may  often  be  gotten  for  disarticulation 
without  severing  the  tendons — otherwise  these  tendons  must  be  cut  and 
subsequently  sutured  with  catgut.  (3)  The  periosteum  is  now  divided  over 
the  fibula,  and  it,  together  with  the  peroneal  sheath,  are  separated  posteriorly, 
with  as  much  as  possible  of  the  periosteum,  from  the  posterior  surface  of 
the  fibula  and  tibia.  (4)  The  periosteum  is  similarly  separated  from  the 
anterior  part  of  the  fibula  and  anterior  surface  of  the  tibia,  carrying  with  it 
the  attachment  of  the  anterior  portion  of  the  capsule.  The  foot  is  thus  freed 
from  its  attachments  to  the  outer  aspect  of  the  fibula  and  to  the  anterior 
and  posterior  aspects  of  the  tibia.  (5)  Forcibly  bend  the  foot  inward  until 
disarticulation  is  so  completely  accomplished  that  the  inner  aspect  of  the 
foot  rests  against  the  leg  and  the  sole  looks  upward  (toward  the  crotch), 
turning  upon  the  internal  lateral  ligament  as  a  hinge — the  ligament  being 
preserved,  if  possible.  All  the  joint  surfaces  are  thus  brought  well  to  view — 
and  no  tendons  are  severed,  except  as  mentioned  above.  (6)  As  much  of 
the  bones  is  now  removed  as  indicated.     It  is  especially  sought  to  avoid 


5i2 


KXCISIONS. 


sawing  off  more  than  the  articular  surface  of  the  astragalus — and  the  gouging 
of  the  articular  surfaces  of  the  tibia  and  fibula,  leaving  the  malleoli  to  prevent 
lateral  displacement  of  the  foot.  If  necessary,  however,  as  much  may  be 
removed  of  the  osseous  tissues  as  in  the  following  operation.  (7)  If  the 
peroneal  tendons  have  been  severed,  these  are  now  sutured  with  chromic  gut 
— replaced  in  their  sheath — and  the  sheath,  in  any  event  (whether  the  tendons 
have  been  divided  or  not),  is  repaired  by  chromic  gut  suturing.  Temporary 
drainage  is  used — the  wound  closed — and  the  foot  put  up  at  a  right  angle. 


EXCISION  OF  ANKLE-JOINT 

BY  EXTERNAL  CURVED  AND  INTERNAL  ANGULAR  INCISIONS. 

Position. — Patient  rests  midway  between  side  and  back,  so  as  to  bring 


Fig.397.— Excisions  about  the  Foot: — A,  Excision  of  ankle-joint  by  transverse  curved  exter- 
nal incision  ;  B,  External  curved  incision,  in  excision  of  ankle-joint  by  external  curved  and  internal 
angular  incisions. 


inner  aspect  of  foot  uppermost  during  the  inner  incision,  and  vice  versa; 
with  foot  supported.     Surgeon  faces  foot.     Assistant  steadies  limb. 

Landmarks. — The  lower  part  of  tibia  and  inner  malleolus;  lower  part 
of  fibula  and  outer  malleolus;  tibio-astragaloid  joint. 

Incisions. — (1)  External  Incision — (with  foot  resting  on  inner  aspect) 
— about  7.5  cm.  (3  inches)  in  length — extends  down  the  antero-lateral  aspect 
of  fibula  to  just  below  the  tip  of  the  outer  malleolus — thence  curves  backward 
around  the  external  malleolus  and  passes  upward  along  the  posterior  border 
of  the  fibula  for  about  2.5  cm.  (1  inch)  (Fig.  397,  B).  (2)  Internal  Incision— 
(with  foot  resting  upon  outer  aspect) — about  7.5  cm.  (3  inches)  in  length — 
extends  down  inner  aspect  of  tibia  to  tip  of  internal  malleolus.  A  second 
incision  may  then  be  added — either  a  transverse  incision  meeting  the  first 
almost  at  a  right  angle,  and  extending  about  1.3  cm.  (5  inch)  on  either  side 
(Fig.  396,  D) — or  a  curved  incision  passing  forward. 

Operation. — (1)  The  outer  incision  passes  down  through  skin,  fascia, 
and  periosteum  as  far  as  it  lies  over  the  fibula — that  portion  below  the  external 


OSTEOPLASTIC    RESECTIONS    ABOUT   FOOT.  513 

malleolus  at  first  passes  through  skin  and  fascia  alone.  The  periosteum  is 
now  turned  forward  and  backward  over  the  fibula — the  external  lateral 
ligament  and  capsule  are  split  in  line  with  the  vertical  incision  and  turned 
backward  and  forward  with  the  periosteum.  The  peroneus  longus  and 
brevis  tendons  are  retracted  backward.  The  anterior  surface  of  the  fibula, 
and  as  much  as  possible  of  the  anterior  surface  of  the  tibia  and  astragalus, 
are  freed  subperiosteally  through  the  outer  wound,  as  well  as  the  posterior 
surface  of  the  fibula,  and  as  much  as  possible  of  the  posterior  surface  of  the 
tibia.  (2)  The  lower  end  of  the  fibula  is  now  divided  with  a  chain  or  Gigli 
saw,  or  with  a  chisel,  about  2.5  cm.  (1  inch)  above  its  tip — and  is  grasped 
bv  bone-forceps  and  removed,  aided  by  a  touch  of  the  rugine  where  necessary. 
(3)  The  internal  incision  is  made  through  skin,  fascia,  and  periosteum  to 
bone,  where  it  lies  over  the  tibia — and  through  skin  and  fascia;  below  the 
tip  of  the  malleolus.  The  periosteum  is  similarly  freed  forward  and  back- 
ward, with  the  overlying  and  connected  ligaments — freeing,  through  the  inner 
wound,  the  outer  and  remaining  portions  of  the  anterior  and  posterior  sur- 
faces of  the  tibia,  and  the  anterior  surface  of  the  astragalus.  The  internal 
lateral  ligament  and  capsule  are  similarly  divided  vertically  and  turned  for- 
ward and  backward  as  part  of  the  periosteo-capsular  covering.  (4)  The 
anterior  and  posterior  tibial  tendons  are  well  retracted  while  working  through 
the  inner  incision — and  if  a  lower  crosscut  be  added  to  the  inner  vertical 
incision,  care  is  taken  that  it  does  not  extend  far  enough  anteriorly  or  pos- 
teriorly to  injure  these  tendons.  (5)  The  lower  end  of  the  tibia  is  now  either 
divided  in  situ  with  a  chain-saw,  or  protruded  through  the  inner  wound, 
grasped  with  forceps,  and  sawed  just  above  its  articular  surface.  (6)  The 
upper  portion  of  the  astragalus  is  then  sawed  off  with  a  thin,  narrow  saw, 
through  the  outer  wound — or  entirely  disarticulated  and  removed,  as  indi- 
cated. (7)  The  inner  and  outer  wounds  are  sutured — temporary  drainage 
established — and  the  foot  dressed  at  a  right  angle  to  the  leg. 


OSTEOPLASTIC    RESECTION    OF    ANTERIOR    TARSUS    AND    TARSO- 

METATARSUS 

BV  INTERNAL  AND  EXTERNAL  DORSOLATERAL  INCISIONS. 

Description. — Consists  in  the  removal  of  the  tarso-metatarsal  joints;  the 
entire  tarsal  bones  distal  to  the  astragalo-scaphoid  and  calcaneo-cuboid,  or 
medio-tarsal.  joint  (namely,  the  scaphoid,  cuboid,  internal,  middle  and  ex- 
ternal cuneiform);  and  the  articular  surfaces  of  the  astragalus  and  os  calcis; 
followed  by  the  approximation  of  the  sawed  proximal  and  distal  bones. 
The  operation  is  resorted  to  in  disease,  especially  tubercle,  of  the  anterior  tarsal 
joints.  Where  the  disease  is  limited  to  the  bases  of  the  metatarsals,  a  tarso- 
metatarsal excision  is  done — the  bases  of  the  metatarsals  and  adjacent  articular 
surfaces  of  the  cuboid,  internal,  middle  and  external  cuneiforms  are  alone 
removed.  Where  the  disease  is  more  general,  in  addition  to  the  tarso-meta- 
tarsal excision,  the  anterior  tarsus  (scaphoid,  cuboid,  and  three  cuneiforms) 
is  also  excised.  And  where  the  disease  is  still  more  extensive,  the  articular 
surfaces  of  the  posterior  tarsus  (astragalus  and  os  calcis)  are  additionally 
removed 

Position. — Patient  supine,  with  foot  over  edge  of  table  and  so  manipulated 
as  to  bring  the  site  of  operation  into  prominence  during  the  various  steps. 
Surgeon  faces  foot.     Assistant  steadies  and  manipulates  foot  and  leg. 

Landmarks. — First  metatarsal,  internal  cuneiform,  scaphoid,  and  head 


514  EXCISIONS. 

of  astragalus,  on  inner  aspect  of  foot, — and  fifth  metatarsal,  cuboid,  head  of 
os  calcis,  and  external  malleolus,  on  outer  aspect. 

Incisions. — Internal  Incision — from  the  posterior  third  of  the  dorsal 
aspect  of  the  first  metatarsal  backward  over  the  internal  cuneiform  and 
scaphoid  to  just  above  the  dorso-lateral  aspect  of  the  head  of  the  astragalus. 
External  Incision — from  the  posterior  third  of  the  dorso-lateral  aspect  of  the 
fifth  metatarsal  (external  to  the  extensor  tendons)  backward  over  the  cuboid 
to  the  dorso-lateral  aspect  of  the  os  calcis,  between  the  calcaneo-cuboid 
articulation  and  external  malleolus.     (Fig.  394,  H,  H'.) 

Operation. — (1)  The  internal  incision  first  passes  through  skin  and 
fascia.  Then  working  upward  and  toward  the  middle  line  of  the  dorsum, 
the  attachment  of  the  tibialis  anticus  is  separated  from  the  first  metatarsal 
and  the  internal  cuneiform — and  the  dorsal  aspect  of  the  first  metatarsal, 
internal  cuneiform,  scaphoid,  and  part  of  astragalus  are  bared,  as  far  toward 
the  middle  of  the  dorsum  as  possible.  Then  working  downward  and  toward 
the  middle  line  of  the  sole,  the  attachment  of  the  posterior  tibial  to  the  tuber- 
osity of  the  scaphoid  and  internal  cuneiform  is  separated — and  the  plantar 
surfaces  of  the  first  metatarsal,  internal  cuneiform,  scaphoid,  and  part  of 
astragalus  are  cleared,  as  far  toward  the  center  of  the  sole  as  possible.  (2) 
The  external  incision  also,  at  first,  involves  skin  and  fascia.  First  working 
toward  the  dorsum,  the  tendon  of  the  peroneus  tertius  is  then  separated  from 
its  attachment  to  the  base  of  the  fifth  metatarsal — and  the  dorsal  aspect  of 
the  outer  metatarsals,  cuboid,  and  part  of  os  calcis,  and  as  far  toward  the 
center  of  the  dorsum  as  possible,  are  cleared.  Then  working  toward  the  sole, 
from  the  outer  aspect,  the  attachment  of  the  peroneus  brevis  is  separated 
from  the  base  of  the  fifth  metatarsal  and  the  tendon  of  the  peroneus  longus 
is  detached  from  the  groove  under  the  cuboid  and  drawn  backward — and  the 
under  surface  of  the  other  metatarsals,  cuboid,  and  part  of  os  calcis  are 
cleared  as  far  toward  the  center  of  the  sole  as  possible.  (3)  The  cuboid, 
three  cuneiforms,  and  scaphoid  are  removed  by  being  grasped  by  bone-forceps 
and  dissected  out  from  the  lateral  wounds.  The  articular  surfaces  of  the 
metatarsals  below,  and  astragalus  and  os  calcis  above,  are  then  sawed  or 
gouged.  (4)  The  sawed  ends  of  the  metatarsals  are  approximated  to  the 
sawed  ends  of  the  astragalus  and  os  calcis — the  dorsal  and  plantar  redundancy 
of  tissue  being  eventually  taken  up.  (5)  Temporary  drainage  is  established — 
the  two  lateral  wounds  sutured — and  the  foot  put  up  upon  a  splint,  at  a  right 
angle  to  the  leg.  Buried  chromic  gut  sutures  between  the  deeper  fibrous 
margins  of  the  wound  should  be  placed  wherever  indicated. 

Comment. — The  anterior  tarsus  alone  may  be  removed,  by  limiting  the 
incision  accordintrlv. 


OSTEOPLASTIC  RESECTION  OF  MID-TARSUS 

BY  EXTERNAL  TRANSVERSE  CURVED  INCISION. 

Description. — Removal  of  anterior  part  of  astragalus  and  os  calcis,  and 
the  posterior  part  of  the  scaphoid  and  cuboid — followed  by  the  approximation 
of  the  sawed  distal  and  proximal  bones. 

Position. — As  in  the  above  operation. 

Landmarks. — Medio-tarsal  joint  line  (astragalo-scaphoid  and  calcaneo- 
cuboid articulations) ;  external  malleolus. 

Incision. — Begins  over  dorsal  aspect  of  astragalo-scaphoid  joint — curves 
obliquely  downward  and  outward  over  upper  part  of  calcaneo-cuboid  joint, 
and  passes  thence  backward  to  a  point  on  a  line  with  and  about  1.3  cm.  (^ 
inch)  below  the  external  malleolus  (Fig.  398,  A). 


OSTEOPLASTIC    RESECTION    OF    POSTERIOR    TARSUS.  515 

Operation. — (i)  Incise  skin  and  fascia.  The  musculocutaneous  nerve 
is  encountered  and  retracted  at  the  upper  angle  of  the  wound,  and  the  external 
saphenous  nerve  and  vein  at  the  lower.  The  tendons  of  the  peroneus  tertius 
and  extensor  longus  digitorum  appear  at  the  upper  part  of  the  wound  and  are 
retracted.  The  tendons  of  the  peroneus  longus  and  brevis  appear  at  the  lower 
part  of  the  wound — their  sheaths  are  slit  and  the  tendons  retracted.  (2)  The 
medio-tarsal  region  is  approached  in  the  interval  thus  made.  The  capsule  is 
incised  over  the  head  of  the  astragalus — the  astragalo-scaphoid  joint  opened 
— and  the  capsule  separated  from  the  articular  ends  of  both  bones.  (3) 
Retract  downward  the  upper  border  of  the  extensor  brevis  digitorum  and 


Fig. 398.— Osteoplastic  Resections  about  the  Foot  : — A,  Osteoplastic  resection  of  mid-tarsus 
by  external  transverse  curved  incision  ;  B,  B',  Osteoplastic  resection  of  posterior  tarsus  by  external 
curved  incision;  B,  C,  Incision  in  osteoplastic  resection  of  foot  by  externo-lateral  curved  incision 
(modification  of  Wladimiroff-Mikulicz  operation  1. 

open  the  calcaneo-cuboid  joint,  and  free  the  capsule  from  the  articular  ends 
of  both  bones.  (4)  Sever  the  greater  process  of  the  os  calcis  and  neck  of 
astragalus  with  chisel  and  remove  with  bone-forceps,  cutting  the  binding 
ligaments  under  traction.  With  chisel  or  gouge,  remove  as  much  of  the 
cuboid  as  indicated — and  the  whole  or  as  much  as  necessary  of  the  scaphoid. 
(5)  The  sawed  scaphoid  and  cuboid  are  approximated  to  the  sawed  astragalus 
and  os  calcis.  The  slit  sheaths  are  sutured  over  the  peronei  tendons — the 
deep  parts  brought  together  with  buried  chromic  gut  sutures — the  wound 
sutured — and  the  foot  put  up  at  a  right  angle  to  the  leg,  with  the  leg  flexed. 
No  drainage  is  established  unless  articular  surfaces  are  left. 


OSTEOPLASTIC  RESECTION  OF  POSTERIOR  TARSUS 

BV  EXTERNAL  CURVED  INCISION. 

Description. — Removal  of  astragalus  and  anterior  half  of  os  calcis; 
together  with  the  articular  surfaces  of  the  tibia  and  fibula,  and  of  the  scaphoid 
and  cuboid;  after  which,  the  anterior  sawed  surface  of  the  posterior  half  of 
the  os  calcis  is  approximated  to  the  sawed  surfaces  of  the  tarsal  bones  (scaphoid 


516  EXCISIONS. 

and  cuboid) ;  and  the  upper  sawed  surface  of  the  posterior  half  of  the  os  calcis 
is  approximated  to  the  sawed  tibia  and  fibula. 

Position. — Patient  supine,  with  foot  resting  upon  its  inner  side.  Surgeon 
stands  upon  the  outer  side — and  an  assistant  steadies  the  leg  and  foot. 

Landmarks. — Tendo  Achillis;  external  malleolus;  base  of  fifth  meta- 
tarsal. 

Incision. — Begins  upon  external  border  of  tendo  Achillis,  about  7.5  cm. 
(3  inches)  above  the  ankle-joint — passes  down  behind  the  tendons  of  the  pero- 
neus  longus  and  brevis  and  external  malleolus — thence  forward,  nearer  the 
sole  than  the  external  malleolus,  to  the  base  of  the  fifth  metatarsal  (Fig. 
398,  BB'). 

Operation. — (1)  Incise  skin  and  fascia.  Slit  sheaths  of  peroneus  longus 
and  brevis  and  retract  the  tendons  forward.  Separating  the  margins  of  the 
wound  as  far  as  possible,  open  the  capsule  of  the  ankle-joint  and,  working 
beneath  this  with  rugine  and  periosteal  elevator,  free  the  surfaces  of  the 
astragalus  and  os  calcis,  and  their  articulations  with  the  scaphoid  and  cuboid, 
as  far  as  possible  in  all  directions,  and  working  as  subperiosteally  as  possible. 
The  origin  of  the  extensor  brevis  digitorum  is  separated  from  the  antero- 
external  aspect  of  the  os  calcis.  The  articular  line  of  the  astragalus  is  freed 
as  fully  as  possible.  (2)  The  foot  is  then  forcibly  inverted  and,  while  in  this 
position,  the  astragalus  is  strongly  prized  and  drawn  out  by  bone-forceps,  the 
binding  ligaments  being  cut  under  tension.  The  peronei  and  tibial  tendons 
are  carefully  preserved.  (3)  The  calcaneo-cuboid  articular  surfaces  are 
then  separated.  The  lower  ends  of  the  tibia  and  fibula  are  projected  into 
the  wound  (by  complete  inversion  of  the  foot)  and  sawed  off  just  above  the 
articular  lines,  leaving  enough  of  the  external  malleolus  for  the  peronei  tendons 
to  hook  behind,  if  possible.  The  anterior  half  of  the  os  calcis  is  then  removed 
by  vertical  section  with  saw  or  chisel.  The  posterior  half  of  the  os  calcis  is 
now  depressed  forward,  so  as  to  render  its  upper  surface  accessible,  and  a 
horizontal  slice  of  bone  is  removed  from  its  upper  surface,  but  not  involving 
the  tendo  Achillis.  The  posterior  articular  surfaces  of  the  scaphoid  and 
cuboid  are  thrust  into  the  wound  (by  twisting  the  anterior  portion  of  the  foot 
inward)  and  a  vertical  section  made  just  posterior  to  their  articular  surfaces. 

(4)  The  vertical  section  of  the  posterior  half  of  the  os  calcis  and  vertical  sec- 
tions of  the  scaphoid  and  cuboid  are  now  approximated — and  the  horizontal 
sections  of  the  tibia  and  fibula  are  dropped  down  upon  and  approximated  to 
the  horizontal  section  of  the  upper  aspect  of  the  posterior  part  of  the  os  calcis. 

(5)  Repair  the  incised  sheaths  of  the  peroneus  tendons  by  suturing  them 
over  the  tendons  with  buried  gut.  The  wound  is  sutured  and  the  foot  put  up 
at  a  right  angle  to  the  leg. 

Comment. — (1)  The  tendons  of  the  peroneus  longus,  brevis,  and  tertius, 
and  of  the  tibialis  anticus  and  posticus,  and  their  attachments,  are  especially 
preserved  intact.  (2)  The  excision  of  the  calcaneo-astragaloid  joint  alone 
may  be  done  through  this  incision. 


OSTEOPLASTIC  RESECTION  OF  FOOT 

BY  TRANSVERSE  UPPER  AND  LOWER  AND  OBLIQUE  LATERAL  INCISIONS  — 
WLADIMIROFF-MIKULICZ  OPERATION. 

Description. — Removal  of  soft  parts  of  heel,  together  with  astragalus 
and  os  calcis,  and  approximation  of  sawed  tibia  and  fibula  to  sawed  scaphoid 
and  cuboid.  A  foot  in  the  permanent  position  of  extreme  talipes  equinus 
results,  the  patent  walking  upon  the  balls  and  phalanges  of  the  toes. 


OSTEOPLASTIC    RESECTION    OF    FOOT. 


5*7 


Position. — Patient  supine,  with  knee  flexed  to  enable  inner  or  outer 
side  of  foot  to  be  turned  uppermost  at  end  of  table.  Surgeon's  position 
will  vary  with  the  varied  steps  of  the  operation. 

Landmarks. — Tuberosity  of  scaphoid;  base  of  fifth  metatarsal;  external 
and  internal  malleoli;  ankle-joint. 

Incisions. — Transverse  Plantar  Incision — from  tuberosity  of  scaphoid 
across  sole  of  foot  to  a  point  slightly  behind  the  base  of  the  fifth  metatarsal. 
Internal  and  External  Oblique  Incisions — pass  from  the  upper  extremities 
of  the  plantar  incisions  obliquely  upward  and  backward  over  the  inner  and 
outer  aspects  of  the  foot  to  the  bases  of  the  internal  and  external  malleoli. 
Posterior  Horizontal  Incision — passes  transversely  backward  around  the 
posterior  aspect  of  the  leg,  connecting  the  upper  extremities  of  the  inner  and 
outer  oblique  incisions.     (Fig.  399,  C,  C,  C",  D,  and  E.) 

Operation. — (1)  The  above  incisions  are  everywhere  carried  to  the  bone 
— the  plantar  vessels  and  posterior  tibial  nerve  being  divided  in  the  transverse 
plantar  incision.  (2)  Flex  the  foot  forcibly — divide  the  tendo  Achillis  and 
the  posterior  ligaments — opening  the  articulation  from  behind.  Further 
flex  the  foot  on  the  leg  and  complete  the  disarticulation  of  the  ankle-joint. 


Fig.399.— Excisions  about  the  Foot  :— A,  Excision  of  first  phalanx  of  great  toe,  by  dorso- 
internal  incision  ;  B,  Excision  of  metatarsophalangeal  joint  of  great  toe  by  dorso-internal  incision  ; 
C,  C,  C",  Skin  incisions  in  Wladimiroff-Mikulicz's  osteoplastic  resection  of  foot  ;  D,  Bone-section  of 
scaphoid  and  cuboid,  in  same  ;  E,  Bone-section  of  tibia  and  fibula,  in  same. 


(3)  By  means  of  rugine  and  periosteal  elevator,  and  approaching  from  the 
lateral  incisions,  detach  the  soft  parts  from  the  dorsum  of  the  foot  as  sub- 
periosteally  as  possible,  thus  guarding  the  anterior  tibial  vessels  and  extensor 
tendons.  (4)  Disarticulate  anteriorly  at  the  astragalo-scaphoid  and  calcaneo- 
cuboid joints,  and  remove  the  astragalus  and  os  calcis  with  the  adherent  soft 
coverings.  (5)  Divide  the  tibia  and  fibula  horizontally  just  above  the  articular 
surfaces.  Divide  the  scaphoid  and  cuboid  vertically  at  about  the  center  of 
each  bone.  Approximate  the  sawed  surfaces  of  the  tibia  and  fibula  above, 
to  the  scaphoid  and  cuboid  below,  in  the  vertical  or  extreme  talipes  equinus 
position — holding  them  in  place  by  kangaroo  tendon,  silver  wire,  or  pegs. 
(6)  Having  tied  all  vessels,  approximate  and    suture   the    cut   ends  of   the 


518  EXCISIONS. 

posterior  tibial  nerve.  Establish  temporary  drainage.  Suture  the  trans- 
verse plantar  incision  and  the  lower  half  of  the  oblique  lateral  incision,  to 
the  upper  half  of  the  oblique  lateral  incision  and  posterior  horizontal  incision. 
The  limb  is  then  put  up  in  a  plaster  cast. 

Comment. — (i)  The  redundancy  of  tissue  is  soon  taken  up.  (2)  The 
limb  is  generally  permanently  a  little  lengthened,  and  a  special  boot  is  always 
to  be  worn.  (3)  Nourishment  of  the  part  occurs  through  the  dorsalis  pedis 
artery  and  its  anastomoses  with  the  plantar.  (4)  The  section  of  bone  below 
may  be  made  through  the  three  cuneiforms  and  cuboid. 


TOTAL    EXCISION    OF   TARSUS  — OR    OSTEOPLASTIC    RESECTION    OF 

FOOT 

BY  EXTERNO-LATERAL  CURVED  INCISION  — MODIFICATION  OF  WLADIMIROFF- 
MIKULICZ  OPERATION. 

Description. — Removal  of  all  the  tarsal  bones,  and  sawing  off  of  distal 
articular  surfaces  of  tibia  and  fibula  and  proximal  articular  surfaces  of  meta- 
tarsals— with  approximation  of  sawed  tibia  and  fibula  to  sawed  metatarsals — 
the  foot  being  brought  into  a  vertical  line  with  the  leg.  This  is  a  modification 
of  the  Wladimiroff-Mikulicz  osteoplastic  resection  of  the  foot,  and  is  prefer- 
able to  that  operation  where  the  soft  tissues  of  the  heel  do  not  have  to  be 
sacrificed.     The  patient  walks  on  the  balls  of  the  toes  and  the  phalanges. 

Position — Landmarks. — As  for  osteoplastic  resection  of  posterior  tarsus, 
page  516. 

Incision. — As  for  osteoplastic  resection  of  posterior  tarsus — except  that 
the  incision  extends  to  near  the  end  of  the  fifth  metatarsal  (Fig.  398,  BC). 

Operation. — The  exposure  and  freeing  of  the  surfaces  of  the  tarsal 
bones,  lower  end  of  the  tibia  and  fibula,  and  bases  of  the  metatarsals  are 
accomplished  in  the  same  manner  as  described  in  freeing  the  bones  involved 
in  osteoplastic  resection  of  the  posterior  tarsus,  except  that  the  clearing  is 
more  extensive.  The  origins  and  insertions  of  all  the  muscles  and  tendons 
into  the  bones  to  be  removed  are  to  be  separated  as  encountered.  All  vessels 
and  nerves  are  carefully  guarded  by  working  close  to  the  bones.  The  tendons 
of  the  peroneus  longus  and  brevis  are  freed  from  their  sheath  and  drawn 
forward.  The  tendo  Achillis  is  subperiosteally  separated  from  the  os  calcis. 
The  long  dorsal,  plantar,  external  and  internal  tendons  are  separated — and 
the  short  muscles  as  well.  The  tarsal  bones  are  to  be  removed  one  by  one 
while  the  foot  is  forcibly  inverted,  access  being  gained  to  the  region,  if  neces- 
sary, by  chiseling  off  the  external  malleolus.  The  articular  ends  of  the 
tibia  and  fibula  and  of  the  metatarsals  are  exposed  by  thrusting  them  through 
the  external  wound  and  are  sawed  off.  Their  sawed  surfaces  are  then 
placed  in  contact  in  a  vertical  line — the  fibrous  tissues  brought  together  with 
chromic  sutures,  where  indicated — the  superficial  wound  closed — and  the 
limb  put  up  in  a  splint,  or  plaster,  in  such  a  manner  as  to  retain  this  position. 

EXCISION  OF  TIBIA.  IN  GENERAL. 

Surgical  Anatomy— Surface  Form  and  Landmarks.— Given  under 
Amputations  about  the  Leg. 

General  Surgical  Considerations. — Where  a  subperiosteal  excision  is 
done,  a  very  useful  limb  often  results,  even  after  the  entire  removal  of  the 
bone.  The'  articular  ends  should  be  left  if  possible.  Any  portion  of  the 
tibia  may  be  removed  through  the  corresponding  part  of  the  following  in- 
cision. 


EXCISION    OF    FIBULA,    IN    GENERAL. 


519 


TOTAL  EXCISION  OF  TIBIA 

BY  INTERNAL  VERTICAL  IN'CISION. 

Position. — Patient  supine;  leg  turned  outward.     Surgeon  to  outer  side 
of  right  limb,  cutting  downward,  and  vice  versa  on  left. 

Landmarks. — Inner   aspect   of   tibia,    which   is   practically   everywhere 
subcutaneous. 

Incision. — Passes  just  in  front  of  the  inner  border  of  the  entire  length 
of  the  tibia,  from  the  knee-joint  to  the  ankle-joint  (Fig.  400,  A). 

Operation. — The  incision  passes  directly  through  periosteum  to  bone — 
running  behind  the  tendons  of  the  sartorius,  gracilis,  and  semitendinosus 
above — and  the  internal  saphenous  nerve  being  recognized  and  retracted 
below.  Once  beneath  the  periosteum,  the  shaft  of  the  bone  is  entirely  freed 
subperiosteal!}'  by  means  of  a  well-curved  perios- 
teal elevator.  The  periosteum,  together  with  all  the 
muscles  and  tendons  attached,  is  freed  to  near 
the  articular  ends.  A  chain  or  Gigli  saw  is  then 
passed  between  the  bone  and  periosteum  and  the 
bone  divided  at  its  center.  Each  end  of  the  tibia  is 
grasped  in  turn,  with  strong  bone-forceps,  and  drawn 
outward — during  which  manoeuvre  the  articular 
end  is  freed  up  to  the  joint  subperiosteo-capsularly 
— and  disarticulated.  The  edges  of  the  incision  in 
the  periosteum  of  the  shaft,  and  in  the  capsules 
of  either  end,  are  now  sutured  with  buried  gut 
stitches.  Temporary  drainage  is  instituted  at 
either  joint  end — the  muscles  and  deep  connective 
tissue  quilted  together,  wherever  indicated — the  skin 
wound  closed — and  the  limb  put  up  on  a  straight 
splint. 


EXCISION  OF  FIBULA.  IN  GENERAL. 

Surgical  Anatomy  —  Surface  Form  and 
Landmarks. — Given  under  Amputations  about 
the  Leg,  pages  417  and  418. 

General  Surgical  Considerations. — (1)  The 
fibula  may  be  removed  in  whole  or  in  part.  (2) 
Removal  of  the  outer  malleolus  is  apt  to  be  fol- 
lowed by  eversion  of  the  foot.  A  very  useful  limb, 
however,  generally  follows  the  subperiosteal  exci- 
sion of  the  bone.  (3)  The  superior  tibio-fibular  ar- 
ticulation often  communicates  with  the  knee-joint 
— it  is,  therefore,  desirable  to  leave,  if  possible, 
the  head  of  the  fibula  entirely,  or,  after  cutting  it 
off,  gouge  out  the  head,  leaving  a  protective  barrier 
of  bone  to  intervene  between  the  knee-joint.  (4) 
In  excising  the  upper  half  of  the  bone  alone,  a 
posterior  vertical  incision  (part  of  the  following 
incision)  is  used,  passing  behind  the  peronei  mus- 
cles. (5)  In  excising  the  lower  half  alone,  an 
antero-external  vertical  incision  is  used,  passing  in 
front  of  the  peronei  muscles. 


Fig. 400.— Excisions  about 
Long  Bones  of  Lower  Ex- 
tremity:— A,  Excision  of  tibia 
by  internal  vertical  incision  ;  B, 
Excision  of  fibula  by  posterior 
vertical  incision  ;  C,  D,  Exci- 
sion of  portions  of  femur  by  ex- 
ternal vertical  incision. 


520  EXCISIONS. 

EXCISION  OF  FIBULA 

BY  POSTERIOR  VERTICAL  INCISION. 

Position. — Patient  supine;  leg  turned  well  to  inner  side.  Surgeon  and 
assistant  stand  as  in  excising  the  tibia  (page  519). 

Landmarks. — Outline  of  fibula;  articulations  of  superior  tibio-fibular 
joint  and  ankle-joint. 

Incision. — Passes  the  entire  length  of  the  bone,  from  the  tibio-fibul  ir 
articulation  to  the  ankle-joint — running  down  behind  the  peroneus  longus 
and  brevis  muscles,  along  the  posterior  aspect  of  the  bone  (Fig.  400,  B). 

Operation. — The  above  incision  is  first  made  through  skin  and  fascia — 
and  then  deepened  through  periosteum  to  bone— guarding  the  external 
popliteal  nerve  above,  where  it  winds  around  the  neck  of  the  bone,  and  the 
peroneal  artery  behind  the  lower  half  of  the  bone.  The  bone  is  reached, 
above,  between  the  peroneus  longus  in  front,  and  soleus,  behind — and, 
below,  between  the  peroneus  longus  and  brevis,  in  front,  and  flexor  longus 
hallucis,  behind.  Once  beneath  the  periosteum,  this  membrane  is  raised 
from  the  bone  in  as  nearly  one  layer  as  possible,  and  to  as  near  the  articular 
ends  of  the  bone  as  possible,  together  with  the  overlying  muscles  and  tendons 
still  attached.  A  chain  or  Gigli  saw  is  then  slipped  between  bone  and  perios- 
teum and  the  bone  divided  in  its  middle.  Each  end  is  then  grasped  by  bone- 
forceps  and  drawn  outward — and,  while  so  held,  is  further  freed  of  its  perios- 
teum, and,  at  its  articular  ends,  of  its  periosteo-capsular  covering.  The 
articular  ends  are  then  disarticulated  at  the  ankle-joint  and  at  the  superior 
tibio-fibular  articulation  (see  General  Surgical  Considerations,  page  519). 
Avoid  opening  into  the  knee-joint,  if  possible,  and  injury  to  the  anterior 
tibial  and  musculocutaneous  nerves.  It  is  preferable  to  preserve  the  upper 
and  lower  articular  ends  in  situ — making  the  section  just  beyond  the  articu- 
lation, unless  contraindicated.  The  long  periosteal  and  peristeo-capsular 
wound  is  now  sutured  with  catgut — muscles  quilted — temporary  drainage 
instituted,  if  the  articulations  have  been  opened  up — the  wound  closed— 
and  the  limb  put  up  on  a  long  splint. 

EXCISION  OF  PATELLA 

BY  VERTICAL  INCISION. 

Description. — The  patella,  which  may  be  considered  a  sesamoid  bone 
developed  in  the  quadriceps  extensor  tendon,  is  simply  shelled  out  of  that 
structure,  through  a  single  anterior  longitudinal  incision,  with  •  minimum 
damage  to  the  surrounding  structures,  and  especially  the  knee-joint. 

Position. — Patient  supine;  limb  extended.  Surgeon  cuts  from  above 
downward  on  right,  and  vice  versa  on  left. 

Landmarks. — Contour  of  patella. 

Incision.— The  incision  passes  through  skin,  fascia,  prepatellar  bursa, 
quadriceps  aponeurotic  expansion,  and  periosteum  to  bone.  Working  be- 
neath the  periosteum  with  rugine  and  curved  periosteal  elevator,  the  bone 
is  freed  from  its  soft  parts  and  from  the  anterior  surface  of  the  capsule  and 
thus  enucleated.  The  cut  margins  of  the  capsule  are  now  sutured  with 
buried  gut  stitches— the  split  quadriceps  expansion  similarly  sutured— the 
wound  closed — and  the  limb  put  up  in  extension. 


EXCISION    OF    KNEE-JOINT,    IN    GENERAL. 


521 


EXCISION  OF  KNEE-JOINT,  IN  GENERAL. 

Surgical  Anatomy— Surface  Form  and  Landmarks.— Given  under  dis 
articulation  at  the  knee-joint,  pages  430  and  431. 

General  Surgical  Considerations. — (1)  In  excision  of  the  knee-joint,  the 
articular  ends  of  the  femur  and  tibia  are  removed — the  sawed  ends  of  the 
bones  are  approximated — and  firm  ankylosis  in  full  extension  is  sought.  (2) 
The  lower  epiphysis  of  the  femur  is  to  be  saved  in  the  young,  if  possible. 
(3)  The  patella  may  be  left,  if  healthy — but  should  be  removed,  in  whole  or 
in  part,  if  diseased.  (4)  The  subperiosteal  method  of  excision  is  almost 
impracticable. 

After-treatment. — The  limb  is  put  up  fully  extended,  and  so  kept  for 


Fig.  401. — Showing  Relations  of  Femur,  Tibia,  and  Fibula  at  the  Knee-joint. 

one  and  a  half  to  three  months — followed  by  other  support  for  several  months 
longer.     An  extra-soled  shoe  is  used  for  the  unavoidable  shortening. 

Results. — The  result  is  satisfactory  where  ankylosis  in  a  good  position 
is  secured.  Flail  and  useless  limbs  sometimes  occur.  There  is  a  tendency 
of  the  femur  to  glide  forward.  If  the  whole  of  the  trochlear  surface  be  re- 
moved, the  epiphysis  (the  chief  source  of  growth  of  the  lower  extremity)  will 
be  lost. 

Best  Method. — Curved  Transverse  Anterior  Incision;  Vertically  Curved 
External  Incision  (Kocher). 


522 


EXCISIONS. 


Other  Methods. — Anterior  U-shaped  Flap;  Anterior  Vertical  Incision, 
with  temporary  splitting  or  retraction  of  patella.  Transverse  Incision  (through 
patella,  or  removing  patella).     Crucial  Incisions.     H -shaped  Incision. 


EXCISION  OF  KNEE-JOINT 

BV  CURVED  TRANSVERSE  ANTERIOR  INCISION. 

Position. — Patient  supine,  near  edge  of  table,  with  leg  half  over  end  of 

table.  Surgeon  on  side  of  operation,  or  on 
outer  side  of  right  and  inner  side  of  left  knee. 
One  assistant  steadies  the  thigh — another  ma- 
nipulates the  leg.  At  the  beginning  of  the 
operation,  the  knee  is  slightly  flexed,  and  subse- 
quently bent  at  a  right  angle. 

Landmarks.  —  Posterior  margins  of  the 
femoral  condyles;  tubercle  of  tibia. 

Incision. — Begins  at  posterior  margin  of 
one  femoral  condyle  (which  is  about  1.3 
cm. — \  inch — above  the  lowest  articular  sur- 
face) and  ends  at  the  posterior  margin  of  the 
opposite  condyle — curving  downward  in  front 
to  midway  between  the  lower  margin  of  the 
patella  and  insertion  of  the  ligamentum  pa- 
tella? (Fig.  402). 

Operation. — (1)  The  above  incision,  made 
while  the  knee  is  slightly  flexed,  passes  through 
skin  and  fascia — and  is  then  deepened,  cutting 
through  anterior  capsule  and  ligamentum  pa- 
tella;, thus  opening  the  knee-joint.  The  divi- 
sion of  the  ligamentum  patella?  at  its  center 
will  permit  of  the  subsequent  suturing  of  its 
ends.  (2)  Turn  the  patella  and  its  apo- 
neurosis upward — further  Ilex  the  joint  and  di- 
vide both  lateral  ligaments  and  both  crucial 
ligaments.  (3)  Bend  the  joint  to  a  right  angle, 
with  sole  of  foot  on  table  and  leg  support- 
ing thigh.  Now  clear  the  femur  to  the  saw- 
line,  retracting  the  soft  parts  and  guarding  the 
popliteal  region.  The  femur  is  then  sawed 
(holding  the  saw  vertically)  just  above  the 
articular  line  —  the  antero-posterior  section 
being  at  a  right  angle  to  the  shaft  of  the 
femur — and  the  transverse  section  parallel  to 
the  articular  surfaces  of  the  condyles  (Fig.  401).  (4)  The  upper  end  of  the 
tibia  is  now  freed  while  in  the  vertical  position,  down  to  the  saw-line — the  soft 
parts  retracted — the  popliteal  region  guarded — and  the  articular  end  of  the 
tibia  sawed  off,  holding  the  saw  horizontal  and  parallel  with  the  articular 
surface.  (5)  If  healthy,  the  patella  may  be  left.  If  the  articular  surface  be 
slightly  diseased,  the  bone  is  steadied  with  bone-holding  forceps  while  the 
articular  surface  is  removed  with  a  saw  or  chisel,  or  the  diseased  bone  is 
gouged  away.  If  badly  diseased,  it  is  entirely  dissected  out.  It  is  often 
removed,  whether  healthy  or  not — but  it  is  better  to  leave  it,  if  uninvolved. 


Fig.  402.— Excision  of  Knee- 
joint  : — By  curved  transverse  ante- 
rior incision. 


EXCISION    OF    THE    KNEE-JOINT.  523 

(6)  The  pouch  beneath  the  quadriceps  extensor  tendon  is  opened  up  and 
curetted  out — and  all  other  synovial  recesses  similarly  treated.  (7)  The  end 
of  the  bones  are  now  approximated  with  extreme  care,  and  retained  in  position 
according  to  the  individual  ideas  of  the  surgeon  (by  pegging,  wiring,  simple 
suturing  of  periosteo-capsular  sheath  and  fibrous  tissues  around  the  margins 
of  the  two  ends ;  or  simply  by  apposition  of  the  ends  and  the  use  of  a  plaster 
or  other  splint).  (8)  If  the  curved  incision  have  severed  the  ligamentum 
patelke  a  short  distance  above  the  tubercle  of  the  tibia,  which  is  desirable, 
the  cut  ends  of  the  ligament  are  now  sutured  with  chromic  gut.  (9)  Tempo- 
rary drainage  is  established  from  either  angle  of  the  wound — the  subcutaneous 
soft  parts  brought  together  with  buried  gut  sutures — the  skin-wound  closed — 
and  the  limb  put  up  upon  a  posterior  splint  in  full  extension. 

Comment.— (1)  Only  branches  of  the  articular,  anastomotica  magna,  and 
anterior  tibial  recurrent  are  cut,  and  rarely  require  ligature.  (2)  Much  of  the 
ease  of  the  efficient  exposure  of  the  joint  structures  will  depend  on  carrying  the 
limbs  of  the  incision  to  the  posterior  margin  of  the  femoral  condyles.  (3)  The 
posterior  ligament  is  separated  from  the  femur  and  tibia,  in  preparing  them 
for  the  saw — and  carefully  kept  intact  throughout  the  operation,  as  a  barrier 
to  the  important  popliteal  region.  (4)  The  retention  of  the  patella  is  of  no 
special  service,  as  ankylosis  of  the  joint  is  sought.  If  removed,  it  should 
be  done  as  subperiosteal^  as  possible,  from  the  articular  aspects,  to  preserve 
all  the  overlying  tissues,  if  these  be  healthy.  (5)  As  little  of  the  femur  should 
be  removed  as  possible,  especially  in  the  young.  (6)  Be  on  guard  for  the 
internal  saphenous  vein  and  nerve  at  the  back  part  of  the  inner  portion  of 
the  incision.  (7)  If  the  bone  sections  be  not  made  in  the  proper  planes,  the 
limb  may  be  knock-kneed  or  bow-legged,  accordingly.  In  such  an  event, 
another  section  of  bone  should  be  made,  of  tibia  or  femur,  or  both.  The 
limb  should  be  absolutely  straight. 


EXCISIONAOF  THE  KNEE-JOINT 

BY    VERTICALLY    CURVED    EXTERNAL    INCISION KOCHER'S    METHOD. 

Description. — The  joint  is  exposed  by  a  curved  external  incision,  having 
a  general  longitudinal  direction.  The  tibial  tubercle  is  chiselled  off,  retaining 
its  periosteal  attachment.  The  soft  parts,  including  the  quadriceps  apparatus, 
are  displaced  to  the  inner  side — the  crucial  ligaments  severed,  and  the  artic- 
ular ends  of  the  bones  thrown  out.  The  femur  is  sawn  convexly  and  the 
tibia  concavely,  so  that  the  sawn  surfaces  will  fit  each  other  reciprocally. 

Position. — For  the  making  of  the  incision,  the  knee  is  placed  somewhat 
upon  its  inner  aspect,  to  render  the  outer  aspect  prominent. 

Landmarks. — Vastus  externus;  patella;  tibial  tuberosity;  anterior  border 
of  tibia. 

Incision. — Begins  over  the  vastus  externus,  about  8  cm.  (3  inches)  above 
the  upper  border  of  the  patella — extends  vertically  downward  1.5  cm.  (J  inch) 
external  to  it — thence  curves  slightly  inward,  ending  at  the  anterior  border 
of  tibia  just  below  the  tibial  tuberosity  (Fig.  403,  A). 

Operation. — Divide  the  skin  and  the  dense  fascia  lata  in  the  line  of  the 
incision.  The  outer  margin  of  the  vastus  externus  is  exposed  and  divided  in 
the  upper  aspect  of  the  wound.  The  external  surface  of  the  capsular  ligament, 
fatty  tissue,  and  the  external  margin  of  the  ligamentum  patella?  are  exposed. 
The  ligament  of  the  patella  is  freed  down  to  the  tubercle  of  the  tibia.  The 
tibial  tubercle,  together  with  the  patellar  ligament  and  periosteum,  are  chiselled 


524 


EXCISIONS. 


off  subcortically  and  retracted  inward — the  soft  attachments  being  carefully 
maintained.  The  capsular  ligament  is  incised  over  the  outer  part  of  the 
external  condyle  and  the  great  synovial  sac  beneath  the  quadriceps  opened  up. 
The  anterior  end  of  the  external  semilunar  cartilage  is  cut  away  from  the  tibia 


Fig.  403. — Excisions  about  the  Lower  Extremity: — A,  Excision  of  knee-joint  by 
vertically  curved  external  incision  (Kocher);  B,  Excision  of  hip-joint  by  external  straight  incision 
(Langenbeck);  C,  Excision  of  innominate  bone  (Kocher). 

and  drawn  aside  without  separating  it  from  the  capsule.  The  patellar  ligament 
is  retracted  inward,  and,  after  severing  the  anterior  end  of  the  internal  semilunar 
cartilage  from  the  head  of  the  tibia,  the  cartilage,  together  with  the  capsule 
and  periosteum,  is  detached  from  the  margin  of  the  internal  condyle.     The 


EXCISION    OF    THE    KXEE-JOIXT. 


525 


patella  is  now  dislocated  to  the  inner  side  of  the  limb.  The  capsular  ligament 
is  detached  from  both  sides  of  the  tibia — until  the  leg  can  be  flexed  completely. 
The  attachments  of  the  crucial  ligaments  and  the  posterior  attachments  of  the 
semilunar  cartilages  are  separated  from  the  head  of  the  tibia  back  to  its  poste- 
rior surface.  If  it  is  intended  to  remove  the  articular  ends  of  the  bones,  the 
upper  ends  of  the  crucial  ligaments  are  detached  from  the  intercondyloid  fossa 
in  such  a  manner  that,  together  with  the  semilunar  cartilages,  they  remain 
attached  to  the  posterior  aspect  of  the  capsule  and  the  periosteum.  The 
capsule  of  the  joint  is  now  divided  on  a  level  with  the  condyloid  cartilages  of 
the  femur — and  (provided  it  is  not  to  be  removed)  it  is  separated  backward 
subperiosteally  to  the  superior  attachments  of  the  lateral  ligaments.     The 


Fig.  404. — -Excision7  of  Knee-joint: — By  anterior  U-shaped  incision. 

capsule  and  periosteum  are  separated  from  the  posterior  aspect  of  the  tibia. 
The  femur  is  then  sawn  below  the  level  of  the  separated  lateral  ligaments  in 
such  a  manner  as  to  leave  a  convex  surface  from  before  backward — and  the 
tibia  is  sawn  so  as  to  leave  a  concave  surface  from  before  backward — thus 
forming  reciprocally  fitting  surfaces  of  bone.  Where  the  capsule  has  been 
preserved,  it  is  sutured  together  along  the  line  of  original  incision,  making 
provision  for  drainage — after  which  the  skin  and  superficial  parts  are  united 
by  suture,  up  to  the  exit  of  the  drains.  The  limb  is  then  dressed  in  an  immo- 
bilizing splint. 

Comment. — Where  the  disease  extends  upward,  the  lateral  ligaments  are 
detached  higher,  chiselling  off  the  epicondyles.  All  involved  tissue  is  removed, 
even  exceeding  the  above  limits  if  indicated. 


526  EXCISIONS. 


EXCISION  OF  FEMUR,  IN  GENERAL. 

Surgical  Anatomy — Surface  Form  and  Landmarks. — Given  under 
Amputations  about  the  Thigh. 

General  Surgical  Considerations. — (1)  Excision  is  generally  confined 
to  the  removal  of  limited  portions  of  the  diaphvsis  of  the  femur.  But  the 
removal  of  the  entire  shaft,  subperiosteally,  especially  in  the  young,  has  been 
followed  bv  the  reproduction  of  bone  and  a  very  useful  limb. 

After-treatment. — In  the  young,  the  limb  should  be  under  traction  to  the 
same  length  as  the  other,  and  held  rigidly  in  a  splint.  In  the  old,  where  only 
a  limited  amount  of  bone  is  removed  and  satisfactory  reproduction  of  bone 
is  not  likely,  the  sawed  ends  are  to  be  approximated,  and  the  shorter  limb 
built  up  by  a  shoe  on  that  side,  as  a  solid  shorter  limb  is  better  than  a  flail 
longer  one. 


EXCISION  OF  PARTS  OF  DIAPHYSIS  OF  FEMUR 

BY  EXTERNAL  VERTICAL  INCISION. 

Description. — Portions  of  the  entire  thickness  of  the  femur,  between  the 
articular  ends,  have  been  removed  with  successful  result.  Also  see  General 
Surgical  Considerations,  page  526. 

Position. — Patient  on  back,  turned  slightly  to  one  side,  to  expose  outer 
aspect  of  thigh.  Surgeon  stands  behind  limb,  cutting  from  above  downward 
on  right,  and  vice  versa.     Assistant  opposite  surgeon. 

Incision.— Down  outer  side  of  thigh,  in  groove  between  posterior  border 
of  vastus  externus  and  biceps — and  extending  from  base  of  great  trochanter 
to  base  of  external  condyle — or  part  of  the  way,  as  indicated — (Fig.  400,  C 
and  D). 

Operation. — The  incision  first  passes  through  skin,  fascia,  and  fascia 
lata.  The  intermuscular  plane  just  mentioned  is  identified  in  the  upper 
portion  of  the  wound  and  followed  to  the  bone.  The  transverse  terminal 
branch  of  the  external  circumflex  artery  is  encountered  above,  passing  beneath 
the  vastus  externus  muscle — and  the  superior  external  articular  artery  below, 
winding  around  the  bone.  The  incision  is  carried  directly  through  perios- 
teum to  bone.  The  periosteum  is  then  freed,  together  with  attached  muscles 
and  tendons,  from  the  entire  circumference  of  the  femur,  by  means  of  fully 
curved  rugine  and  periosteal  elevators,  especially  along  the  inner  and  outer 
lips  of  the  linea  aspera.  Having  freed  the  center  of  the  shaft,  pass  a  chain 
or  Gigli  saw  between  bone  and  periosteum — divide  the  bone — grasp  either 
end  with  bone-forceps  and  draw  outward — and  further  free  the  bone  while 
thus  held,  as  far  upward  and  downward  as  indicated.  Then  again  pass  the 
chain  saw  subperiosteally  at  either  end  and  divide.  If  feasible,  the  femur 
may  be  freed  over  the  entire  length  and  circumference  of  the  part  to  be  re- 
moved, and  then  a  chain  saw  passed  at  the  upper  and  lower  limits  and  the 
bone  thus  divided  but  twice.  Suture  periosteal  sheath — quilt  the  muscles 
with  buried  sutures — close  the  wound — and  put  the  limb  up  in  a  rigid,  straight 
splint  (v.  After-treatment,  page  526). 


EXCISION  OF  HIP- JOINT,  IN  GENERAL. 

Surgical  Anatomy — Surface   Form  and   Landmarks. — Given  under 
Disarticulation  of  Hip-joint,  pages  450  and  451. 


EXCISION    OF    HIP-JOINT,    IN    GENERAL. 


527 


General  Surgical  Considerations. — (1)  Excision  of  the  hip-joint  con- 
sists in  the  removal  of  the  upper  end  of  the  femur  and  scraping  of  the  acetabu- 
lum. (2)  No  tourniquet  is  necessary — the  slight  hemorrhage  encountered 
is  from  small  vessels  which  are  controlled  as  divided.  (3)  According  to  some, 
the  section  of  the  bone  should,  as  a  rule,  be  made  below  the  great  trochanter, 
for  even  where  less  of  the  bone  is  involved,  retention  of  the  great  trochanter 
is  apt  to  be  followed  by  harmful  pressure  (Fig.  405,  B).  According  to  other 
surgeons,  as  little  of  the  bone  should  be  removed  as  possible,  together  with  the 
minimum  disturbance  of  the  muscles  of  the  trochanters  (Fig.  405,  A) . 

After-treatment. — The  limb  is  kept  at  absolute  rest- — in  full  extension 
— with  the  sawed  end  of  the  femur  slightly  separated  from  the  acetabular 
cavity. 

Results. — A  movable  and  useful  joint  generallv  follows.  Ankvlosis  or 
a  flail  limb  is  exceptional.  Some  atrophy  generally  occurs — and  there  is 
always  some  shortening. 


Fig.   405. — Lines   of   Section  of  Head  of  Femur  in  Excision  of  the  Hii'-joint: — A, 
Transcervical  section;  B,  Subtrochanteric  section.     (Modified  from  Gray. J 


Best  Methods. — Anterior  Straight  Incision  (Barker).  External  Straight 
Incision  (Langenbeck).     Posterior  Angular  Incision  (Kocher). 

Other  Methods. — Curved  Retro-trochanteric  Incision. 

Comparison  of  Methods. — Each  method  has  its  own  special  indication. 
The  method  by  external  incision  is,  on  the  whole,  probably  the  best.  The 
anterior  incision  does  least  harm  to  neighboring  structures,  dividing  no 
muscles  (which  the  external  and  posterior  incisions  do).  The  posterior 
incision  gives  the  freest  access  to  the  joint  and  the  best  drainage. 


528  EXCISIONS. 

EXCISION  OF  HIP- JOINT 

BY  EXTERNAL  STRAIGHT  INCISION  —  LANGENBECK'S  OPERATION. 

Position. — Patient  on  sound  side;  thigh  flexed  at  an  angle  of  45  degrees 
and  rotated  inward.  Surgeon  to  outer  side  of  hip.  Assistant,  grasping  knee 
and  foot,  rotates  and  manipulates  the  limb  as  indicated. 

Landmarks. — Great  trochanter. 

Incision. — Begins  over  the  ilium,  about  7.5  cm.  (3  inches)  above  the 
upper  border  of  the  great  trochanter  (which  is  about  opposite  the  upper 
margin  of  the  great  sacrosciatic  notch) — passes  downward  for  11.5  to  12.5 
cm.  (4 \  to  5  inches)  in  the  long  axis  of  the  limb,  lying  just  behind  the  center 
of  the  outer  surface  of  the  great  trochanter,  and  ends  just  below  the  base 
of  the  great  trochanter.  (In  the  above  position  of  the  limb,  the  direction 
of  the  incision  will  be  represented  by  a  straight  line  from  the  posterior  superior 
iliac  spine,  passing  down  the  center  of  the  long  axis  of  the  limb.)  (Fig.  403,6.) 

Operation. — (1)  This  incision  passes,  at  first,  through  skin  and  fascia — 
then  through  the  gluteus  maximus,  dividing  it,  approximately,  in  the  line  of 
its  fibers.  (2)  The  gap  between  the  gluteus  medius  in  front,  and  pyriformis 
behind,  is  sought  and  widened  to  the  joint  by  retraction — and  the  capsule 
of  the  joint  and  periosteum  of  the  great  trochanter  are  divided  to  the  bone 
in  the  line  of  the  original  incision.  If  necessary,  the  capsule  of  the  joint  is 
further  divided  transversely.  By  means  of  curved  rugine  and  periosteal 
elevator,  the  anterior  and  posterior  capsulo-periosteal  flaps  are  raised,  sub- 
periosieally,  if  possible — or  by  the  open  method.  (3)  The  cotyloid  ligament 
is  cut  by  thrusting  a  stout  knife  between  the  head  of  the  bone  and  the  cotyloid 
ligament  and  cutting  the  ligament  toward  the  rim  of  the  acetabulum,  and  air 
thus  allowed  to  enter  and  separate  the  articular  surfaces.  In  those  cases  where 
difficulty  is  experienced  in  admitting  air  to  the  joint  cavity,  a  small  portion  of 
the  rim  of  the  acetabulum,  with  its  cotyloid  cartilage,  may  be  chiseled  away 
'over  about  1.3  cm.  (J  inch)  of  the  circumference.  (4)  The  muscles  attached 
to  the  outer  and  posterior  surfaces  of  the  great  trochanter  are  now  raised  sub- 
periosteally,  or  severed,  while  an  assistant,  grasping  the  knee  and  foot,  rotates 
the  thigh  inward, — and  those  attached  to  the  anterior  surface  and  lesser  tro- 
chanter while  the  thigh  is  rotated  outward.  (5)  The  ligamentum  teres  is 
now  divided  and  the  head  of  the  bone  dislocated  backward  and  outward  bv 
depressing  the  limb  (if  the  thigh  partly  rests  over  the  end  of  the  table  as  a 
fulcrum)  and  rotating  outward.  (6)  The  soft  parts  are  further  cleared  from 
the  upper  end  of  the  femur  and  retracted.  While  steadied  with  bone-holding 
forceps,  the  head  of  the  femur  is  sawed  below  the  great  trochanter,  with  slight 
obliquity,  from  above  downward,  and  from  without  inward.  (7)  The  ace- 
tabular cavity  is  scraped  or  cleared  with  a  gouge.  All  synovial  recesses  are 
curetted.  (8)  Temporary  drainage  is  instituted — the  capsule  sutured — the 
muscles  quilted — the  wound  sutured — and  the  limb  put  up  in  extension  (see 
After-treatment,  page  527). 

Comment. — (1)  Only  minor  hemorrhage  occurs,  seldom  necessitating 
ligature.  (2)  The  strength  of  the  capsule  is  increased  if  its  transverse  division 
be  avoided.  (3)  Some  surgeons  remove  as  little  of  the  head  of  the  femur  as 
possible,  sawing  through  the  neck — but  it  is  generally  better  *to  saw  below 
the  great  trochanter,  as  this  mass  of  bone,  if  left,  is  apt  to  be  drawn  up  and 
constantly  press  the  cicatrix.     (4)  Considerable  division  of  muscle  is  made. 


EXCISION    OF    HIP-JOINT. 


529 


EXCISION  OF  HIP- JOINT 

BY  ANTERIOR    STRAIGHT    INCISION  —  BARKER'S  OPERATION. 

Position. — Patient  supine;  limb  extended.     Surgeon  on  side  of  operation. 
Assistant  steadies  limb. 

Landmarks. — Anterior  superior  iliac  spine;  groove  between  tensor  vagi- 
na? femoris  and   glutei  on   outer 
side,  and  sartorius  and  rectus  on 
inner  side. 

Incision.  —  Begins  on  front 
of  thigh,  about  1.3  cm.  (h  inch) 
below  the  anterior  superior  iliac 
spine  —  passing  downward  and 
slightly  inward  for  7.5  to  10  cm. 
(3  to  4  inches),  in  groove  formed, 
on  inner  side,  by  sartorius  and 
rectus,  and,  on  outer  side,  by  ten- 
sor vaginae  femoris  and  glutei 
(Fig.  406). 

Operation. — (1)  This  incision 
passes  through  skin  and  fascia, 
at  first.  The  external  cutaneous 
nerve  is  avoided,  being  retracted 
outward,  if  in  the  way.  The 
above  intermuscular  groove  is  rec- 
ognized and  the  muscles  forming 
it  retracted  inward  and  outward. 
(2)  The  terminal  branch  of  the 
transverse  division  of  the  external 
circumflex  artery  is  encountered 
and  generally  requires  ligation. 
The  parts  are  further  drawn  aside 
and  the  joint  reached  without  any 
division  of  muscles  whatever,  or 
of  any  vessels  or  nerves  of  im 
portance.  (3)  An  incision  is  now 
made  over  the  anterior  aspect  of 

the  joint,  in  line  with  the  original  incision,  passing  through  the  capsule  into 
the  joint  and  on  to  the  head  of  the  femur.  (4)  The  cotyloid  ligament  is  in- 
cised to  admit  air  into  the  joint  and  enable  the  head  of  the  femur  to  be  drawn 
down  lower.  The  neck  of  the  bone  is  exposed  and  divided  in  situ  with  a  nar- 
row saw,  or  with  a  chain  or  Gigli  saw — the  soft  parts  being  as  much  retracted 
as  possible.  The  severed  head  is  then  seized  with  strong  bone-forceps  and 
removed,  the  ligamentum  teres  having  been  cut.  (5)  The  acetabular  cavity 
and  recesses  of  synovial  membrane  are  curetted  with  Barker's  flushing-gouge 
— and  the  operation  completed  as  in  the  excision  by  external  incision.  Tem- 
porary drainage  is  used  and  is  best  accomplished  through  a  counter-opening 
made  posteriorly. 

Comment. — Disarticulation    may   be   accomplished    as   in    the  external 
incision  and  the  head  excised  outside  of  the  wound. 


Fig.  406. 


-hxcisioN  of  Hip-joint  : — By  anterior 
straight  incision. 


53° 


EXCISIONS. 


EXCISION  OF  HIP-JOINT 

BY    POSTERIOR    ANGULAR    OR    CURVED    INCISION — KOCHER'S    OPERATION. 

Position. — Patient  on  sound  side;  hip  prominent;  knee  semiflexed  and 
rotated  inward.     Surgeon  stands  behind  hip.     Assistant  steadies  the  part. 

Landmarks.  —  Great  trochanter; 
direction  of  fibers  of  gluteus  maximus. 
Incision. — Begins  at  base  of  exter- 
nal aspect  of  great  trochanter — passes 
thence  upward  and  forward  to  its  an- 
terior superior  angle — and  then  runs 
obliquely  upward  and  inward  in  the 
line  of  the  filters  of  the  gluteus  maxi- 
mus (Fig.  407). 

Operation. — (1)  Theincision  passes 
through  skin  and  fascia,  at  first.  Di- 
vide the  aponeurosis  of  the  gluteus 
maximus  over  the  external  aspect  of 
the  great  trochanter — and  ligate  the  cut 
branches  of  the  external  circumflex  ar- 
tery. (2)  Divide  the  fibers  of  the  mus- 
cular portion  of  the  gluteus  maximus  in 
the  upper  part  of  the  wound,  and  ligate 
the  cut  branches  of  the  gluteal  artery. 
(3)  Dissect  through  the  intermuscular 
fat  and  fascia  and  expose  the  interval 
between  the  gluteus  medius  and  mini- 
mus above  and  pyriformis  below — 
drawing  the  two  former  upward  and 
the  latter  downward.  Thus  the  pos- 
terior part  of  the  capsule  and  acetabu- 
lum are  approached  and  exposed.  (4) 
Divide  the  capsule  along  the  superior 
border  of  the  pyriformis.  Rotate  the 
thigh  outward  and  subperiosteally  sep- 
arate the  gluteus  medius  from  the  outer 
surface  and  the  gluteus  minimus  from  the  anterior  border  of  the  great 
trochanter,  raising  a  thin  layer  of  bone,  with  rugine  or  chisel,  if  necessary. 
Then  subperiosteally  detach  the  pyriformis,  obturator  interims,  and  gemelli 
from  the  inner  aspect  of  the  great  trochanter,  and  the  obturator  externus  from 
the  digital  fossa.  (5)  Rotate  the  thigh  inward  and  free  the  inner  and  posterior 
aspects  of  the  great  trochanter.  The  head,  neck,  and  great  trochanter  are 
thus  cleared.  Some  branches  of  the  internal  circumflex  may  require  ligation 
near  the  capsule  of  the  joint,  and  branches  of  the  external  circumflex  near 
the  base  of  the  great  trochanter.  (6)  Cut  the  internal  cotyloid  ligament  to 
admit  air — divide  the  ligamentum  teres  from  behind,  on  the  head  of  the 
femur  while  the  limb  is  adducted,  flexed,  and  rotated  inward.  The  head  is 
now  dislocated  through  the  wound  by  outward  rotation,  and  removed.  (7) 
The  periosteo-muscular  wound  is  sutured  with  buried  chromic  gut  stitches 
— the  muscles  quilted — temporary  drainage  established — the  wound  closed — 
and  the  limb  put  up  upon  a  splint  in  extension. 

Comment. — The  above  operation  is  really  a  development  of  Langenbeck's 
external  incision,  but  admits  of  freer  access  to  the  joint  and  gives  better 
drainage. 


Fig.  407. — Excision  of  Hip- joint: — 
By  posterior  angular  incision.  The 
angularity  of  this  incision  may  be  changed  to 
a  curve. 


EXCISION    OF    THE    INNOMINATE    BONE.  53 1 

EXCISION  OF  THE    INNOMINATE   BONE 
kocher's   operation. 

Description. — The  entire  removal  of  one  of  the  innominate  bones  may 
be  required  by  extensive  growths  of  the  bony  pelvis. 

Position. — The  patient  rests  upon  the  uninvolved  side,  and  is  turned 
toward  his  face  or  his  back  during  the  progress  of  the  operation. 

Landmarks. — Sacro-iliac  joint;  crest  of  ilium;  Poupart's  ligament. 

Incision. — Begins  at  the  sacro-iliac  joint — passes  along  the  crest  of  the 
ilium — and  thence  along  Poupart's  ligament  (Fig.  403,  C). 

Operation. — Divide  the  abdominal  muscles  from  their  attachment  to 
Poupart's  ligament  and  the  crest  of  the  ilium.  Separate  the  transversalis 
fascia  and  the  peritoneum  from  the  pelvic  floor  as  far  inward  as  the  iliac 
vessels  and  retract  them  further  inward.  The  smaller  nerves  are  cut — and 
the  smaller  arteries  clamped  and  tied.  The  muscles  posterior  to  Poupart's 
ligament  and  external  to  the  iliac  vessels  are  isolated  and  divided.  Separate 
and  detach  as  far  back  as  the  sacro-iliac  joint  the  rectus  femoris,  sartorius, 
tensor  vaginae  femoris,  and  the  iliac  attachments  of  the  gluteus  medius  and 
minimus.  Divide  the  ilio-psoas  muscle  and  the  capsule  of  the  joint.  Sub- 
periosteally  expose  the  pubis  and  ischium  and  divide  them  with  Gigli  saw, 
chisel,  or  bone-cutting  forceps.  The  innominate  bone  can  now  be  displaced 
downward.  The  remainder  of  the  posterior  aspect  of  the  pelvis  is  exposed 
and  the  attachments  of  the  flexor  muscles  severed.  The  great  sacro-sciatic 
ligament  is  cut  from  the  tuber  ischii,  and  the  lesser  sacro-sciatic  ligament  from 
the  ischial  spine.  While  there  is  considerable  bleeding  from  smaller  vessels, 
no  artery  had  to  be  ligated  in  Kocher's  case.  The  wound  healed  by  primary 
union.  Kocher  suggests,  however,  that  the  internal  iliac  vessels  be  ligated 
when  exposed  in  the  wound.  The  lower  limb  is  immobilized  in  line  with  the 
trunk. 


PART  II. 
THE  OPERATIONS  OF  SPECIAL  SURGERY. 


CHAPTER  I. 

OPERATIONS  UPON  THE  HEAD. 
I.  THE  CRANIO-CEREBRAL  REGION. 

SURGICAL  ANATOMY  OF  SCALP,  SKULL,  AND  BRAIN. 

Muscles   in   Relation  with    Outer  Surface   of   Skull.— Anteriorly; 

frontal  portion  of  occipitofrontalis;  corrugator  supercilii;  orbicularis  pal- 
pebrarum. Posteriorly;  occipital  portion  of  occipitofrontalis;  trapezius; 
sternomastoid ;  complexus;  splenius  capitis;  rectus  capitis  posticus  minor  and 
major;  obliquus  capitis  superior;  trachelomastoid;  digastric;  rectus  capitis 
lateralis.  Laterally;  aponeurosis  of  occipitofrontalis;  temporal;  attrahens 
aurem;  attolens  aurem;  retrahens  aurem;  external  pterygoid.  Superiorly; 
aponeurosis  of  occipitofrontalis. 

Arteries  of  Scalp. — Anteriorly;  frontal  and  supraorbital  branches  of 
ophthalmic.  Posteriorly;  occipital  and  posterior  auricular  branches  of 
external  carotid.  Laterally ;  superficial  temporal  branch  of  external  carotid, 
with  its  anterior  and  posterior  branches;  posterior  auricular  branch  of  ex- 
ternal carotid. 

Veins  of  Scalp. — Anteriorly;  frontal,  emptying  into  angular  vein; 
supraorbital,  emptying  into  frontal  and  ophthalmic  veins.  Posteriorly; 
occipital,  emptying  into  deep  cervical  vein;  posterior  auricular,  emptying 
into  temporomaxillary  vein.  Laterally;  anterior,  middle,  and  posterior 
temporal  veins;  forming  common  temporal,  which  empties  into  temporo- 
maxillary vein;  posterior  auricular,  emptying  into  external  jugular. 

Nerves  of  Scalp. — Anteriorly;  supraorbital  branch  of  ophthalmic. 
Posteriorly;  occipitalis  major,  from  cervical  plexus.  Laterally;  temporal 
branches  of  facial;  auriculotemporal  branch  of  inferior  maxillary;  occipitalis 
minor,  from  cervical  plexus;  auricularis  magnus,  from  cervical  plexus. 

Parts  of  Brain. — Medulla  oblongata;  pons  varolii;  cerebellum;  crura 
cerebri  (mid-brain) ;  cerebrum.  The  only  parts  of  the  brain  at  present 
accessible  to  operation  are  the  cerebrum  and  cerebellum. 

Chief  Fissures  upon  Surface  of  Cerebrum. — Great  Longitudinal 
Fissure ;  extending  antero-posteriorly  in  the  median  line  and  separating  the 
hemispheres  of  the  cerebrum.  Sylvian  fissure;  most  important  of  the  in- 
complete fissures  of  the  brain.  Forms  boundary  between  frontal  and  tem- 
poro-sphenoidal  lobes.  Contains  middle  cerebral  artery.  Begins  at  anterior 
perforated  space,  upon  base  of  brain,  and,  running  outward,  divides  into  an 
anterior  limb  (passing  forward  into  inferior  frontal  convolution),  an  ascending 

533 


534  OPERATIONS  UPON  THE  HEAD. 

limb  (passing  upward  also  into  inferior  frontal  convolution),  and  a  horizontal 
or  posterior  limb  (representing  the  continuation  of  sylvian  fissure,  passing 
backward  and  upward).  Rolandic  fissure;  second  most  important  incom- 
plete fissure  of  brain.  Forms  boundary  between  frontal  and  parietal  lobes. 
Extends  from  great  longitudinal  fissure,  at  a  point  about  55  per  cent,  of  the 
distance  from  the  nasion  to  the  inion,  to  or  nearly  to  horizontal  limb  of  fissure 
of  Sylvius.  Parieto-occipital  fissure  ;  forms  boundary  between  parietal  and 
occipital  lobes.  Begins  about  half-way  between  rolandic  fissure  and  posterior 
extremity  of  brain — its  outer  portion  extending  downward  and  forward  upon 
external  aspect  of  brain  for  about  one  inch — its  inner  portion  extending  upon 
internal  aspect  of  hemisphere.  These  four  fissures  just  mentioned  divide 
the  surface  of  the  cerebrum  into  the  five  following  lobes. 

Chief  Lobes  of  Cerebrum. — Frontal  lobe;  forms  forepart  of  hemi- 
sphere— rests  upon  orbital  plate  of  frontal  bone — presents  three  surfaces. 
Boundaries;  Posteriorly,  rolandic  fissure, — Inferiorly,  orbital  plate  of  frontal 
bone  and  horizontal  limb  of  sylvian  fissure, — Internally,  calloso-marginal 
fissure.  Frontal  (supero-external)  surface,  presents  precentral,  superior 
frontal,  and  inferior  frontal  sulci, — and  ascending  frontal,  superior  frontal, 
middle  frontal,  and  inferior  frontal  convolutions.  Orbital  (inferior)  surface, 
presents  triradiate  (or  orbital)  and  olfactory  sulci, — and  internal  orbital, 
anterior  orbital,  and  posterior  orbital  convolutions.  Mesial  (internal)  sur- 
face, is  given  below.  Parietal  lobe ;  that  portion  of  convexity  of  brain 
lying  between  frontal  and  occipital  and  above  temporal  lobes.  Boundaries; 
Anteriorly,  rolandic  fissure, — Posteriorly,  external  parieto-occipital  fissure 
and  a  line  continuing  its  course, — Inferiorly,  horizontal  limb  of  sylvian 
fissure  and  a  line  connecting  this  fissure  with  inferior  end  of  superior  occipital 
sulcus, — Internally,  it  is  continued  into  the  mesial  surface  of  the  hemisphere. 
Sulcus;  intraparietal  (consisting  of  superior  and  inferior  vertical  and  horizontal 
parts).  Convolutions;  ascending  parietal;  superior  parietal;  supramarginal 
and  angular  gyrus.  Occipital  lobe ;  posterior  extremity  of  hemisphere — 
rests  upon  tentorium — continuous  with  parietal  lobe  above  and  temporal 
lobe  below.  Boundaries;  Anteriorly;  external  parieto-occipital  fissure  and 
a  line  continuing  its  course, — Posteriorly;  superior  fossa  of  occipital  bone, — 
Inferiorly;  tentorium, — Internally;  it  is  continued  into  the  mesial  surface  of 
hemisphere.  Sulci;  superior,  middle  (often  but  faintly  marked)  and  inferior 
occipital.  Convolutions;  superior,  middle,  and  inferior  occipital.  Temporal 
or  temporo-sphenoidal  lobe ;  that  portion  of  hemisphere  within  middle 
fossa  of  skull — continuous  with  parietal  and  occipital  lobes  behind.  Boun- 
daries; Anteriorly  and  Superiorly;  sylvian  fissure, — Inferiorly,  middle  fossa  of 
skull, — Posteriorly;  continuous  with  parietal  and  occipital  lobes.  Sulci; 
superior  (first  temporal  or  parallel),  middle  (second  temporal),  inferior 
temporal  (on  under  surface).  Convolutions;  superior,  middle,  inferior  (or 
first,  second,  third)  temporal, — and  an  external  occipitotemporal  (or  fourth 
temporal)  on  the  under  surface.  Central  lobe,  or  island  of  Reil;  corre- 
sponds to  floor  of  embryonic  fossa  of  Sylvius — is  situated  at  base  of  brain, 
in  fissure  of  Sylvius — and  is  composed  of  five  to  seven  gyri  operti  divided  by 
the  sulci  of  Reil.  Boundaries;  separated  by  anterior  sulcus  Reilii  from  poste- 
rior orbital  convolution;  by  external  sulcus  Reilii  from  inferior  frontal,  ascend- 
ing frontal,  and  ascending  parietal  convolutions;  by  posterior  sulcus  Reilii 
from  temporal  lobe. 

Mesial  Fissures  and  Lobes  of  Cerebrum. — Fissures;  calloso-marginal; 
parieto-occipital;    calcarine;    collateral;   dentate.     Lobes;   gyrus   fornicatus, 


SURGICAL  ANATOMY  OF  SCALP,  SKULL,  AND  BRAIX.  535 

marginal,  paracentral,  quadrate  (precuneus);  cuneate;  infracalcarine  (fifth 
temporal);  hippocampal;  uncinate;  fourth  temporal. 

Cerebellum. — Occupies  inferior  occipital  fossae  of  skull,  separated  from 
occipital  lobes  of  brain  by  tentorium — and  is  divided  into  a  central  lobe  (or 
worm)  and  two  lateral  lobes  (or  hemispheres).  Fissures  upon  superior 
surface  of  central  and  lateral  lobes;  precentral,  post-central,  preclival,  post- 
clival.  Lobules  upon  superior  surface  of  central  and  lateral  lobes;  lingula; 
lobulus  centralis;  culmen;  clivus;  folium  cacuminis,  lobules  of  the  central 
lobe; — and  frenulum ;  ala;  anterior  crescentic,  posterior  crescentic  and 
posterior  superior,  lobules  of  the  lateral  lobes.  Fissures  upon  the  inferior 
surface  of  central  and  lateral  lobes;  post-nodular;  prepyramidal;  post-pyr- 
amidal. Lobules  upon  inferior  surface  of  central  and  lateral  lobes;  tuber 
valvulae;  pyramid;  uvula  and  nodulus,  lobules  of  central  lobe; — and  postero- 
inferior;  digastric;  amygdala  and  flocculus;  lobules  of  lateral  lobes. 

Meningeal  Arteries. — Chief  meningeal  arteries;  Middle  Meningeal 
branch  of  internal  maxillary,  entering  skull  through  foramen  spinosum  in 
middle  fossa,  ascends  a  short  distance  in  groove  on  great  wing  of  sphenoid, 
dividing  into  anterior  and  posterior  branches.  Anterior  Branch  of  middle 
meningeal  ascends  in  groove  upon  great  wing  of  sphenoid,  up  to  and  upon 
anterior  inferior  angle  of  parietal  bone  (corresponding  to  a  point  on  exterior 
of  skull  approximately  3.8  cm.  [1^  inches]  behind  and  2.5  cm.  [1  inch]  above 
external  angular  process  of  frontal  bone),  and  is  continued  thence  upward 
and  backward,  more  or  less  parallel  with  anterior  border  of  parietal  bone, 
nearly  to  superior  longitudinal  sinus,  giving  off  branches  running  backward. 
Corresponds,  approximately,  with  points  respectively  2.5,  3.8,  and  5  cm.  (1, 
ii,  and  2  inches)  both  above  zygoma  and  behind  external  angular  process. 
Posterior  Branch  of  middle  meningeal  runs  backward  and  upward  over 
squamous  portion  of  temporal  bone — less  regular  in  its  course  than  anterior 
branch — gives  off  branches  which  pass  upward  to  superior  longitudinal  sinus 
and  backward  to  lateral  sinus.  (For  anatomy  of  these  important  arteries 
in  greater  detail,  see  Ligations,  pages  44-46.)  Other  meningeal  arteries; 
In  Anterior  Cranial  Fossa ;  anterior  meningeal  branches  of  anterior  and  pos- 
terior ethmoidal  (through  anterior  and  posterior  internal  orbital  canals) ;  twigs 
of  middle  meningeal  (through  great  wing  of  sphenoid) ; — In  Middle  Cranial 
Fossa ;  branch  of  ascending  pharyngeal  (through  cartilage  of  foramen  lacerum 
medium) ;  meningea  parva  (through  foramen  ovale) ;  meningeal  branch  of 
internal  carotid;  twigs  of  middle  meningeal, — In  Posterior  Cranial  Fossa; 
meningeal  branch  of  occipital  (through  posterior  compartment  of  jugular 
foramen) ;  another  meningeal  branch  of  occipital  (through  mastoid  foramen) ; 
meningeal  branch  of  ascending  pharyngeal  (through  posterior  compartment 
of  jugular  foramen) ;  another  meningeal  branch  of  ascending  pharyngeal 
(through  anterior  condyloid  foramen) ;  meningeal  branch  of  vertebral  (through 
foramen  magnum).  Another  meningeal  branch  of  occipital  sometimes  enters 
through  parietal  foramen. 

Chief  Cerebral  Arteries. — Anterior  Cerebral; — Middle  Cerebral,  larger 
terminal  division  of  internal  carotid  and  most  important,  surgically,  of  the 
intracerebral  vessels,  supplying  the  motor  convolutions  of  the  brain — runs 
upward  and  outward  in  fissure  of  Sylvius,  dividing  opposite  island  of  Reil 
into,  (1)  Ganglionic  or  Central  Branches  (caudate  branches;  antero-lateral 
branches):  Lenticulo-striate  branch,  or  "artery  of  cerebral  hemorrhage," 
a  larger  branch  of  antero-lateral  set,  enters  outer  part  of  anterior  perforated 
space,  passes  upward  between  lenticular  nucleus  and  external  capsule, 
pierces  internal  capsule  and  ends  in  caudate  nucleus:    (2)  Hemispheral   or 


536  OPERATIONS  UPON  THE  HEAD. 

Cortical  Brandies  (inferior  or  orbitofrontal;  ascending  frontal;  parietal; 
parieto-temporal) ; — Posterior  Cerebral: — Anterior  Communicating; — Poste- 
rior Communicating; — Basilar. 

Chief  Cerebellar  Arteries. — Superior  cerebellar;  anterior  cerebellar; 
inferior  cerebellar. 

Venous  Sinuses  of  Dura  Mater. — (i)  More  superficial  sinuses; — 
Superior  longitudinal  sinus;  extends  from  foramen  caecum,  at  lower  part 
of  frontal  bone,  along  median  line,  in  attached  margin  of  falx  cerebri,  to 
torcular  Herophili  in  depression  of  internal  occipital  protuberance.  Generally 
deviates  slightly  to  right  in  the  back  part  of  the  skull.  Posteriorly,  the 
longitudinal  sinus  extends  6  mm.  (j  inch)  to  left,  and  15  mm.  (f  inch)  to 
right  of  external  occipital  protuberance,  which  measurement  of  2  cm.  (f 
inch)  represents  width  of  longitudinal  sinus,  at  this  site,  and  attachment 
of  falx  cerebri.  Lateral  sinus;  extends  outward,  forward,  and  downward, 
passing  from  internal  occipital  protuberance  along  lateral  sinus  groove  of 
occipital,  posterior  inferior  angle  of  parietal,  mastoid  process  of  temporal 
and  jugular  process  of  occipital,  to  end  in  posterior  compartment  of  jugular 
fossa.  From  the  internal  occipital  protuberance  the  lateral  sinus  forms  a 
slight  curve,  with  upward  convexity,  to  back  of  ear,  on  level  with  upper 
border  of  meatus  auditorius  externus,  constituting  the  transverse  portion  of 
the  lateral  sinus, — and  thence  passes  in  a  curved  line,  convexity  forward,  over 
prominence  of  mastoid  process  to  its  apex,  as  far  as  a  point  5  mm.  (T3g-  inch) 
below  lower  border  of  external  auditory  meatus,  thus  forming  the  sigmoid 
portion  of  the  lateral  sinus.  The  Transverse  portion  of  the  Longitudinal 
Sinus  lies  above  a  straight  line  drawn  from  the  external  occipital  protuberance 
to  the  center  of  the  external  auditory  canal — its  highest  portion  (which  is 
opposite  the  posterior  inferior  angle  of  the  parietal,  at  masto-parietal  suture) 
lying  from  15  to  25  mm.  (f  to  1  inch),  generally  averaging  from  15  to  20  mm. 
(I  to  if  inch),  above  this  line,  and  somewhat  external  to  its  center.  The 
Sigmoid  portion  of  the  Longitudinal  Sinus  generally  lies  from  10  to  12  mm., 
or  -j-7^  to  h  inch  (extremes  2  to  12  mm.,  or  nearly  §  to  ^  inch),  from  the  poste- 
rior wall  of  meatus  auditorius  externus  (corresponding,  approximately,  to 
posterior  reflection  of  skin  from  pinna  of  ear  to  head).  Distance  of  sinus 
from  surface  of  mastoid  process  varies  from  1  to  15  mm.,  or  from  nearly 
y1^  to  f  inch  (average  distance  being  about  7  mm.,  or  f  inch).  Width  of  sig- 
moid portion  of  sinus  (which  is  larger  than  transverse  portion)  is  from  5  to 
15  mm.  (j  to  f  inch).  Right  lateral  sinus  is  generally  larger,  more  forward, 
and  more  superficial  than  left.  Junction  of  transverse  and  sigmoid  portions 
lies  directly  below  anterior  part  of  parieto-mastoid  suture.  Inferior  longi- 
tudinal sinus;  situated  in  free  margin  of  falx  cerebri.  Straight  sinus; 
extends  along  line  of  junction  of  falx  cerebri  and  tentorium.  Occipital 
sinus;  contained  within  attached  border  of  falx  cerebelli.  (2)  Sinuses  at 
base  of  skull; — circular,  transverse,  cavernous,  superior  petrosal,  inferior 
petrosal. 

Chief  Veins  of  Cerebrum. — Cortical  (Hemispheral  or  Superficial), 
consisting  of  superior  and  inferior  cortical  veins,  which  empty  chiefly  into 
the  more  superficial  venous  sinuses  of  the  dura  mater; — Central  (Ganglionic 
or  Deep),  collect  into  two  venae  Galeni,  which  unite  to  form  the  vena  magna 
Galeni,  which  empties  into  the  straight  sinus; — Basilar,  which  enters  vein 
of  Galen. 

Chief  Veins  of  Cerebellum. — Superior  and  Inferior  veins. 


CHIEF  CRANIAL  LANDMARKS. 


CHIEF  CRANIAL  LANDMARKS. 


537 


Nasion:  mid-point  of  naso-frontal  suture;  most  important  anterior  median 
landmark. 

Glabella:  point  in  median  line  between  superciliary  arches;  unreliable, 
may  be  an  elevation  or  a  depression. 

Bregma  (anterior  fontanelle) :  point  where  coronal,  sagittal,  and  frontal 
sutures  meet;  just  in  front  of  center  of  line  between  the  two  auditory  meatuses. 

Coronal  Suture:  on  line  from  bregma  to  middle  of  zygomatic  arch,  running 
2.5  to  3.8  cm.  (1  to  ij  inches)  anterior  to  rolandic  fissure. 

Obelion:  point  on  sagittal  suture  on  a  line  running  between  the  two 
parietal  foramina. 

Lambda  (posterior  fontanelle):  junction  of  lambdoid  and  sagittal  sutures; 
8  to  10  cm.  (3y\  to  4  inches)  behind  superior  rolandic  point  (a  point  55  per 
cent,  of  distance  from  nasion  to  inion,  on  median  line),  or  6  to  7  cm. 
(2§  to  2|  inches)  above  external  occipital  protuberance. 

Lambdoid  (or  parieto-occipital)  Suture:  sometimes  an  elevation  of  superior 
border  of  occipital  bone  marks  this  suture,  which  is  roughlv  represented  by 
a  line  from  the  external  occipital  protuberance  to  the  lower  part  of  the  tip 
of  the  mastoid  process. 

Inion  (or  external  occipital  protuberance) :  most  important  posterior 
median  landmark. 

Superior  Occipital  Curved  Lines  (nuchal  line) :  running  from  the  external 
occipital  protuberance  outward  toward  mastoid  process,  marking  the  posterior 
junction  of  the  head  and  neck. 

External  Occipital  Crest:  from  external  occipital  protuberance  to  center 
of  posterior  border  of  foramen  magnum;  sometimes  palpable. 

Nuchal  Furrow:  depression  in  median  vertical  line  between  posterior 
muscles  of  neck,  having  in  its  center,  above,  the  external  occipital  protuberance; 
its  upper  end  corresponding  with  inner  ends  of  superior  curved  occipital 
lines. 

Orbit:  margin  everywhere  palpable. 

Supraorbital  Arch:  palpable  throughout. 

Internal  Angular  process:  inner  end  of  supraorbital  arch. 

External  Angular  Process:  outer  end  of  supraorbital  arch. 

Superciliary  Ridge:  first  prominence  above  supraorbital  arch. 

Frontal  Eminence:  second  prominence  above  supraorbital  arch. 

Superior  Temporal  Ridge:  especially  marked  at  forepart  of  lateral  aspect, 
leading  downward  and  forward  to  external  angular  process;  gives  attachment 
to  temporal  fascia. 

Superior  Stephanion:  where  coronal  suture  crosses  superior  temporal 
ridge. 

Inferior  Temporal  Ridge:  indicates  upper  boundary  and  attachment  oc 
temporal  muscle,  the  contraction  of  which  muscle  will  aid  in  determining 
site  of  ridge. 

Inferior  Stephanion:  where  coronal  suture  crosses  inferior  temporal  ridge. 

Pterion:  point  in  zygomatic  fossa,  from  3.8  to  5  cm.  (  t+  to  2  inches)  behind 
external  angular  process  and  same  distance  above  zygoma,  where  parietal, 
temporal,  frontal,  and  sphenoid  bones  meet. 

Sylvian  Point:  where  sylvian  fissure  reaches  the  convexity  of  the  hemi- 
sphere, at  a  point  from  2.9  to  3.2  cm.  (ij  to  i^  inches)  directly  behind  external 
angular  process. 


538  OPERATIONS  UPON  THE  HEAD. 

Parietal  Eminence:  most  prominent  postero-lateral  eminence. 

Malar  Bone:  palpable  throughout. 

Retro-orbital  Tubercle :  apophysis  upon  posterior  border  of  upper  part  of 
frontal  process  of  malar  bone,  a  short  distance  below  malo-frontal  suture; 
the  most  important  anterior  lateral  landmark. 

Zygomatic  Arch:  palpable  throughout;  its  upper  border  may  be  taken  as 
a  practically  horizontal  measurement,  in  the  upright  position  of  the  body. 

Auricular  Point:  center  of  external  auditory  meatus;  most  reliable  middle 
lateral  landmark. 

Preauricular  Point:  point  on  Reid's  base-line  (v.  i.)  in  depression  between 
tragus  of  the  ear  and  condyle  of  inferior  maxilla. 

Supra-auricular  Point:  point  vertically  above  auricular  point,  at  root  of 
zygomatic  process. 

Squamous  Suture:  summit  of  which  is  4.4  cm.  (if  inches)  above  zygoma. 

Mastoid  Process  of  Temporal:  palpable  throughout. 

Asterion:  point  behind  ear  where  parietal,  temporal,  and  occipital  bones 
and  lambdoid  and  squamous  sutures  meet;  about  1.8  cm.  (f  inch)  behind 
and  1.2  cm.  (^  inch)  above  upper  part  of  posterior  border  of  mastoid  process. 

Note: — For  other  landmarks  of  the  cranio-cerebral  region,  see  the  methods 
of  Chipault  (page  546),  Kroenlein  (page  553),  Reid  (page  551),  and  Chiene 
(page  554)  for  localizing  the  brain  areas,  and  also  the  data  under  the  following 
division  of  the  subject. 

CRANIO-CEREBRAL  TOPOGRAPHY. 

Description. — Relation  of  areas  and  structures  of  brain  to  the  cranial 
bones.  While  discrepancies  are  found  in  the  statements  of  the  highest 
authorities  in  this  department  of  surgical  work,  and  differences  actually  exist 
in  different  heads,  the  following  may  be  considered  the  most  generally  accepted 
data,  for  the  average  head. 

Extent  of  Cerebral  Hemispheres. — (1)  Superior  or  mesial  border; 
extends  from  mid-point  of  naso-frontal  suture  to  a  point  averaging  1  cm., 
or  y7^  inch  (extremes,  5  to  15  mm.,  or  \  to  f  inch),  above  the  external  occipital 
protuberance,  and  5  mm.  (\  inch)  to  its  left  and  15  mm.  (f  inch)  to  its  right 
(representing  the  width  of  the  superior  longitudinal  sinus  and  attachment  of 
the  dural  walls).  It  is  separated  from  the  opposite  hemisphere  by  the  superior 
longitudinal  sinus  above,  which  deviates  slightly  to  right,  and  by  falx  cerebri 
below.  (2)  Inferior  or  lateral  border;  (a)  Frontal  Portion; — begins  in 
median  line,  opposite  floor  of  naso-frontal  groove — arches  upward  and  out- 
ward 8  mm.  (f  inch)  above  center  of  supraorbital  margin  of  frontal  bone — 
crosses  temporal  crest  just  above  external  angular  process — thence  descends 
slightly  to  a  point  in  temporal  fossa  about  30  mm.,  or  iy^g-  inches  (extremes, 
29  to  32  mm.,  or  iy2^  to  iy4^  inches),  directly  behind  external  angular  process, 
where  it  coincides  with  margin  of  temporal  lobe  at  a  point  where  the  sylvian 
fissure  reaches  the  convexity  of  the  hemisphere  (the  sylvian  point) — the 
frontal  lobe  in  front  and  above  and  the  temporal  lobe  behind  and  below 
forming  a  receding  angle  here.  (More  roughly  outlined,  the  frontal  portion 
lies  just  above  the  eyebrow  in  front,  and  just  above  the  upper  margin  of  the 
zygoma  laterally.)  (b)  Temporo-occipital  Portion; — -continuing  the  line  of 
lower  margin  of  frontal  portion  from  the  sylvian  point,  at  receding  angle 
formed  by  svlvian  fissure,  it  curves  slightly  downward  and  forward  from  the 
lower  margin  of  frontal  lobe  to  a  point  20  mm.  (yf  inch)  above  the  zygoma, 
and   15   mm.    (f  inch)   behind   external  angular  process   (which   marks  the 


CRANIOCEREBRAL  TOPOGRAPHY.  539 

anterior  pole  of  the  temporal  lobe) — thence  passes  backward  on  level  with 
upper  border  of  posterior  half  of  zygomatic  arch — thence  still  backward  at 
an  average  distance  of  6  mm.,  or  £  inch  (extremes,  3  to  9  mm.,  or  ^  to  | 
inch),  above  the  roof  of  meatus  auditorius  externus — continuing  horizontally 
backward  it  crosses  the  supramastoid  crest — and  runs  thence  to  a  point 
5  to  15  mm.  (j  to  f  inch)  above  the  external  occipital  protuberance,  5  mm.  (j 
inch)  external  to  the  protuberance  on  the  left,  and  18  mm.  (f  inch)  external 
to  it  on  the  right.  (More  roughly  outlined,  the  temporo-occipital  portion  co- 
incides with  the  upper  margin  of  the  zygoma  laterally,  and  the  superior 
curved  line  of  the  occipital  posteriorly.) 

Extent  of  Cerebellum.— Occupies  inferior  cerebellar  fossae  and  is  in 
contact  with  cranial  wall,  extending  upward  to  lower  margin  of  transverse 
portion  of  lateral  sinus  above,  and  forward  to  posterior  margin  of  sigmoid 
portion  of  lateral  sinus  in  front. 

Great  Longitudinal  Fissure. — Straight  median  line  from  mid-point  of 
naso-frontal  suture  to  center  of  external  occipital  protuberance — with  a 
slight  tendency  to  the  left,  especially  posteriorly. 

Great  Transverse  Fissure. — (Between  cerebrum  and  cerebellum.) 
Represented,  approximately,  by  a  line  between  external  occipital  protuberance 
and  center  of  external  auditory  meatus. 

Sylvian  Fissure. — The  parts  of  the  sylvian  fissure  may  be  traced  out  by 
measurement,  or  by  means  of  the  sutures  of  the  skull,  (a)  Location  of 
parts  of  Sylvian  Fissure  by  Measurement;  Sylvian  Point — found  by  carrying 
straight  line  from  posterior  margin  of  fronto-malar  junction  directly  horizon- 
tally backward  for  3.1  to  3.5  cm.,  or  i\  to  if  inches  (average,  ^.^  cm.,  or  iT5g 
inches),  thence  vertically  upward  for  6  to  12  mm.,  or  J  to  \  inch  (average  9 
mm.,  or  §  inch),  the  termination  of  which  latter  line  marks  the  sylvian  point, 
where  the  anterior  branches  of  the  sylvian  fissure  are  given  off.  Sylvian  Line 
— found  by  carrying  a  straight  line  from  the  sylvian  point  backward  and 
upward  to  a  point  from  1.2  to  1.8  cm.  (^  to  £  inch)  below  the  most  prominent 
part  of  the  parietal  eminence.  Horizontal  or  Posterior  Limb  of  Sylvian 
Fissure — that  portion  just  mentioned  (from  sylvian  point  to  lower  part  of 
parietal  eminence)  having  a  length  of  7.5  to  10  cm.  (3  to  4  inches).  Ascending 
Limb  of  Sylvian  Fissure — a  line  3  cm.  (iT3g-  inches)  long,  drawn  upward  and 
forward  from  the  sylvian  point,  at  right  angle  to  sylvian  line.  Anterior 
Limb  of  Sylvian  Fissure — a  line  2  cm.  (yf  inch)  long,  drawn  horizontally 
forward  from  the  sylvian  point,  (b)  Location  of  Parts  of  Sylvian  Fissure 
by  means  of  Sutures  of  Skull;  Point  of  Division  of  Sylvian  Fissure — in  the 
pterion,  under  or  very  near  the  spheno-parietal  suture,  near  its  posterior  end. 
Horizontal  or  Posterior  Limb  of  Sylvian  Fissure — runs  from  the  point  of 
division  backward  and  slightly  upward,  following  the  squamous  suture  at 
first,  and  then  crossing  the  temporal  portion  of  the  parietal  bone  to  the  inferior 
temporal  line,  and  thence  ascending  beneath  the  parietal  eminence.  Ascending 
Limb  of  Sylvian  Fissure — runs  from  the  point  of  division  obliquely  upward 
and  forward,  crossing  the  lower  end  of  the  coronal  suture.  Anterior  Limb 
of  Sylvian  Fissure — runs  from  point  of  division  forward  in  the  direction  of 
the  spheno-parietal  suture. 

The  horizontal  limb  of  the  sylvian  fissure  is  more  oblique,  and  further 
above  the  squamous  suture,  up  to  the  third  or  fourth  year  than  subsequently. 

Rolandic  Fissure. — The  parts  of  the  Rolandic  Fissure  may  also  be 
traced  out  bv  measurement,  or  by  means  of  the  sutures  and  bony  landmarks, 
in  the  exposed  skull;  (a)  Location  of  position  and  direction  of  Rolandic 
Fissure  by  Measurement;  Superior  Rolandic  Point— variously  estimated  at 


540  OPERATIONS  UPON  THE  HEAD. 

from  55  to  57  per  cent,  (average  being  between  55  and' 56  per  cent.,  probably 
about  55.7  per  cent.)  of  distance  from  mid-point  of  naso-frontal  suture  to 
external  occipital  protuberance.  Quain,  upon  another  basis,  gives  the  point 
at  1  cm.  (j\  inch)  behind  the  center  of  the  naso-inial  line,  and  Poirier  as  2  cm. 
(Tf  inch)  behind  that  center.  Where  the  inion  is  indistinct,  the  superior  ro- 
landic  point  may  be  considered  as  18  cm.,  or  7^  inches,  in  large  (and  17  cm., 
or6yi  inches,  in  small)  heads  posterior  to  the  nasion,  in  the  median  line.  Direc- 
tion of  Rolandic  Line — forms  an  angle  generally  averaging  about  70  degrees 
(extremes  64  degrees  to  75  degrees)  with  the  median  line.  (Formerly  the  angle 
was  generally  considered  67 ^  degrees.  Different  writers  have  given  the  wide 
variations  covered  in  the  above  extremes.)  The  rolandic  line  coincides  with  the 
rolandic  fissure  more  accurately  in  its  upper  part — the  inferior  genu  of  the 
rolandic  fissure  projecting  slightly  in  front  of  the  rolandic  line  below  its  cen- 
ter, corresponding  to  a  point  5  to  15  mm.  (j  to  f  inch)  above  the  lower  tem- 
poral line.  Inferior  Rolandic  Point — lies  on  the  rolandic  line  generally  1  cm. 
(-j\  inch)  above  the  sylvian  line  (v.  s.).  Length  of  Rolandic  Fissure— gen- 
erally from  8.5  to  9.5  cm.  (3!  to  3!  inches).  (b)  Location  of  Rolandic  Fis- 
sure by  Bony  Landmarks;  lies  entirely  under  the  parietal  bone,  the  superior 
rolandic  point  being  from  4  to  5  cm.  (iyV  to  2  inches)  and  the  inferior  rolandic 
point  about  3  cm.  (iy3g-  inches)  posterior  to  the  coronal  suture. 

The  rolandic  fissure  is  somewhat  further  forward  and  more  obliquely 
placed  in  children  under  nine  years. 

Parieto-occipital  Fissure. — A  line  about  2  cm.  (Tf-  inch)  long  running 
transversely  outward,  at  right  angle  to  naso-inial  line,  from  a  point  averaging 
about  6  mm.,  or  \  inch  (extremes,  from  lambda  itself  to  a  point  15  mm.,  or 
f  inch),  in  front  of  lambda.  Where  the  lambda  is  not  distinct,  its  position 
lies  from  6  to  7  cm.  (2§  to  2f  inches)  above  the  external  occipital  protuberance, 
or  8  to  10  cm.  (3J  to  4  inches)  behind  the  superior  rolandic  point.  The 
above  line  represents  the  external  portion  of  the  fissure,  the  internal  portion 
lying  upon  the  mesial  aspect  of  the  hemisphere.  (If  the  horizontal  limb  of 
the  sylvian  fissure  be  continued  backward  to  the  median  line,  its  last  2  cm. 
— yf  inch — would  represent,  approximately,  the  external  portion  of  the 
parieto-occipito  fissure.)  In  children  this  fissure  lies  somewhat  further 
forward. 

Precentral  Fissure. — Runs  downward  and  forward  about  15  mm.  (f 
inch)  anterior  to  and  nearly  parallel  with  the  rolandic  fissure.  Its  upper 
portion  lies  from  2  to  3  cm.  (Tf  to  iT3¥  inches)  behind  the  upper  part,  and 
its  lower  portion  from  1  to  2  cm.  (f  to  Tf  inch)  behind  the  lower  part  of  the 
coronal  suture.  Its  lower  end  terminates  about  1  cm.  (§  inch)  above  the 
sylvian  fissure. 

Postcentral  Fissure. — Runs  downward  and  forward  about  15  mm.  (f 
inch)  posterior  to  and  nearly  parallel  with  the  rolandic  fissure. 

Superior  Frontal  Fissure. — Line  running  forward,  approximately 
parallel  with  the  naso-inial  line,  from  the  precentral  fissure,  just  internal  to 
mid-distance  between  temporal  crest  and  median  line,  to  the  supraorbital 
notch. 

Inferior  Frontal  Fissure. — Line  running  forward  and  slightly  down- 
ward from  the  precentral  fissure  to  just  above  the  superior  stephanion  (inter- 
section of  superior  temporal  ridge  and  coronal  suture),  and  thence  forward, 
nearly  coinciding  with  the  anterior  portion  of  the  temporal  ridge. 

Intraparietal  Fissure. — The  ascending  portion  runs  upward  for  about 
1.8  cm.  (f  inch)  nearly  parallel  with  and  about  1.5  cm.  (f  inch)  posterior  to 
the  rolandic  fissure.     The  longitudinal  portion  runs  thence  backward  and 


CRANIO-CEREBRAL  TOPOGRAPHY.  541 

slightly  inward  just  above  the  parietal  eminence,  being  about  4.5  cm.  (i|f 
inches)  from  the  median  line  anteriorly,  and  about  3.5  cm.  (if  inches)  poste- 
riorly, at  a  point  opposite  the  lambda. 

Superior  Temporo-sphenoidal  (Parallel)  Fissure. — General  direction 
of  this  fissure  is  represented  by  a  straight  line  passing  from  the  retro-orbital 
tubercle  to  the  lambda,  which  line  coincides  more  accurately  with  the  tem- 
poral part  of  the  fissure.  This  fissure  lies  beneath  the  superior  part  of  the 
squamous  portion  of  the  temporal,  and  posterior  part  of  temporal  portion  of 
parietal,  and  thence  turns  upward  across  the  temporal  lines  and  passes  under 
the  upper  division  of  the  parietal  bone.     Placed  somewhat  higher  in  children. 

Ascending  Frontal  Convolution. — Lies  beneath  the  anterior  third  of 
the  parietal  bone. 

Superior  Frontal  Convolution. — Its  base  lies  under  the  anterior  third 
of  the  parietal,  and  its  main  part  corresponds  to  somewhat  less  than  the  inner 
half  of  the  frontal  region  of  the  frontal  bone. 

Middle  Frontal  Convolution, — Its  base  lies  under  the  anterior  third 
of  the  parietal;  its  main  part  corresponds  to  somewhat  more  than  the  outer 
half  of  the  frontal  region  of  the  frontal  bone,  and  its  anterior  portion  lies 
under  the  frontal  eminence. 

Inferior  Frontal  Convolution. — Its  base  lies  under  the  anterior  third 
of  the  parietal;  the  apex  of  its  triangular  part  lies  under  the  anterior  inferior 
angle  of  the  parietal;  and  its  orbital  part  lies  beneath  the  temporal  division 
of  the  frontal  and  superoir  end  of  great  wing  of  sphenoid. 

Island  of  Reil. — Pole  of  the  triangular  island  of  Reil  corresponds  with 
the  sylvian  point.  Posterior  Angle  corresponds  with  a  point  on  the  sylvian 
line  3.5  cm.  (if  inches)  behind  the  sylvian  point.  Superior  Boundary  is 
indicated  by  an  evenly  curved  line,  with  upward  convexity,  extending  from 
the  posterior  angle  to  the  upper  extremity  of  the  ascending  limb  of  the  sylvian 
fissure,  and  thence  forward  in  the  same  curve  1.5  cm.  (f  inch)  beyond  a 
vertical  line  passing  upward  from  the  sylvian  point.  Postero-inferior  Boun- 
dary extends  from  the  posterior  angle  downward  and  forward  to  a  point  on 
the  superior  temporo-sphenoidal  line  directly  below  the  sylvian  point. 

Parietal  Lobe. — Lies  beneath  the  parietal  bone,  the  parietal  eminence 
overlying  some  part  of  the  supramarginal  convolution. 

Ascending  Parietal  Convolution. — Lies  between  the  rolandic  fissure 
and  the  ascending  portion  of  the  intraparietal  fissure. 

Angular  Gyrus. — At  the  intersection  of  Reid's  posterior  perpendicular 
line  (v.  i.)  and  the  direct  continuation  of  the  sylvian  line. 

Temporal  Lobe. — Lies  chiefly  beneath  the  squamous  part  of  the  temporal 
and  the  posterior  and  inferior  fourth  of  the  parietal — its  anterior  end  lying 
under  the  great  wing  of  the  sphenoid — its  posterior  part  (inferior  temporal 
convolution)  lying  beneath  the  occipital  lobe. 

Occipital  Lobe. — Lies  in  the  cerebral  portion  of  the  occipital  bone,  and 
sometimes  slightly  beneath  the  adjoining  parietal. 

Basal  Ganglia. — Consist  of  the  following;  nucleus  caudatus  and  nu- 
cleus lenticularis,  forming  the  corpus  striatum;  claustra;  amygdaloid  nuclei. 
The  optic  thalami  lie  near  the  corpora  striata,  but  belong  to  the  thalamen- 
cephalon  or  interbrain.  The  above  ganglia,  except  the  amygdaloid  nucleus, 
lie  subjacent  to  the  island  of  Reil — they  extend  slightly  beyond  the  limits 
of  the  island — and  are  circumscribed  by  the  curved  line  limiting  the  main 
part  of  the  lateral  ventricle  (v.  i.).  The  following  important  white  fasciculi 
are  closely  related  to  the  corpora  striata;  inner  capsule;  outer  capsule:  anterior 
commissure;  taenia  semicircularis. 


542  OPERATIONS  UPON  THE  HEAD. 

Lateral  Ventricle. — Commencing  at  the  anterior  extremity  of  the  Ante- 
rior Horn,  i  cm.  (f  inch)  in  front  of  the  most  anterior  point  of  the  outline 
of  the  island  of  Reil  (v.  s.),  pass  backward  along  the  Body  of  the  Lateral 
Ventricle  in  a  curve  following  parallel  with  and  i  cm.  (f  inch)  above  the 
superior  boundary  of  the  island  of  Reil,  to  a  point  2  cm.  (|f  inch)  behind  its 
posterior  limit — thence  the  Descending  Horn  curves  forward  and  downward 
to  terminate  1  cm.  (§  inch)  below  the  level  of  the  superior  temporo-sphenoidal 
(parallel)  fissure  and  slightly  anterior  to  a  line  from  the  lower  rolandic  point 
to  the  preauricular  point — while  the  Posterior  Horn  passes  backward  from 
this  curve,  a  variable  distance,  toward  the  back  part  of  the  hemisphere, 
which  is  somewhat  higher  than  the  occipital  pole.  Another  method  of  locating 
the  lateral  ventricle  is  to  take  a  point  3.1  cm.  (i|  inches)  above  and  the  same 
distance  behind  the  external  auditory  meatus  (Keen).  Ordinarily  the  lateral 
ventricle  lies  at  a  distance  of  5.7  to  6.3  cm.  (2^  to  2+  inches)  from  the  surface. 

Naso-lambdoidal  Line. — Begins  at  naso-frontal  groove — passes  directly 
backward  6  mm.  (j  inch)  above  the  external  auditory  meatus  to  end  1  cm. 
(f  inch)  above  the  lambda  (or,  if  that  is  not  recognizable,  about  7  cm.,  or  2§ 
inches,  above  the  external  occipital  protuberance).  It  passes  through  the 
lower  part  of  Broca's  (inferior  frontal)  convolution — runs  along  the  posterior 
limb  of  the  sylvian  fissure  for  4  to  6  cm.  (iT!V  to  2|  inches) — touches  the 
lower  part  of  the  supramarginal  convolution — passes  through  the  base  of  the 
angular  gyrus — and  ends  in  the  parietooccipital  fissure. 

Superior  Longitudinal  Sinus. — Is  represented  by  two  straight  lines, 
both  beginning  together  from  the  mid-point  of  the  naso-frontal  suture  (foramen 
caecum)  and  slightly  diverging  as  they  pass  posteriorly,  one  going  to  a  point 
opposite  the  external  occipital  protuberance  and  5  mm.  (y\  inch)  to  its  left, 
the  other  to  a  corresponding  point  15  mm.  (§  inch)  to  the  right  of  the  external 
occipital  protuberance.  This  divergence  represents  the  attachment  of  the 
laminae  of  the  falx  cerebri  forming  the  sinus,  which  increases  in  width  poste- 
riorly. 

Lateral  Sinuses. — Transverse  Portion  forms  a  slight  curve,  with  upward 
convexitv,  from  external  occipital  protuberance  to  back  of  ear,  on  level  with 
upper  border  of  external  auditory  meatus.  The  highest  part  of  the  sinus 
(opposite  masto-parietal  suture)  lies  from  1.5  to  2.5  cm.  (f  to  1  inch)  above  a 
straight  line  drawn  from  the  external  occipital  protuberance  to  the  center  of  the 
external  auditory  meatus  and  a  little  external  to  its  center.  Sigmoid  Portion 
passes  from  back  of  ear,  on  level  with  upper  border  of  external  auditory  mea- 
tus, in  a  sigmoidally  curved  direction  (convexity  forward)  over  the  prominence 
of  the  mastoid  process  to  its  apex,  lying  generally  from  10  to  12  mm.,  or  y^  to 
\  inch  (extremes,  2  to  12  mm.,  or  nearly  \  to  \  inch),  behind  the  posterioi 
wall  of  the  external  auditory  meatus,  and  extending  downward  about  5  mm. 
(-£r  inch)  below  the  lower  border  of  the  external  auditory  meatus.  Distance 
of  sigmoid  portion  from  outer  surface  of  mastoid  process  is  about  7  mm., 
or  f  inch  (extremes,  1  to  15  mm.,  or  TV  to  f-  inch).  Width  of  sigmoid  portion 
is  about  10  mm.,  or  §  inch  (extremes,  5  to  15  mm.,  or  T:V  to  f  inch).  (For 
other  data  concerning  the  Lateral  Sinuses,  see  Surgical  Anatomy  of  Brain 
[page  532],  and  Relations  of  Mastoid  Antrum,  [page  602].) 

Middle  Meningeal  Artery  and  Its  Branches. — For  course  and  rela- 
tions, see  under  Surgical  Anatomy  of  the  Brain  (page  535),  and  under 
the   Surgical  Anatomy   in    connection  with    the    ligation    of    those    vessels 

(pages  47-49)- 

Facial  Nerve. — Descends  in  fallopian  canal  through  the  mastoid  pro- 
cess, lying  between  the  sigmoid  portion  of  the  lateral  sinus  and  the  external 


LOCALIZATION  OF  BRAIN  AREAS. 


543 


auditory  meatus  (very  near  the  latter).     For  fuller  description  of  its  relations, 
see  under  Surgical  Anatomy  of  the  Mastoid  region  (pages  602  and  603). 


LOCALIZATION  OF  BRAIN  AREAS. 

Description. — The  determination  of  the  situation  of  those  areas  of  the 
Brain  which  are  concerned  with  certain  functions.     These  centers  do  not 


fra<*c 


\_... 


o$S\lv'iu.s 


>*^ 


EcfyuiLtn 


uA 


-rM 


5^ 


2 
5  ? 

.it 

£  o  • 


Fig.  40S. — Craniocerebral  Topography: — Cortical  areas  of  the  right  outer  surface  of  the 
brain.     (Modified  from  Dalton.) 

necessarily  coincide  with  fixed  convolutions — are  not  limited  in  extent  by 
hard  and  fast  lines — often  overlap  each  other — and  their  position  and  dimen- 
sions are  not,  in  all  cases,  invariably  fixed,  nor  absolutely  ascertained.  Each 
functional  center  most  probably  has  a  wider  general  representation  over  the 
adjacent  areas  and  a  more  limited  special  representation,  whereby  a  small 
area  may  be  removed  without  total  paralysis  of  that  part  of  the  limb  specially 
represented  by  that  area.  The  following  summary  may  be  taken  as  repre- 
senting the  present  state  of  knowledge  of  the  best  authorities,  and  was  kindly 
prepared  by  Dr.  Roy  M.  Van  Wart,  who  has  done  creditable  work  in  this  field. 
What  slight  discrepancies  between  the  plates,  Figs.  40S,  409,  410,  and  the 
text  appear,  the  text,  being  later,  should  be  followed,  especially  as  to  the  non- 
saddling  of  the  Rolandic  fissure  by  the  motor  and  sensory  centers,  which  are, 
in  fact,  divided  from  each  other  by  this  fissure. 

"  The  localization  of  brain  areas  is  the  determination  of  those  areas  of  the 


544 


OPERATIONS    UPON    THE    HEAD. 


brain  which  are  concerned  with  certain  functions.  These  centers  do  not 
necessarily  coincide  with  the  convolutions.  They  are,  however,  as  far  as 
certain  areas  are  concerned,  fairly  definitely  determined. 

"Histological  studies  have  shown  that  various  areas  are  sharply  marked  off 
from  the  surrounding  parts  by  some  peculiarity  in  structure,  and  this  has  been 
shown  to  correspond  in  the  motor  area  with  the  physiological  delineation  with 
the  ampolar  electrode.  As  this  peculiarity  in  structure  is  found  to  correspond 
to  certain  areas  whose  function  is  more  or  less  definitely  known,  it  is  probable 
that  the  future  will  enable  us  to  mark  off  sharply  the  functions  of  the  various 
parts. 

"Motor  Areas. — The  area  controlling  the  movements  of  the  various  parts 


~Rul 


cr-*? 


ffj(       s*f 


-/"-SSUreof  ^oJan£y0 


T°«5 


Fissure.  0F  SUvius 


Fig.  409. 


-Cranio  cerebral  Topography: — Cortical  areas  of  the  left  outer  surface  of  the 
brain.      (Modified  from  Dalton.) 


of  the  body  is  now  definitely  known,  and  is  found  to  be  separate  and  distinct 
from  that  of  sensation.  The  posterior  limitation  is  the  fissure  of  Rolando, 
and  anteriorly  it  is  bounded  by  a  line  cutting  off  a  small  part  of  the  horizontal 
frontal  convolutions.  The  movements  are  distributed  on  the  convolutions 
from  below  upward  as  follows; — Tongue,  face,  head,  and  neck; — Thumb, 
fingers,  forearm,  arm,  and  shoulder; — Trunk,  thigh,  leg,  foot,  and  toes. 
Some  of  the  movements  of  the  lower  extremity  are  situated  on  the  median 
surface. 

"Sensory  Areas. — These  are  limited  anteriorly  by  the  fissure  of  Rolando. 
The  posterior  boundary  is  not  yet  definitely  known.  They  are  arranged  in 
the  same  order  from  below  upward  as  those  of  motion.     It  is  probable  that 


LOCALIZATION    OF    BRAIN    AREAS. 


545 


areas  exist  for  the  different  forms  of  sensation,  and  some  writers  show  areas 
for  the  stereognostic  sense,  cutaneous  sensation,  and  muscular  sensation. 

"Speech  Areas. — Most  of  the  older  works  give  complicated  diagrams 
showing  the  various  speech  centers  and  their  connections,  but  recently  con- 
siderable doubt  has  been  thrown  on  their  actual  existence  by  the  studies  of 
Marie.  The  following,  however,  may  be  stated — centers  for  the  sending  out 
of  speech  and  writing  impulses  exist,  but  probably  in  conjunction  with  those 
for  other  movements  of  the  parts  used  in  speaking  and  writing. 

"Auditory  and  Visual  Word  Memories. — What  has  just  been  said  of 
the  Speech  Areas  may  also  be  said  of  these  areas. 

"Area  of  Sight  Sensation. — This  area  occupies  a  site  in  the  cortex 
around  the  calcarine  fissure.  It  may  be  divided  into  two  parts — that  for  the 
reception  of  sight  sensations,  visuo-sensory — and  that  for  their  interpretation, 
visuo-psychic. 


Motor 


Fig.  410. 


-Craniocerebral  Topography: — Areas  of  the  median  aspect  of  the  brain.    1  Mod- 
ified from  Dalton.) 


"Area  of  Sound  Sensation. — The  center  for  the  reception  of  auditory 
sensations,  audito-sensory,  is  in  the  first  temporal  convolution — that  for  their 
elaboration,  visuo-psychic,  in  the  second  temporal  convolution. 

"Areas  of  Smell  and  Taste  Sensations. — These  probably  lie,  respec- 
tively, in  the  cortex  of  the  uncus  hippocampi  and  the  fusiform  gyrus  (Mills). 

"Higher  Psychical  Centers. — Large  areas  of  the  brain  are  without 
projection  fibers,  and  it  is  probable  that  they  have  to  do  with  the  higher 
psychical  functions.  The  anterior  part  of  the  frontal  lobe  is  the  most  import- 
ant of  these  areas. 

"Crura  Cerebri — Pons — Medulla. — Embrace  the  centers  of  cranial 
nerve  nuclei  and  contain  the  motor  and  sensory  fibers  passing  to  and  from 
the  spinal  cord. 

"Cerebellum. — Regulates  the  equilibrium  of  the  body." 

35 


546  OPERATIONS    UPON    THE    HEAD. 


CHIPAULT'S  METHOD  OF  CRANIO-CEREBRAL  LOCALIZATION. 

Description. — This  method  of  cranio-cerebral  localization  is  based 
upon  the  relations  of  the  parts  of  the  brain  to  the  skull,  as  determined  by 
the  percentage  measurements  of  the  skull  made  in  the  metric  system.  It 
is,  therefore,  equally  applicable  to  skulls  of  different  sizes,  shapes,  and 
ages. 

Following  Fixed  Bony  Landmarks  of  Measurement  are  taken: — 
Nasion — mid-point  of  naso-frontal  suture  (avoid  confusing  this  with  the 
glabella).  Inion — external  occipital  protuberance.  Retro-orbital  Tubercle 
— the  apophysis  upon  the  posterior  border  of  the  upper  part  of  the  frontal 
process  of  the  malar  bone,  a  short  distance  below  the  fronto-malar  suture. 
The  most  prominent  part  of  this  apophysis  forms  the  lower  limit  of  the  three 
primary  lines  of  Chipault's  method  (avoid  confusing  this  with  the  external 
angular  process  of  the  frontal  bone).     (Fig.  411.) 

Following  Percentage  Points  are  Marked  upon  the  Median  Naso- 
inial  Line  (a  line  extending  in  the  median  line  of  the  head,  from  nasion  to 
inion) — which  percentage  points  are  to  become  the  median  or  upper  limits 
of  lines  to  be  subsequently  drawn: — Precentral  Point  is  marked  at  45  per 
cent,  of  the  distance  from  nasion  to  inion.  Rolandic  Point  is  marked  at  55 
per  cent,  of  the  distance  from  nasion  to  inion.  Sylvian  Point  is  marked  at 
70  per  cent,  of  the  distance  from  nasion  to  inion.  Lambdoidal,  or  Superior 
Te-mporo-sphenoidal  Point,  is  marked  at  80  per  cent,  of  the  distance  from 
nasion  to  inion.  Lateral  Sinus  Point  is  marked  at  95  per  cent,  of  the 
distance  from  nasion  to  inion.     (Fig.  412.) 

(Illustration — suppose  distance  from  nasion  to  inion  to  be  30  centimeters 
— then  t4q%  of  that  distance,  or  the  Precentral  point,  will  be  13.5  cm.  from 
the  nasion; — -f$\,  or  the  Rolandic  point,  16.5  cm.; — TW,  or  the  Sylvian  point, 
21  cm.; — j8^,  or  the  Superior  Temporo-sphenoidal  point,  24  cm.; — y%\, 
or  the  Lateral  Sinus  point,  28.5  cm.  If  measured  in  inches,  and  the  naso- 
inial  line  measured  12  inches,  t4q%  of  12  inches,  or  the  Precentral  point,  would 
lie  5.4  inches  from  the  nasion,  etc.) 

Three  Primary  Lines  are  Drawn. — Sylvian  Line — from  retro-orbital 
tubercle  to  sylvian  point  (70  per  cent.) — its  anterior  portion  marking  the 
sylvian  fissure.  Superior  Temporo-sphenoidal  Line — from  retro-orbital 
tubercle  to  lambdoidal  or  superior  temporo-sphenoidal  point  (80  per  cent.) 
— its  anterior  part  marking  the  superior  temporo-sphenoidal  fissure.  Lateral 
Sinus  Line — from  retro-orbital  tubercle  to  lateral  sinus  point  (95  per  cent.) 
—its  anterior  part  crossing  the  lower  portion  of  the  temporal  lobe — its  poste- 
rior portion  marking  the  upper  part  of  the  transverse  portion  of  the  lateral 
sinus,  the  tentorium  cerebelli,  and  the  great  transverse  fissure  of  the  brain. 
(Fig-  413O 

These  three  primary  lines  are  now  marked  off  into  tenths  of  their  lengths. 
(For  instance,  if  the  sylvian  line  measures  21  cm.,  this  line  is  divided  off  into 
ten  parts  of  2.1  cm.  each.) 

Two  Secondary  Lines  are  Drawn. — Precentral  Line — from  junction  of 
second  and  third  tenths  of  sylvian  line,  to  precentral  point  (45  per  cent.) — 
commencing  at  the  bifurcation  of  the  sylvian  fissure,  it  at  first  follows  the 
ascending  limb  of  the  sylvian  fissure,  and  then  corresponds  in  its  two  upper 
thirds  to  the  precentral  fissure.  Rolandic  Line — from  junction  of  third  and 
fourth  tenths  of  sylvian  line,  to  rolandic  point  (55  per  cent.) — beginning  at 
lower  extremity  of  rolandic  fissure  and  following  its  entire  length. 


CHIPAULTS    METHOD    OF    CRAXIO-CEREBRAL    LOCALIZATION.       547 

These  two  secondary  lines  are  now  divided  and  marked  off  into  tenths. 
Thus,  with  the  tenths  marked  on  the  three  primary  lines,  sufficient  data  are 
furnished  for  all  practical  purposes  of  localization." 

Other  Points  and  Lines. — Inferior  Frontal  Fissure— begins  at  junction 
of  third  and  fourth   tenths  of  precentral  line— Anterior  Branch  of  Middle 


H5% 


Fig.41 1.— Chipault's  Method  of  Cranio-cerebral  Localization— Scalp  View  :— A,  Nasion  ; 
B,  Inion  ;  C,  Retro-orbital  tubercle  ;  45^,  or  Precentral  point ;  55^,  or  Rolandic  point ;  70^,  or  Sylvian 
point;  80^,  or  Superior  temporo-sphenoidal  uoint  ;  95^,  or  Lateral  sinus  point;  D,  Sylvian  line;  E, 
Superior  temporo-sphenoidal  line;  F,  Lateral  sinus  line;  G,  Precentral  line;  H  Rolandic  line  ;  I, 
Junction  of  second  and  third  tenths  of  sylvian  line;  J,  Junction  of  third  and  fourth  tenths  of  sylvian 
line. 


Meningeal  Artery — crosses  the  second  tenths  of  the  three  primary  lines. 
Lateral  Ventricle — lies  directly  opposite  the  junction  of  the  third  and  fourth 
tenths  of  the  superior  temporo-sphenoidal  line.  This  point  strikes  the  Body 
of  the  lateral  ventricle  at  its  posterior  part.  Hartley  has  determined  that 
the  cavity  of  the  ventricle  is  reached  at  a  distance  from  the  surface  of  the 
brain  equal  to  one-third  of  the  transverse  diameter  of  the  brain  itself  opposite 


54« 


OPERATIONS    UPON    THE    HEAD. 


this  point.  (For  example,  take  the  full  diameter  of  the  skull  and  scalp  with 
calipers,  say  15  cm. — take  thickness  of  skull  and  scalp  of  the  side  opened, 
say  1  cm. — double  this  for  the  opposite  side — take  result  of  this  doubling, 
say  2  cm.,  from  the  total  transverse  diameter,  which  will  give  the  diameter 
of  the  brain  alone,  say  13  cm. — take  one-third  of  this,  say  4.3  cm.- — and 
enter  the  brain  to  that  depth  upon  a  direct  horizontal  line.)  To  puncture 
the  Descending  Horn  of  the  lateral  ventricle,  Hartley  passes  through  the 


Fig.  412.— Chipault's  Method  oh  Craniocerebral  Localization — Skull  View  :— A,  Nasion; 
B,  Inion  ;  C,  Retro-orbital  tubercle  ;  45;*,  or  Precentral  point  ;  554,  or  Rolandic  point ;  70$,  or  Sylvian 
point;  80$,  or  Superior  temporo-sphenoidal  point;  95$,  or  Lateral  sinus  point;  D,  Sylvian  line;  E, 
Superior  temporo-sphenoidal  line  ;  F,  Lateral  sinus  line;  G,  Precentral  line;  H,  Rolandic  line;  I, 
Junction  of  second  and  third  tenths  of  sylvian  line  ;  J,  Junction  of  third  and  fourth  tenths  of  sylvian 
line  ;  K,  Lateral  sinus. 


middle  temporo-sphenoidal  convolution  in  a  line  directly  above  the  external 
auditory  meatus.  To  puncture  the  Posterior  Horn  of  the  lateral  ventricle, 
he  passes  through  the  middle  temporo-sphenoidal  convolution  in  a  line  with 
the  posterior  border  of  the  mastoid  process. 

Summary. — Having  determined  the  position  of  the  chief  fissures  of  the 


CHIPAULT'S    METHOD    OF    CRANIOCEREBRAL    LOCALIZATION.       549 

brain  in  the  above  manner,  and  knowing  the  general  relations  of  the  convo- 
lutions, structures,  and  functional  areas  to  these  fissures,  any  desired  area 
may  be  exposed.  Preference  is  given  to  the  method  of  Chipault  over  the 
several  others  in  use,  for  while  none  are  perfect,  or  absolutely  simple,  this 
method  has  proved  itself  quite  accurate  and  fairly  easy  of  application,  and 
furnishes  sufficient  data  from  which  to  locate  any  desired  area  of  cerebrum 
or  cerebellum. 


%7> 


Fig.41,3  —  Chipaui.t's  Method  of  Cranio-cerebral  Localization— Brain  View  :— A,  Nasion  ; 
B,  Inion  ;  C,  Retro-orbital  tubercle ;  45:;,  or  Precentral  point;  55$,  or  Rolandic  point ;  7u.n1  Sylvian 
point ;  hov.  ur  Superior  temporo-sphenoidal  point ;  95^,  or  Lateral  sinus  point  ;  L).  Sylvian  line,  over- 
lying sylvian  fissure  ;  E,  Superior  temporo-sphenoidal  line,  overlying  superior  temporo-sphenoidal 
fissure;  F,  Lateral  sinus  line;  G,  Precentral  line,  overlying  precentral  fissure;  H,  Rolandic  line, 
overlying  Rolandic  fissure  ;  I,  Junction  of  second  and  third  tenths  of  sylvian  line  ;  J,  Junction  of  third 
and  fourth  tenths  of  sylvian  line  ;   K,  Lateral  sinus  ;   L.  Cerebellum. 


The  manner  of  applying  these  (or  any  other)  measurements  is  to  shave 
the  head  and  mark  out  the  landmarks  and  the  desired  areas  upon  the  scalp, 
by  means  of  a  solution  of  nitrate  of  silver  or  a  dermographic  pencil — then, 
with  a  sharp-pointed  instrument  of  small  circumference  inserted  through  the 
scalp  to  the  bone,  a  slight  blow  or  two  is  given  with  a  mallet  just  sufficiently 


550  OPERATIONS    UPON    THE    HEAD. 

to  mark  the  bone — the  soft  parts  are  then  turned  back  and  the  bone  removed 
by  the  method  elected,  preferably  some  form  of  motor  saw,  with  or  without 
the  aid  of  previous  small  trephine-openings  outlining  the  area  to  be  removed. 
Where  a  trephine-opening  is  used  as  the  entire  means  of  exposure,  an  instru- 
ment of  sufficiently  large  diameter  should  be  used  to  allow  of  the  possibility 
of  a  smaller  opening  not  fully  covering  the  area  sought.  Of  course,  it  is 
only  necessary,  in  operating  in  life,  to  mark  out  upon  the  scalp  the  particular 
area  desired,  and  then  to  mark,  in  the  above  manner,  the  corresponding  site 
on  the  skull — for  instance,  if  one  sought  a  motor  center  lying  along  the  rolandic 
fissure,  only  the  sylvian  and  rolandic  points  and  the  sylvian  and  rolandic 
lines  of  the  above  system  need  be  marked  out  on  the  scalp — and  only  the  center 
of  the  motor  area  itself  on  the  bone.  For  the  technique  of  the  operations 
whereby  this  method  of  localization  may  be  applied,  see  the  operations  of 
craniotomy  (page  558)  and  osteoplastic  resection  of  the  skull  (page  565). 


THE   USE  OF  BELL'S  GEOMETRICAL   CYRTOMETER   FOR  THE  EASY 

APPLICATION  OF  CHIPAULT'S  METHOD  OF  CRANIO-CEREBRAL 

LOCALIZATION. 

William  H.  Bell  has  worked  out,  geometrically,  a  device  for  use  in  connec- 
tion with  Chipault's  method,  whereby  is  avoided  the  necessity  of  calculating 
each  time  the  percentage  distances  from  nasion  to  inion  and  dividing  the  pri- 
mary and  secondary  lines  into  tenths.  His  description  of  its  application  is 
here  given. 

The  device  is  based  upon  the  maximum  and  minimum  measurements 
between  the  bony  landmarks  concerned.  "These  are  three  in  number: — 
First,  The  greatest  distance  from  Nasion  to  Inion  over  the  cranial  vault  along 
the  median  longitudinal  line; — second,  The  shortest  distance  from  Nasion  to 
Inion  over  the  cranial  vault  along  the  median  longitudinal  line; — and  third, 
The  shortest  distance  from  a  point  dividing  the  third  and  fourth  tenths  on 
the  Sylvian  line  to  the  55  per  cent,  point  on  the  above  line  from  Nasion  to 
Inion.     (See  Fig.  411.) 


Fig.  414. — The  Geometrical  Cyrtometer  of  Bell: — B  C,  Least  distance  from 
Nasion  to  Inion;  A  C,  Greatest  distance  from  Nasion  to  Inion;  also  greatest  distance  in 
tenths;  A  B,  The  shortest  distance  from  a  point  dividing  the  third  and  fourth  tenths  on  the 
Sylvian  line  to  the  55  per  cent,  point  on  the  line  from  the  Nasion  to  Inion.  (Modified  from 
Bell.) 

"  The  accompanying  diagram  (Fig.  414)  illustrates  the  idea  and,  indeed, 
is  the  cyrtometer  itself.  It  is  to  be  printed  on  some  soft,  tough  paper  and  used 
in  that  way,  or  blue  prints  can  be  made  from  a  tracing.  Either  can  be  sterilized 
in  lots  if  desired.  The  edge  A  C  (40.5  m.,  or  16  inches)  represents  the  first 
dimension  (v.  s.) ;  B  C  (30.5  m.,  or  12  inches)  the  second  dimension;  A  B 
(12.5  cm.,  or  5  inches)  the  third  dimension.  The  per  cents.,  45,  55,  70,  80, 
and  Q5  are  pointed  off  on  the  line  A  C,  and,  from  these,  lines  are  drawn  across 
the  diagram  parallel  with  dimensions  A  B.     The  dimension  A  B  is  divided 


REID'S    METHOD    OF    CRANIO-CEREBRAL    LOCALIZATION.  551 

into  tenths  and  from  each  point  a  line  is  drawn  across  the  diagram  parallel  to 
the  dimension  B  C. 

"  The  employment  of  this  simple  paper  triangular  chart  is  easy,  and  the 
manner  of  applying  it  is  as  with  any  other  system  of  surgical  craniometry: 
by  shaving  the  head  and  marking  the  craniometric  points  and  desired  areas 
upon  the  scalp  by  means  of  a  solution  of  nitrate  of  silver,  or  a  dermographic 
pencil,  etc. 

"  To  find  the  desired  per  cent,  distance,  or  distances,  along  the  median  longi- 
tudinal line,  place  the  apex  C  on  the  inion  and  swing  the  base  A  B  across  the 
forehead  until  some  point  on  this  base  corresponds  to  the  nasion  (e.  g.,  a, 
Fig.  414) .  Mark  and  fold,  or  cut  off  in  a  straight  line  from  a  to  C,  and  replace 
along  the  longitudinal  line  from  Nasion  to  Inion,  when  you  immediately  and 
automatically  obtain  the  per  cent,  distances  desired  and  can  point  them  off 
on  the  scalp  in  the  usual  way. 

"  If  the  paper  has  been  folded  it  can  be  used  for  the  other  measurements. 
If  it  has  been  cut  (and  this  seems  the  better  plan)  take  a  new  diagram  and 
proceed  as  follows:  Place  the  apex  A  at  the  Retro-orbital  Tubercle  and  swing 
the  base  B  C  across  the  cranium  until  some  point  (for  example,  b,  Fig.  414) 
on  this  base  corresponds  with  the  per  cent,  mark,  say,  70  per  cent.,  obtained 
by  the  previous  proceeding.  Mark  and  fold,  or  cut  off  in  a  straight  line,  from 
b  to  a  and  replace,  when  you  immediately  and  automatically  divide  the  dis- 
tance into  tenths,  by  which  to  locate  the  area  desired. 

"  These  two  lines  involve  the  cranial  landmarks  and  may  be  regarded  as  the 
guides  in  Chipault's  method,  and  they  also  demonstrate  the  use  of  the  Geomet- 
rical Cyrtometer.  All  other  lines  and  areas  are  located  by  a  similar  proceed- 
ing." 


REID'S  METHOD  OF  CRANIO-CEREBRAL  LOCALIZATION. 

Description. — A  method  of  determining  the  relations  of  the  principal 
parts  of  the  brain  to  the  skull,  by  means  of  certain  lines  drawn  upon  the 
scalp  between  known  landmarks.     (See  Fig.  415.) 

Fundamental  Lines. — Base  Line: — a  horizontal  line  from  the  lowest 
part  of  the  infraorbital  border,  through  center  of  external  auditory  meatus, 
thence  directly  backward  (Fig.  415,  A  B).  Anterior  Perpendicular  Line: — 
from  preauricular  point  (a  depression  upon  the  base-line,  between  tragus 
and  condyle  of  jaw)  to  longitudinal  fissure  (E  D).  Posterior  Perpendicular 
Line: — along  posterior  border  of  mastoid  process,  from  base-line  to  longi- 
tudinal fissure  (G  F).  Some  of  the  structures  are  located  in  connection  with 
these  lines,  and  others  are  located  upon  other  data.  An  average  adult  head 
is  supposed. 

Longitudinal  Fissure. — From  mid-point  of  the  naso-frontal  suture  to 
external  occipital  protuberance. 

Sylvian  Fissure. — Extends  from  a  point  3.1  cm.  (i|  inches)  horizontally 
behind  the  external  angular  process  to  a  point  1.8  cm.  (f  inch)  below  the 
most  prominent  part  of  the  parietal  eminence  (Fig.  415,  H  J).  Main 
part  of  the  sylvian  fissure  is  represented  by  the  anterior  1.8  cm.  (f  inch)  of 
the  above  line  (HI).  Horizontal  Limb  of  the  fissure  is  represented  by  the 
remainder  of  the  line  (I  J).  Ascending  Limb  of  the  fissure  extends  from  the 
posterior  end  of  the  main  fissure  vertically  upward  for  2.5  cm.  (1  inch)  (IK). 
Bifurcation  of  the  sylvian  fissure,  therefore,  lies  5  cm.  (2  inches)  posteriorly 


55- 


OPERATIONS    UPON    THE    HEAD, 


to  the  external  angular  process,  and  about  6  mm.  (|  inch)  above  the  level 
of  the  external  angular  process  (I). 

Rolandic  Fissure. — Represented  by  a  diagonal  line  from  upper  end  of 
posterior  perpendicular  line  to  junction  of  anterior  perpendicular  line  with 
the  sylvian  fissure  (L  F). 

Sigmoid  Portion  of  the  Lateral  Sinus.  Point  on  the  baseline  1.8 
cm.  (f  inch)  behind  the  center  of  the  external  auditory  meatus  (M). 

Transverse  Portion  of  the  Lateral  Sinus. — Point  2.5  cm.  (1  inch) 
behind  the  center  of  the  external  auditory  meatus,  and  6  mm.  (|  inch)  above 
the  base-line  (N). 

Mastoid  Antrum. — Intersection  of  line  drawn  along  the  superior  wall 


Fig.  415. — Reid's  Method  of  Cranio-cerebral  Localization: — A  B,  Base-line;  E, 
Preauricular  point;  E  D,  Anterior  perpendicular  line;  G  F,  Posterior  perpendicular  line;  H  I, 
Main  part  of  Sylvian  fissure;  I  J,  Horizontal  limb  of  Sylvian  fissure;  I  K,  Ascending  limb  of 
Sylvian  fissure;  L  F,  Rolandic  fissure;  M,  Sigmoid  portion  of  lateral  sinus;  N,  Transverse  portion 
of  lateral  sinus;  O,  Mastoid  antrum;  P,  Lateral  ventricle;  R,  Main  trunk  of  middle  meningeal 
artery;  S,  Cerebral  abscess;  T,  Cerebellar  abscess.     (For  explanations,  see  text.) 


of  the  auditory  meatus  parallel  with  the  basedine,  with  line  drawn  along  the 
posterior  wall  of  the  auditory  meatus  perpendicular  to  the  basedine  ((  >). 

Lateral  Ventricle. — Lies  3.8  cm.  (i|  inches)  directly  above  the  center 
of  the  external  auditory  meatus  (P). 

Anterior  Branch  of  the  Middle  Meningeal  Artery. —Encountered 
at  a  point  3.8  cm.  (ij  inches)  behind  external  angular  process,  and  3.8  cm. 
(1^  inches)  above  zygomatic  arch  (Q). 

Posterior  Branch  of  Middle  Meningeal  Artery. — Encountered  at  a 
point  4.4  cm.  (if  inches)  behind  external  angular  process,  and  6  mm.  (j 
inch)  above  zvgomatic  arch   (R). 

Usual  Site  of  Cerebral  Abscess. — In  the  temporo-sphenoidal  lobe  at 


KROENLEIN'S    METHOD    OF    CRANIO-CEREBRAL    LOCALIZATION.      553 

a  point  1.8  cm.  (f  inch)  above  the  base-line,  on  a  line  drawn  along  the  pos- 
terior wall  of  the  auditory  meatus  perpendicular  to  the  base-line  (S). 

Usual  Site  of  Cerebellar  Abscess. — Opposite  a  point  3.8  cm.  (i|  inches) 
behind  center  of  external  auditory  meatus,  and  6  mm.  (\  inch)  below  the 
base-line  (T). 

KROENLEIN'S  METHOD  OF  CRANIO-CEREBRAL   LOCALIZATION. 

Kroenlein's  construction  is  formed  by  two  parallel  horizontal,  two  parallel 
vertical,  and  two  oblique  lines. 

(A)  Horizontal  Lines; — (1)  The  Inferior,  or  fundamental  line,  passes 
through  the  inferior  border  of  the  orbit  and  the  superior  border  of  the  auditory 


Fig.  416. — Kroenlein's  Method  of  Craniocerebral  Localization: — A,  The  German, 
or  lower,  horizontal  line;  B,  Superior  horizontal;  C,  Anterior  vertical;  D,  Middle  vertical;  E, 
Posterior  vertical;  F,  Rolandic  line  and  fissure;  L,  Lower  end  of  Rolandic  fissure;  G,  Sylvian 
line;  I,  O,  Sylvian  fissure;  H,  I,  J,  Main  trunk  and  anterior  and  posterior  branches  of  middle 
meningeal  artery;  H,  I,  J,  K,  Square  within  which  von  Bergmann  recommends  opening  the 
skull  for  otitic  abscess  in  the  temporal  lobe. 


meatus  (Fig.  416,  A).     (2)   The  Superior  Horizontal,  parallel  with  the  pre- 
ceding, passes  through  the  upper  border  of  the  orbit  (Fig.  416,  B). 

(B)  Vertical  Lines; — (1)  The  Anterior  Vertical,  perpendicular  to  the 
Inferior  Horizontal,  passes  through  the  middle  of  the  zygoma  (Fig.  416,  C). 
(2)  The  Middle  Vertical,  perpendicular  to  the  Inferior  Horizontal,  passes 
through  the  temporo-maxillary  joint  (Fig.  416,  D).  (3)  The  Posterior  Ver- 
tical, perpendicular  to  the  Inferior  Horizontal,  passes  through  the  most  poste- 
rior border  of  the  mastoid  process  (Fig.  416,  E). 


554 


OPERATIONS    UPON    THE    HEAD. 


E 


(C)  Oblique  Lines; — (i)  The  Rolandic  Line  passes  from  the  point  of 
intersection  of  the  Superior  Horizontal  and  Anterior  Vertical,  to  the  point 
where  the  Posterior  Vertical  crosses  the  sagittal  suture  (Fig.  416,  I,  F).  The 
inferior  extremity  of  the  Rolandic  Fissure  is  found  at  the  point  where  the 
Rolandic  Line  crosses  the  Middle  Vertical  (Fig.  416,  L).  (2)  The  Sylvian 
Line  is  found  in  the  following  way: — Bisect  the  angle  formed  by  the  inter- 
section of  the  Rolandic  Line  with  the  Superior  Horizontal  (Fig.  416,  I,  G) — 
the  Sylvian  fissure  will  be  represented  by  that  portion  of  the  bisector  which 
extends  from  this  intersection  to  the  Posterior  Vertical  (Fig.  416,  I,  O). 

The  main  trunk  and  the  anterior  and  posterior  branches  of  the  middle 
meningeal  artery  are  to  be  sought,  respectively,  at  the  points  H,  I,  and  J. 

Von  Bergmann  recommends  exploring  for  otitic  abscess  of  the  temporal 
lobe  within  the  square  M,  J,  N,  K. 

CHIENE'S  METHOD  OF  DETERMINING  THE  ROLANDIC  FISSURE. 

Take  a  piece  of  paper  about  three  inches  square — crease  it  diagonally 

from  A  to  D,  so  that  A  B  D 
coincides  with  A  E  D.  A  E  D 
will  then  represent  an  angle  of 
45  degrees.  Then,  after  open- 
ing out  the  square,  crease  A 
BD  along  A  C,  so  that  A  B 
C  coincides  with  A  C  D,  and 
allow  the  last  folding  to  re- 
main creased.  A  C  D  (half  of 
an  angle  of  45  degrees)  will 
represent  22 \  degrees.  There- 
fore E  A  C  will  be  equal  to 
an  angle  of  67^ degrees.  Apply 
figure  A  EDC  to  the  head 
so  that  A  E  falls  upon  the 
median  line,  with  A  1.2  cm. 
(h  inch)  posterior  to  the  mid- 
point of  the  line  from  nasion 
to  inion,  with  E  forward — 
when  the  line  A  C  will  repre- 
sent an  angle  of  67J  degrees 
with  the  median  line,  and, 
therefore,  approximately,  the 
rolandic    fissure.      (See    Fig. 

4I7-) 

As    the    angle,    however, 

which  the   rolandic  fissure   makes  with   the  median   line  is  now  generally 

regarded  as  somewhat  greater  than  6jh  degrees    (see    Fissure   of  Rolando, 

Cranio-cerebral  Topography,  page  539)",  a  somewhat  greater  allowance,  say 

about  70  degrees,  should  be  made. 


[ 


D 


Fig.417.— Chiene's  Method  of  Determining  the 
Rolandic  Fissure:— A  B  D  E,  a  square;  A  E  D  (one- 
half  of  A  B  D  E,  creased  diagonally),  an  angle  of  45  de- 
grees :  A  B  C  (one-half  of  A  B  D),  an  angle  of  22^  degrees. 
Therefore  E  A  C  represents  an  angle  of  67^  degrees. 


GENERAL  SURGICAL  CONSIDERATIONS  IN  CRANIO-CEREBRAL 

OPERATIONS. 

Relations  of  Cranial  Contents  to  Cranial  Bones.— It  has  been  noted 
that  irregularities  of  relationships  do  sometimes  occur,  and  that  discrepancies 
sometimes  exist  in  the  statements  of  the  different  methods  of  localizing,  as 


SURGICAL    CONSIDERATIONS    IN    CRANTO-CEREBRAL    OPERATIONS.    555 

given  by  different  men  of  extended  experience— but  these  irregularities  and 
discrepancies  are  generally  so  slight  that  the  structures  or  areas  sought  are 
readily  accessible  through  the  data  given— and  if  not  found  directly  in  the 
center  of  the  site  exposed  by  operation,  are  usually  within  reach  of  the  opening 
made.  As  a  rule,  apparent  discrepancies  are  generally  the  result  of  an  error 
in  applying  the  special  method  of  localizing. 


Fig.  418. — Rubber  Tourniquet  for  Control  of  Hemorrhage  from  the  Scalp  in  Opera- 
ting ABOUT  THE  HEAD. 

Preparation. — Head  shaved.  Ears  cleansed  and  packed  with  sterile 
cotton. 

Position. — Patient  supine,  head  elevated  upon  a  firm  support,  at  end  of 
table,  and  turned  so  as  to  give  freest  access  to  site  of  operation.  Surgeon  on 
side  of  operation,  or  directly  behind  patient's  head.  Assistant  opposite 
surgeon,  or  at  his  side. 


Fig.  419.  —  Doyen's  Saw: — The  guard  set  at  10  mm.  (i  in.). 

Control  of  Hemorrhage. — Hemorrhage  from  the  scalp  is  generally  con- 
trolled by  clamp-forceps,  applied  immediately  upon  the  completion  of  the 
incision,  followed  by  ligation  with  gut  of  the  clamped  vessels.  Where  ex- 
tensive bleeding  from  the  scalp  is  anticipated,  especially  in  removing  growths 
of  that  structure,  a  circular  constrictor  around  the  lower  part  of  the  skull 
(passing  just  above  the  nose  and  ears  and  just  below  the  external  occipital 
protuberance)  may  sometimes  be  advantageously  used — such  as  the  narrow 


556 


OPERATIONS    UPON    THE    HEAD. 


flat  band  of  the  Esmarch  set,  or  a  rubber  tube  which  flattens  as  it  is  applied 
(Fig.  418).  To  aid  in  its  effectiveness,  small  compresses  may  be  first  placed 
over  the  temporal,  posterior  auricular,  and  occipital  arteries,  upon  one  or, 
preferably,  both  sides,  and  held  in  place  by  rubber  plaster — and  the  con- 
strictor applied  over  these.  Intracranial  hemorrhage  (from  middle  meningeal 
arteries,  venous  sinuses,  and  the  intracerebral  vessels)  will  be  specially  men- 
tioned among  the  operations  upon  the  cerebral  contents. 


Figs.  420  and  421. 


-A,  MacEwen's  Trephining-brace,  with  Various  Sizes  of  Conical 
Trephines;  B,  An  Interchangeable  Trephine. 


Manner  of  Making  the  Cranial  Section. — The  use  of  a  saw  (motor 
or  hand,  including  the  trephine,  which  is  practically  a  circular  saw)  is  prefer- 
able for  all  forms  of  cranial  section.  MacEwen's  trephine-brace  is  a  valuable 
modification  of  the  trephine  (Figs.  420,  421).  In  this  category  the  chain 
and  Gigli  saws  are  also  included.  Next  to  the  saw,  the  bone-cutting  forceps 
are  to  be  chosen.  And  last  to  be  recommended  are  the  various  forms  of 
chisels,  used  with  mallets.     The  only  field  for  these  last-mentioned  instruments 


CRANIOTOMY    IN    GENERAL.  557 

(owing  to  the  concussion  caused)  is  where  a  moderate  blow  or  two  will  accom- 
plish the  object.     Doyen's  hand-saw  is  an  excellent  instrument  (Fig.  419) . 

Thickness  of  Skull. — Average  thickness  is  about  5  mm.  (A  inch).  In 
early  life  and  in  oid  age  the  skull  is  thinnest,  and  at  these  ages  the  diploe  is 
absent  from  the  squamous  bone,  the  parietal  in  the  neighborhood  of  the 
squamous,  and  in  the  fossae  of  the  occipital.  Thinnest  parts  of  the  cranial 
bones— squamous  part  of  temporal;  inferior  occipital  fossae;  over  venous 
sinuses;  over  frontal  sinuses;  over  grooves  for  meningeal  vessels.  Thickest 
parts  of  cranial  bones — occipital  protuberance  of  occipital;  mastiod  portion 
of  temporal;  lower  part  of  frontal  (except  over  frontal  sinuses). 

Use  of  Electrode  in  Corroborating  Motor  Centers. — First  try  to  get 
reaction  through  dura,  without  opening  this  membrane.  In  applying  to 
brain  itself,  guard  against  burning  by  too  strong  a  current. 

Where  part  of  dura  is  permanently  removed,  gold-foil,  or  some  similar 
substance  may  be  advantageously  used  to  prevent  cortical  adhesions. 

Where  much  brain  tissue  is  removed,  as  in  operations  for  tumors,  etc., 
temporary  packing  should  be  used,  to  equalize  brain  pressure. 

Cranio-cerebral  Operations  in  Two  Stages. — Some  surgeons  open  the 
cranium,  down  to  the  dura,  at  the  first  operation — and  open  the  dura  and 
complete  the  operation  several  days  later — upon  the  ground  of  less  shi  ck, 
less  hemorrhage,  and  a  better  protection  of  surrounding  parts  by  adhesions. 
The  majority  of  operators,  however,  complete  the  operation  at  one  sitting, 
unless  specially  contraindicated. 


INSTRUMENTS  USED  IN  CRANIO-CEREBRAL  OPERATIONS. 

Scalpels,  light  and  heavy;  dissecting  forceps;  toothed  forceps;  fine  forceps 
for  holding  dura,  various  shapes;  artery-clamp  forceps;  sinus  forceps;  scissors, 
sharp  and  blunt,  curved,  straight  and  angular;  trephines  (of  Gait  pattern, 
or  with  guard),  various  sizes;  trephine  brushes;  saws,  motor  and  hand;  Doyen's 
saw;  chain  saw;  Gigli  saw  and  carrier;  bone-cutting  forceps,  various  sizes 
and  shapes;  bone-holding  forceps,  various;  rongeur  forceps;  periosteal  elevator; 
bone  elevator;  gouges;  curettes;  retractors;  spatulae;  dural  separator;  grooved 
director;  probe,  with  one  flat  end,  to  detect  depth  of  trephine  cut;  tenacula; 
chisels,  various  sizes  and  shapes;  mallets;  aneurism-needles,  various;  brad 
awl;  Fluhrer's  probe;  metal  meter  measure,  in  millimeters  and  centimeters; 
electrode  for  diagnosis;  measurer  of  skull-thickness;  surgeon's  wax  for  plugging 
bony  canals  of  vessels;  needles,  various,  especially  fine  curved;  needle-holders; 
sutures  and  ligatures,  of  silk,  plain  and  chromic  gut,  and  silkworm-gut; 
drains;  gauze;  rubber-band  tourniquet;  gold  foil;   rubber  tissue. 


CRANIOTOMY  IN  GENERAL. 

Description. — Section  of  cranial  bones.  Operations  upon  the  cranio- 
cerebral region  resolve  themselves,  as  far  as  the  operation  upon  the  cranium 
is  concerned,  into  the  making  of  an  opening  in  the  bony  vault  for  the  pur- 
pose of  reaching  the  object  itself  of  the  special  operation — and  these  openings 
are  either  simple  trephinings,  irregular  cranial  sections,  or  some  form  of 
osteoplastic  resection.  The  operation  of  cutting  through  the  bones  of  the 
skull  is,  after  shaving  the  head,  preceded  by  either  the  turning  back  of  a 
flap  composed  of  the  soft  tissues  of  the  scalp,  or  the  flap  turned  back  consists 
of  combined  soft  parts  and  bone  undetached  from  each  other.     The  flap,  in 


558  OPERATIONS    UPON    THE    HEAD. 

either  case,  is  so  planned  as  to  have  its  pedicle  below,  that  the  arteries  supplying 
its  nutriment  may  not  be  severed.  At  the  end  of  the  operation  the  flap  is 
dropped  back  into  place  and  sutured.  One  or  the  other  of  these  is  the  common 
method  of  approach,  no  matter  what  the  subsequent  steps  may  be.  When 
the  portion  of  bone  is  not  returned,  the  operation  becomes,  strictly  speaking, 
a  partial  craniectomy. 

Varieties. — (I)  Circular  Craniotomv,  or  Trephining;  generally  per- 
formed with  the  conical  (Gait's)  trephine.  The  diameter  of  the  opening 
thus  made  may  be  from  1.2  to  6.3  cm.  (|  to  2+  inches).  Generally  resorted 
to  where  a  more  limited  opening  will  suffice.  (2)  Linear  Craniotomy;  division 
of  cranial  bones  in  straight  lines — preferably  by  means  of  a  motor  saw,  gener- 
ally preceded  by  a  small  trephine-opening  through  which  to  begin  the  section. 
Generally  used  as  a  simple  section  in  the  course  of  some  operation.  (3) 
Irregular  Craniotomy;  openings  of  irregular  outline  and  varying  size,  such 
as  may  be  unexpectedly  indicated  in  the  course  of  some  operation.  For 
example,  original  openings,  when  found  inadequate,  may  be  increased  to  the 
desired  extent  and  form  by  the  further  application  of  trephine,  saw,  chisel, 
or  bone-cutting  forceps.  (4)  Osteoplastic  Resection;  a  form  of  irregular 
craniotomy  in  which  an  area  of  scalp  and  cranium  are  cut  through  throughout 
the  greater  portion  of  their  extent,  but  not  separated  from  each  other — and 
are  then  temporarily  turned  back,  partly  by  breaking,  partly  by  bending  the 
unsevered  portion — and  subsequently  replaced.  Generally  resorted  to  where 
the  largest  openings  are  required. 

TREPHINING,   OR   CIRCULAR   CRANIOTOMY. 

Description. — The  division  of  the  cranial  bones  by  means  of  a  trephine, 
preferably  of  the  conical  or  Gait  tvpe  (Fig.  423) — preceded  by  the  temporary 
turning  back  of  a  flap  composed  of  the  soft  parts.  Indications:  intracranial 
hemorrhage;  abscess;  fracture;  foreign  body;  evacuation  of  cerebrospinal 
fluid  through  the  lateral  ventricle;  as  a  preliminary  step  to  osteoplastic  resec- 
tion and  to  linear  craniectomy;  epilepsy;  bullet  and  other  wounds;  small 
tumors;  drainage  of  frontal  sinus;  drainage  of  mastoid  antrum  and  cells; 
thrombosis  of  venous  sinuses. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations. 

Landmarks. — Determined  by  bony  landmarks  of  skull,  or  calculated  by 
some  method  of  cranio-cerebral  localization,  according  to  special  operation. 

Control  of  Hemorrhage. — Ordinarily  the  hemorrhage  is  controlled  by 
clamping  the  arteries  in  the  margin  of  wound  as  cut.  Excess  of  bleeding 
can  be  temporarily  controlled,  until  arteries  are  clamped,  by  digital  com- 
pression of  temporal,  occipital,  or  posterior  auricular  vessels  against  the 
skull.  Where  much  bleeding  is  anticipated,  the  arteries  may  be  compressed 
against  the  skull  by  circular  constriction,  as  explained  under  General  Surgical 
Considerations  in  Cranio-cerebral  Operations  (page  555).  See  also  under 
Comment  at  end  of  this  operation,  and  under  Operations  for  Intracranial 
Hemorrhage  (page  586). 

Incision. — An  incision  is  made  outlining  an  oval  or  U-shaped  flap,  with 
its  convexity  toward  the  crown  of  the  head  and  its  pedicle  toward  the  base, 
its  sides  corresponding  with  the  general  direction  of  the  vessels  and  nerves, 
thus  providing  for  free  ingress  of  arteries  into  the  flap.  Where  possible,  so 
place  the  flap  as  to  avoid  the  main  arteries.  Size  of  flap  should  be  consider- 
ably greater  (at  least  1.2  cm.,  or  \  inch,  all  around)  than  the  disc  of  bone 


TREPHINING,    OR    CIRCULAR    CRANIOTOMY 


559 


to  be  removed,  so  that  the  cicatrix  of  the  soft  parts  should  not  overlie  the 
margin  of  the  bone-opening.  The  center  of  the  soft  flap  should  about  corre- 
spond with  the  center  of  the  bone-disc  to  be  removed.  (The  oval-flap  incision 
is  distinctly  superior  to  the  crucial  or  other  form  of  incision.)     (Fig.  422.) 

Operation. — (1)  The  original  incision  passes  directly  through  skin, 
fascia,  muscle  (or  aponeurosis),  and  periosteum  to  the  bone  throughout. 
Clamp  arteries  as  cut,  followed  by  ligation  of  main  vessels  with  gut  and  removal 
of  clamp  forceps,  so  as  to  avoid  encumbering  the  site  of  operation  with  instru- 
ments.    (2)  The  periosteum,  together  with  the  overlying  parts  adherent  to 


422. — Trephining,  or  Circular  Craniotomy: — I. 

of  soft  parts. 


-Subperiosteal  elevation  of  the  flap 


it,  is  then  detached  from  the  bone,  en  masse,  with  periosteal  elevator  (its 
adherence  being  firmest  along  the  suture  lines),  and  the  entire  flap  turned 
down  (Fig.  422) — and  either  held  out  of  the  way  by  a  metallic  or  thread 
"retractor,  or  stitched  to  the  neighboring  soft  parts.  (3)  When  all  bleeding 
has  been  controlled,  apply  trephine  to  desired  site,  with  its  pin  slightly  pro- 
jecting, withdrawing  pin  as  soon  as  teeth  of  instrument  have  cut  a  groove  in 
the  bone.  By  repeated  right  to  left  pronations  and  supinations  of  wrist,  con- 
tinue the  half-circular  movements  of  the  trephine  until  the  section  is  made 
through  the  bone,  to  but  not  into  the  dura  (Fig.  423).  The  progress  of  the 
trephine  is  best  determined  at  intervals  by  withdrawing  the  instrument  and 


560 


OPERATIONS    UPON    THE    HEAD. 


ascertaining  the  depth  of  the  groove  by  the  tip  of  the  flat  end  of  the  ordinary 
probe,  which  readily  detects  the  yielding  dura.  Additional  pressure  should 
be  made  upon  that  aspect  of  the  incision  which  is  thickest  or  is  least  cut,  while 
the  trephine  is  tilted  away  from  the  part  completely  divided.  If  the  teeth  of 
the  trephine  become  blocked  with  bone-dust,  remove  such  dust  with  trephine- 
brush  or  gauze.  Pressure  upon  the  instrument  should  decrease  as  the  brain 
is  approached.  At  first,  greater  resistance  in  going  through  the  outer  table 
of  the  skull  is  offered — then  less  resistance  as  the  instrument  passes  through 
the  diploe,  and  the  bone-dust  of  the  diploetic  region  is  usually  more  blood- 


Fig.  423. — Trephining: — II. — Application  of  the  Gait  conical  trephine  to  the  skul 


stained — then  finally  greater  resistance  is  experienced  again  in  passing  through 
the  inner  table.  When  section  of  bone  has  been  almost  or  quite  completed, 
the  button  of  bone  may  generally  be  lifted  out  by  means  of  an  elevator  (Fig. 
424)  or  in  the  grasp  of  special  curved,  thin-bladed  trephine-forceps.  (4)  If 
more  space  be  required  than  afforded  by  the  removal  of  the  button,  it  may  be 
gotten  by  biting  out  pieces  of  bone  from  the  circumference  of  the  opening  by 
means  of  suitably  curved  rongeur  forceps — or  by  making  an  additional  con- 
tiguous trephine-opening  of  the  same  or  smaller  size,  followed  by  biting  out  of 


TREPHINING,    OR    CIRCULAR    CRANIOTOMY. 


56l 


the  intervening  bridge-work  of  bone.  (5)  The  dura  mater  is  now  exposed,  and 
should  be  opened  by  marking  out,  on  a  very  small  scale,  a  flap  very  similar 
to  the  scalp-flap — its  pedicle  should  be  placed  so  as  to  best  preserve  its  blood- 
supply  (without  reference  to  coinciding  with  the  pedicle  of  the  scalp-flap)— 
its  convexity  should  lie  in  the  opposite  direction  and  be  everywhere  sufficiently 
far  from  the  edge  of  the  bone  (at  least  6  mm.,  or  \  inch)  to  enable  the  cut 
margins  of  dura  to  be  sutured  at  the  end  of  the  operation  (Fig.  425,  D).  If 
arteries  of  fair  size  cross  the  dura,  they  should  be  ligated,  where  possible,  prior 
to  incising  the  dura,  by  passing  a  small,  fully  curved  needle,  armed  with  fine 


Fig.  424. — Trephining:— III. — Levering  out   the  excised   button   of  bone. 

gut,  beneath  them,  including  the  dura.  Arteries  should  be  tied  along  the  line 
which  will  form  the  convexity  of  the  flap,  rather  than  where  they  enter  its 
pedicle.  If  not  possible  to  tie  them  in  advance,  they  should  be  caught  as  soon 
as  cut  and  tied  or  twisted.  The  dura  should  be  carefully  incised  with  a  light 
touch  of  the  point  of  a  fine,  sharp  knife,  or  cut  with  fine  curved  scissors,  aided 
by  grasping  the  small  dural  flap  with  delicate  forceps  as  soon  as  a  margin  of  it 
is  free,  and  taking  care  not  to  wound  the  surface  of  the  brain  or  the  vessels 
coursing  over  it.  (6)  The  special  object  of  the  operation,  whatever  it  may  be, 
is  now  carried  out.  (7)  Having  accomplished  the  particular  object  ot  the 
operation,  the  dural  flap  is  dropped  into  place  and  sutured  with  two  or  three 
36 


562 


OPERATIONS    UPON    THE    HEAD. 


or  more,  fine  gut  sutures,  by  means  of  a  small,  fully  curved  needle  held  by 
needle-forceps,  while  the  dura  is  steadied  by  fine  forceps  (Fig.  425,  E).  (8) 
The  opening  in  the  bone  may  now  be  treated  in  one  of  several  ways:  (a) 
Left  without  replacement  of  any  bone-tissue,  which  is  especially  done  in  the 
making  of  small  trephine-openings; — (b)  The  button  of  bone  may  be  replaced 
intact  upon  the  dura,  and  the  soft  flap  of  periosteum  and  other  tissues  brought 
over  the  button — a  method  which  may  be  pursued  in  dealing  with  buttons  of 
larger  size; — (c)  The  button  may  be  divided  into  parts  by  fragmentation  and 
sprinkled  over  the  dura,  where  they  form  the  nucleus  of  new  bone  growth ; — 


Fig.425.— Trephining,  or  Circular  Craniotomy  : — A,  Circle  left  by  removed  disc  of  bone  ;  B, 
Incised  dura  mater;  C,  Surface  of  brain;  D,  Dural  flap,  with  meningeal  vessels,  turned  back  ;  E, 
Gut-sutures  through  margins  of  incised  dura  and  dural  flap  ;  F,  Scalp-flap,  with  branches  of  occipital 
vessels,  turned  down. 


(d)  A  celluloid,  metallic,  or  gutta-percha  plate  may  be  placed  in  the  opening. 
In  trephinings  of  small  diameter  the  button  is  not  generally  replaced. 
In  large  openings  some  surgeons  do,  and  some  do  not,  replace  the  button,  whole 
or  fragmented,  or  some  artificial  covering.  Where  the  button,  either  intact 
or  fragmented,  is  used,  it  is  dropped  into  warm  normal  salt  solution  as  soon 
as  removed.  (9)  The  flap  of  scalp  tissues  is  now  brought  back  into  its  original 
position — the  edges  of  the  periosteum  are  sutured  with  catgut — and  the  edges 
of  the  overlying  soft  parts  are  sutured  interruptedly  with  silkworm-gut,  silk, 


TREPHINING,    OR    CIRCULAR    CRANIOTOMY. 


563 


Fig.  426. — deVilbiss'    Cranial    Bone-gouging    Forceps: — The    biting-blade    is    shown    in 
detail.     Also  known  as  Dalgrene's  bone  forceps. 

or  catgut,  passing  through  all  the  soft  tissues  down  to  the  periosteum.     (10) 
No  drainage  is  ordinarily  used  unless  specially  indicated — and,  if  indicated, 

■       i^gflHH"1  ""■■if 

Fig.  427. — Doyen's  Cranial  Chisel. 

a  few  strands  of  catgut,  horsehair,  silk,  or  gauze  suffice.     A  full  dressing  is 
applied. 

p 


Fig.  428.— Osteoplastic  Repair  of  a  Trephine  or  other  Opening:— I.— A,  Flap 
raised  in  exposing  site  for  trephining;  B,  Flap  to  be  raised,  including  a  portion  of  bone  (the 
outer  tablet  of  the  skull)  and  to  be  shifted  to  cover  the  trephine-opening. 

Comment.— Bleeding  from  the  diploe  may  be  stopped  by  compressing 
a  small  part  of  the  bone  upon  the  vessel  with  bone-forceps,  or  by  plugging 


564 


OPERATIONS    UPON    THE    HEAD. 


with  catgut  or  surgeon's  wax.  Bleeding  from  the  dura  may  be  checked  by 
fine  catgut  ligature.  For  bleeding  from  venous  sinuses,  see  Ligation  of  Longi- 
tudinal and  Lateral  Sinuses  (page  586). 

It  is  probably  always  best  to  open  the  dura  in  all  cases  of  trephining. 

If  more  room  be  required  than  is  furnished  by  the  trephine-opening, 
additional  bone  may  be  bitten  away  by  some  special  instrument,  such  as  de 
Vilbiss'  bone-gouging  forceps  (Fig.  426),  or  less  desirably  may  be  chiselled 
away  by  such  an  instrument  as  Doyen's  cranial  chisel  (Fig.  427),  using  in 
either  case  the  margin  of  the  trephine-opening  as  a  starting  point. 

Though  not  frequently  resorted  to,  or  indicated,  it  may  be  possible  to  make 
an  osteoplastic  closure  of  a  trephine  opening.     In  order  to  accomplish  this, 


Fig.  429. — Osteoplastic  Repair  of  a  Trephine  or  other  Opening: — II. — A,  Flap 
raised  in  exposing  site  for  trephining  and  about  to  be  shifted  to  cover  site  of  Flap  B,  and  the 
shallow  bony  opening  left  by  removing  the  outer  tablet  of  the  skull  under  and  along  with  Flap  B; 
B,  Hap,  including  attached  bone-graft,  shifted  so  as  to  bring  the  autoplastic  bone-graft  over  the 
trephine  or  other  opening. 

an  adjacent  flap  may  be  raised,  corresponding  somewhat  with  the  flap  raised 
for  the  original  exposure,  but  with  its  base  lying  in  the  opposite  direction.  In 
the  act  of  raising  this  secondary  flap  a  portion  of  the  outer  layer  of  the  skull 
is  chiselled  off,  retaining  its  connection  with  the  secondary  flap  and  so  planned 
as  to  approximately  fit  the  defect  which  it  is  intended  to  cover.  Each  flap  is 
then  so  shifted  as  to  lie  in  the  position  formerly  occupied  by  its  neighbor — the 
bone-bearing  flap  covering  the  exposed  brain,  and  the  boneless  flap  covering 
the  site  furnishing  the  bone-flap.  These  steps  are  shown  in  Figs.  428  and 
429. 


OSTEOPLASTIC    RESECTION    OF    SKULL. 


565 


OSTEOPLASTIC  RESECTION  OF  THE  SKULL. 

Description. — Temporary  partial  displacement  of  a  section  of  the  skull, 
together  with  its  overlying  soft  parts  unseparated — accomplished  by  partly 
bending,  partly  breaking  backward,  the  base  of  the  bony  section  from  the 
dura,  upon  a  hinge,  as  it  were,  of  the  soft  parts,  without  complete  severance 


Fig. 430— Osteoplastic  Resection  of  thk  Skill:— A.  Cutaiieo-musculo-osseous  flap  tempo- 
rarily turned  back  ;  the  component  parts  adherent,  and  with  scalp  vessels  cut  along  the  margin  ;  B,  B.  B, 
B,  Four  trephine-openings  made  preceding  the  sawing  of  the  bon~  ;  C,  Line  along  which  the  bone  was 
cracked  back;  D,  Incised  dura,  with  divided  vessels  ligated  ;  E,  Dural  flap  turned  back;  F,  Gut- 
sutures  through  margins  of  incised  dura  and  dural  flap  ;  G,  Periosteum  retracted  from  line  of  saw- 
cut;  H,  Margin  of  skull  left  by  temporary  removal  of  osteoplastic  flap  ;  I,  Surface  of  brain. 


of  the  vascular  supply — followed  by  the  replacement  of  the  flap  of  bony 
and  soft  parts  into  apposition.     (See  Fig.  430.) 

(The  replacement  of  a  trephined  button  of  bone  is,  strictly,  an  instance 
of  osteoplastic  resection  with  temporary  complete  displacement  of  the  excised 
piece  of  bone.) 

Indications.  -For  exploration;  tumors;  intracranial  abscess;  intracranial 


566 


OPERATIONS    UPON    THE    HEAD, 


hemorrhage;  exposure  of  Gasserian  ganglion;  wounds.     In  general,  where 
the  freest  access  to  brain  is  required. 


Fig.  431. — Osteoplastic  Exposure  of  the  Brain: — A  horseshoe  flap  has  been  incised 
to  the  bone.  Burr-openings  are  being  made  by  a  Doyen  hand-drill,  to  which  a  fraise  (burr) 
i-.  attached.     The  commencement  of  an  opening,  made  by  the  perforator,  is  also  shown. 

Preparation  and  Position. — See  under  General  Surgical  Considerations 
in  Cranio-cerebral  Operations  (page  554)  • 


Figs.  432-436. — Doyen's   Brace,   with  several  sizes  of   Burr-drills   (Fraises)  and  a 

Perforator. 


Landmarks. — Same  as  for  trephining  (q.  v.). 

Control    of    Hemorrhage  from  Scalp. — Hemorrhages  ordinarily  con- 
trolled as  in  trephining  (q.  v.).     Where  extensive  hemorrhage  is  anticipated 


OSTEOPLASTIC    RESECTION    OF    SKULL. 


567 


the  vessels  may  be  controlled  by  circular  constriction,  as  explained  under 
General  Surgical  Considerations  in  Cranio-cerebral  Operations. 

Form  of  Cranial  Opening.— (1)   The  best  and  general  form  is  that  of  a 


Fig.  437. — Perforator: — A,  Fraise  or  burr;  B,  in  section  of  the  skull. 

horseshoe,  with  its  broader  convexity  upward  and  its  more  contracted  base 
downward  (Fig.  430) — or  an  i-'-shaped  flap,  the  horizontal  cuts  at  base  (which 
may  or  may  not  be  made)  serving  as  liberating  incisions.     (2)  A  square,  or  a 


Fig.  438. — Osteoplastic  Exposure  of  the  Braix: — Application  of  the  mensurator 
through  a  cranial  drill-opening,  in  order  to  ascertain  the  thickness  of  the  skull  at  the  different 
openings,  as  a  guide  to  the  setting  of  the  guard  in  the  Doyen  or  other  form  of  saw. 

rectangular  piece,  longer  than  broad,  may  be  used — though  the  process  oi 
bending  backward  is  always  aided  if  the  base  be  somewhat  narrower  thai* 
the  free  portion  (Fig.  468).     (3)   A  second  horseshoe,  or  square  of  bone,  may 


568 


OPERATIONS    UPON    THE    HEAD. 


Fig.  439. — Showing  the  method   of  application  of  the  mensurator,   between  dura  and  skull, 
demonstrating,   at  this  particular  site,  a  skull   5   mm.   (T3B   inch)   thick. 

be  turned  back,  if  the  original  flap  do  not  furnish  sufficient  room — the  second 
being  either  turned  back  in  an  opposite  direction  from  the  first  but  in  the  same 
line,  or  from  one  side  of  the  original  opening  (Fig.  469) . 


Fig.  440.— Osteoplastic  Exposure  of  the  Brain:— Doyen  hand-saw,  set  to  cut,  say, 
through  7  mm.  ($  inch)  thickness  of  skull,  in  the  act  of  making  a  bevelled  bone-section  between 
two  drill-openings — bevelling  at  the  expense  of  the  inner  surface. 

Incision  of  Scalp. — The  form  of  scalp  incision  will  be  regulated  by  the 
previously  determined  form  of  bone  section.     Having  decided  this,  the  incision 


OSTEOPLASTIC    RESECTION    OF    SKILL. 


569 


through  the  soft  parts  should  conform,  in  general  outline,  with  the  bone  section 
to  be  made,  but  should  extend  at  least  1.2  cm.  {h  inch)  beyond  the  line  of 
bone  section,  so  that  the  cicatrix  of  soft  parts  will  not  fall  directly  over  the  line 
of  bony  union  or  repair.     The  incision  should  be  so  placed,  where  possible, 


Fig.  441. — Osteoplastic  Exposure  of  the  Brain: — The  starting  outward  (by  means  of 
an  osteotome  carefully  introduced  down  to  the  dura)  of  the  composite  flap — the  bone  of  which 
is  to  be  snapped  back  and  broken  at  its  base  on  a  transverse  line  with  the  two  lowermost  drill- 
holes. 

as  to  give  free  ingress  of  the  neighboring  arteries  into  its  substance,  especially 
the  chief  artery  of  the  region.  The  removal  of  an  area  of  bone  greater  than 
7.5  cm.  (3  inches)  square  is  rarely  called  for — and  this  would  require  a  skin- 
flap  at  least  10  cm.  (4  inches)  broad. 


Fig.  442. — Marion's  Gigli-saw  Conductor. 

Operation. — (1)  The  incision  passes  everywhere  through  skin,  fascia, 
muscle,  aponeurosis,  and  periosteum  directly  to  the  bone  (Fig.  431).  Or 
the  incision  may  pass  down  to  the  periosteum — these  allowed  to  retract,  and 
periosteum  cut  on  line  of  retracted  soft  parts,  midway  between  the  line  of  the 
skin  incision  and  the  line  of  the  bone  incision,  so  that  periosteal  and  skin  cica- 


57° 


OPERATIONS    UPON    THE    HEAD. 


trices  do  not  fall  together,  nor  periosteal  and  bony  cicatrices  coincide.  (2)  A 
rim  of  periosteum,  without  separating  the  overlying  soft  parts,  is  carefully 
detached  to  the  extent  of  about  1.2  cm.  (^  inch)  around  the  horseshoe  flap, 
separating  it  chiefly  toward  center  of  flap,  and  but  slightly  upon  the  outer  edge 
of  the  incision.  (3)  Having  exposed  the  entire  area  for  the  bone  section,  the 
bone  is  divided  about  6  mm.  (|  inch)  inside  of  the  division  of  the  periosteum 
in  one  of  several  ways: — (a)  By  means  of  Doyen's  Hand-drill  and  Hand-saw; 
— Doyen's  special  brace,  with  perforators  and  burr-drills,  is  used  (Figs.  432- 
436) .  The  beginning  of  the  opening  is  made  by  means  of  the  perforator  (Fig. 
437,  A),  which  cuts  into  the  bone  in  such  fashion  as  to  enable  the  burr  to  keep 
its  hold  and  not  slip  over  the  convex  surface  of  the  skull.     The  burr  is  then 


Fig.  443. — Osteoplastic   Exposure  of  the   Brain: — Gigli  saw   being   carried   beneath   the 
skull,  between  the  burr-openings,  by  means  of  the  Marion  conductor. 

applied  and  cuts  its  way  through  the  entire  thickness  of  the  skull  down  to  the 
dura  mater — its  form  being  such  as  to  make  it  impossible  to  crush  into  the 
brain,  except  through  carelessness — and  its  cutting  surface  so  modelled  as  to 
revolve  upon  the  dura  without  cutting  it,  unless  driven  too  far  through  the 
skull  (Fig.  437,  B).  During  the  use  of  the  burr  the  instrument  should  be 
removed  and  the  depth  of  the  opening  sounded.  The  position  of  the  brace, 
during  these  manoeuvres,  is  shown  in  Fig.  431.  Having  made  these  openings 
at  sufficiently  close  intervals  in  the  outline  of  the  intended  bone-flap,  the  thick- 
ness of  the  skull  is  ascertained  by  means  of  the  mensurator  (Figs.  438  and 
439).  These  soundings  (made  in  millimeters)  through  any  two  contiguous 
openings  will  usually  give  the  thickness  of  the  skull  for  that  special  interval 
with  sufficient  accuracy  (barring  such  accidental  occurrence  as  the  presence 


OSTEOPLASTIC    RESECTION    OF    SKULL. 


571 


of  a  depression  in  the  skull  for  a  Pacchionian  body).  Having  set  the  guard 
of  the  Doyen  saw  (Fig.  419)  at  the  number  of  millimeters  indicated  by  the 
mensurator,  the  skull  is  cut  through  between  each  pair  of  drill-openings — ■ 
changing  the  guard  to  correspond  with  the  thickness  of  the  skull  in  each  region. 
The  saw  sections  are  always  made  on  the  bevel — in  such  a  manner  as  to  cut 
at  the  expense  of  the  inner  surface  of  the  bone-flap — so  that  when  it  is  replaced 
the  flap  of  bone  will  rest  upon  a  ledge  of  bone  furnished  by  the  margin  of  the 
opening  and  thus  not  be  depressed  upon  the  brain  (Fig.  440).  It  is  better 
to  saw  nearly  through  rather  than  .entirely  through  the  skull — leaving  the 
limited  bony  attachments  which  may  still  exist  to  be  broken  by  the  slight, 
light  tap  of  a  wooden  mallet  upon  an  osteotome  (not  a  chisel)  (Fig.  441), 


Fig.  444. — Osteoplastic  Exposure  of  the  Brain: — Gigli  saw  making  a  bevelled  section 
between  two  drill-openings.  The  bevelling  is  made  at  the  expense  of  the  inner  surface  of  the 
bone-flap,  so  that,  when  replaced,  the  bone-flap  will  rest  upon  the  skull  and  not  be  pressed  against 
the  brain. 


preparatory  to  breaking  back  (hinging  back)  the  bone-flap,  (b)  By  means 
of  a  Gigli  saw  conducted  between  burr-openings  or  small  trephine  openings, 
between  skull  and  dura ; — The  burr  openings  may  be  made  as  in  the  preceding 
technic,  by  the  Doyen  hand-drill — or  small  trephine  openings  may  be  made 
along  the  line  of  the  intended  flap.  A  pliable  dural  separator  is  then  passed 
from  hole  to  hole,  detaching  and  depressing  the  dura  from  the  skull.  A 
Gigli  saw  is  now  conducted  beneath  the  bone  by  a  special  carrier  (such  as 
Marion's  Gigli-saw  conductor  (Fig.  442)  between  two  contiguous  holes  (Fig. 
443)  and  the  bone  divided — and  this  repeated  until  the  section  is  completed — 
the  saw  bevelling  the  bone  as  described  in  the  last  method  (Fig.  444).  (c) 
By  means  of  Doyen's  Flectric-Motor  Drills  and  Saws; — This  instrument  is 


572 


OPERATIONS    UPON    THE    HEAD. 


driven  by  electric  power  and  is  a  combination  of  drill  and  saw  (Figs.  445- 
447).  The  drill-* tpenings  in  the  line  of  the  flap  are  made  in  the  same  manner 
as  are  the  drill-  or  burr-openings  made  by  Doyen's  hand-drill  and  saw  (Fig. 
448) .  As  soon  as  the  burr-openings  have  been  made  and  their  depth  measured, 
an  appropriate  saw,  with  its  proper  guard,  is  chosen  (Figs.  449-452 — a  guard 
which  will  enable  the  saw  to  cut  nearly  through  (as  previously  determined  by 
the  mensurator),  but  not  entirely  through,  the  skull — leaving  a  thin  portion  of 
the  inner  plate  to  be  divided  by  a  stroke  or  two  of  mallet  against  osteotome. 
The  section  between  burr-holes  is  then  made  in  the  same  general  way  as  by 
the  hand  saw — and  bevelled  in  the  same  fashion.  Another  form  of  the  Doyen 
Electric-Motor  Saw  is  provided  with  a  dural  guard  and  separator,  which 

D 


Figs.  445-447. — Doyen's  Electric-motor  Drill  and  Saw: — A,  Metallic  cylinder  for 
reception  of  special  instrument;  B,  Rubber  tube  enclosing  metallic  core  connected  with  motor; 
C,  C,  C,  Handle,  in  various  positions,  to  accommodate  application  of  instrument  to  different 
aspects  of  skull;  D,  Fraise;  E,  Saw,  with  guard-disc  limiting  depth  of  section.  (Modified  from 
Marion.) 

travels  between  skull  and  bone  and  ahead  of  the  saw  (Fig.  453) — and  is 
applied  as  shown  in  Fig.  454.  (d)  By  means  of  Hartley's  Electric  Motor; — 
The  source  of  electric  power  is,  in  this  case,  contained  within  the  instrument 
itself — consisting  of  a  motor  furnishing  about  one-eighth  horsepower — yielding 
2100  revolutions  per  minute — the  entire  instrument  weighing  8J  pounds. 
The  outer  casing  is  sterilized  before  the  motor  is  placed  within  it  (Fig.  455). 
The  cutting  instruments  used  with  this  motor  are  shown  in  Figs.  456-459, — 
the  saws  being  of  the  same  general  type  as  the  Doyen  saws  (Figs.  449-452). 
(e)  By  means  of  Hartley's  Compressed-air  Motor; — This  instrument  is 
pictured  in  Fig.  460 — the  same  cutting  instruments  being  adjustable  to  both 
it  and  the  Electric  Motor,  (f)  By  means  of  Sudeck's  Fraise; — The  fraise 
is  shown  in  Fig.  461.     The  instrument  is  attached  to  some  form  of  motor — 


OSTEOPLASTIC    RESECTION    OF    SKULL, 


573 


Fig.  44S. — Osteoplastic    Exposure    of    the    Braix: — Same    as    preceding    figure — except 
Doyen's  electric  motor  drill,  with  fraise  attachment,  is  here  shown. 

and   used  as  pictured  in   Fig.  462.     (4)   When   the  bone   has  been   divided 
throughout  down  to  the  base  of  the  bone-flap,  provision  must  be  made  for  the 


'A 


Figs.  449-452. — A,  A,  Doyen's  circular  saws  of  various  sizes,  adjustable  to  the  common 
handle  of  his  motor  saw.  B,  B,  Doyen's  safety-discs  of  various  sizes,  adjustable  to  various 
sizes  of  saws  in  order  to  limit  the  depth  of  their  cutting-edge.  (The  saws  and  discs  are  shown 
in  groups  and  separately.) 


bending  and  breaking  back  of  the  bone  at  the  site  which  will  form  the  hinge 
of  the  osteoplastic  flap — this  hinging  of  the  flap  may  be  accomplished  in  one 


574 


OPERATIONS    UPON    THE    HEAD. 


Fig.  453. — Another  form  of  Doyen  saw,  driven  by  electric  motor — with  attached  guard  and 
dural  separator  passing  between  skull  and  dura. 

of  several  ways; — (a)   When  all  is  in  readiness,  and  without  having  previously 
partly  divided  the  bridge  of  bone  at  the  base  of  the  flap,  a  stout  steel  elevator 


■ 


Fig.  454. — Osteoplastic  Exposure  of  the  Brain: — The  Doyen  electric  motor,  with 
combined  saw  attachment  and  dural  separator — the  latter  being  inserted  through  one  cranial 
opening,  while  the  saw  is  cutting  its  way  to  the  next. 

may  be  inserted  under  the  edge  of  the  convexity  of  the  bone-flap  (that  part 
opposite  the  narrow  base  of  the  flap)  so  as  to  rest  upon  the  intact  portion  of 


OSTEOPLASTIC    RESECTION    OE    SKULL. 


575 


Fig.  455. — The  Hartley  Electric  Motor  with  Sterilizable  Casing: — The  various 
cutting  instruments  are  attached  directly  to  the  armature  by  means  of  an  adjustable  chuck. 
(Modified  from  Hartley  and  Kenyon.) 

the  skull  {Fig.  463) — the  fingers  of  the  surgeon's  left  hand  pressing  upon  the 

"i 


Figs.  456-459. — Skull-cutting  Instruments  Adjustable  to  the  Hartley  Motor: — 
A,  B,  Conical  cutters;  C,  Cutting  ball  mounted  upon  cutting  cone;  D,  Composite  cutter,  com- 
bining the  features  of  B  and  C.  (Modified  from  Hartley  and  Kenyon.)  The  saws  and  guards 
are  of  the  same  general  type  as  Doyen's,  shown  in  Pigs.  449-452. 

skull  immediately  below  the  line  where  it  is  sought  to  bend  and  break  the  bone 
— and  then  with'  a  sudden  sharp  (not  slow  and  deliberate)  movement  of  the 


576 


OPERATIONS    UPON    THE    HEAD. 


lever  the  bone  is  sprung  hack — and  generally  breaks  accurately  enough  for 
all  practical  purposes,  and  drops  outward  and  downward  still  clinging  to  its 
hinge  of  soft  parts  (Fig.  464) .  (b)  To  insure  a  more  accurate  line  of  break- 
age, as  well  as  against  splintering  of  the  bone  and  wounding  of  the  brain, 
two  small  trephine-openings  may  be  made  immediately  opposite  each  other, 
at  the  base  of  the  bone-flap  and  on  the  line  to  be  broken,  provided  it  be  not  too 
long — a  pliable  dural  separator  is  now  passed  between  the  openings — a  Gigli 


Fig.  460. — Hartley's  Sterilizable  Compressed-air  Motor: — Driven  by  compressed 
air,  at  a  pressure  of  75  to  90  pounds;  the  bone-cutting  instruments  pictured  in  Figs.  456-459 
are  adjustable  to  it.      (Modified  from  Hartley  and  Kenyon.) 

saw  is  conducted  beneath  the  bone — and  the  bone  is  sawed  sufficiently  far 
through,  especially  at  its  edges,  to  insure  an  accurate  breakage  and  freedom 
from  splintering  when  the  elevator  is  used  as  a  lever  as  just  described.  (5) 
As  the  bone  is  broken  back,  it  is  separated  from  the  dura,  where  not  already 
detached  by  dural  separator  or  otherwise.  The  osteoplastic  flap  of  bone  and 
soft  parts  is  allowed  to  fall  back  upon  its  hinge  out  of  the  way.  (6)  Before 
proceeding,  all  bleeding  from  the  diploe  is  controlled  by  pressure,  plugging 
the  openings  with  catgut  or  sterilized  wax,  or  by  gently  crushing  the  bony 


Fig.  461. — Sudeck's  Fraise. 

opening  together  with  bone  forceps.  (7)  The  dura  is  now  opened  in  the  form 
of  a  flap  (Fig.  464),  by  picking  it  up  with  two  forceps,  incising  with  knife,  and 
further  cutting  with  curved,  blunt  scissors  (just  as  described  in  trephining, 
q.  v.),  the  division  being  made  sufficiently  far  from  the  margin  of  the  bone 
(at  least  6  mm.,  or  I  inch)  to  allow  the  suturing — and  this  little  flap  should 
be  so  planned  as  to  preserve  the  arteries  intact  which  enter  its  base,  ligating 
them  with  fine  catgut  only  where  they  cross  the  line  of  incised  dura  (they  are 


OSTEOPLASTIC    RESECTION    OF    SKULL. 


577 


Fig.  462. — Osteoplastic  Exposure  of  the  Brain: — Manner  of  using  Sudeck's  fraise- 
motor  attachment  not  being  here  shown. 


-the 


Pi„    463  — Osteoplastic  Exposure  of  the  Brain: — The  final  loosening  of  parts  of  the 
inner  tablet  of  the  bone-flap  in  places  where  the  saw-section  may  not  have  passed  entirely  through 
the  skull,  by  a  few  light  taps  with  a  wooden  mallet  upon  a  chisel  carefully  held  so  as  not  to  pene- 
trate the  brain. 
37 


578 


OPERATIONS    UPON    THE    HEAD. 


best  taken  up  in  advance  by  passing  a  small,  fully  curved  needle  beneath 
them).  The  position  of  the  base  of  the  small  dural  flap  will  be  determined 
by  the  position  of  the  dural  vessels,  and  while  it  need  not  necessarily  corre- 
spond with  that  of  the  osteoplastic  flap,  yet  it  usually  does  so  in  a  general  way. 
(8)  The  dural  flap  having  been  turned  back  out  of  the  way,  the  surface  of 
the  brain  is  exposed  and  the  special  object  of  the  operation  accomplished  (Fig. 
4°5)  •     (9)   Upon  the  completion  of  the  operation  the  dural  flap  is  sutured 


Pig.  464. — Osteoplastic  Exposure  of  the  Brain: — I. — A  composite  flap  of  soft  parts 
and  skull  has  been  turned  down.  The  vessels  which  will  be  cut  in  incising  the  membranes  along 
the  dotted  line  are  ligatured  in  advance  by  passing  a  threaded  needle  beneath  them.  Scissors 
are  about  to  divide  the  membranes  which  have  been  lifted  away  from  the  brain  between  two 
forceps,   throwing  them   into  a  ridge. 


back  with  fine  gut  to  the  margin  from  which  cut.  (10)  The  question  of  intra  - 
or  extra-dural  drainage,  if  any,  will  be  determined  by  the  special  operation. 
Strands  of  silk,  silkworm-gut,  or  fine  twists  of  gauze  are  usually  employed. 
When  used,  provision  must  be  made  for  their  passage  through  the  membranes 
and  through  the  bone-flap — as  shown  in  Figs.  466  and  467.  (n)  The  osseo- 
cutaneous  flap  is  now  turned  back  into  place.  The  previously  freed  margin 
of  periosteum  clinging  to  the  bone-flap  is  sutured  with  interrupted  catgut 
sutures  to  the  margin  of  the  main  periosteum  from  which  cut.     If  muscles 


OSTEOPLASTIC    RESECTION    OF    SKULL. 


579 


of  any  thickness  have  been  involved,  these  are  united  by  buried  catgut  sutures. 
Finally,  the  skin  wound  is  closed  with  silk,  silkworm-gut,  catgut,  or  silk,  by 
means  of  interrupted  sutures  (Fig.  467).  If  drainage  of  the  extra-cranial 
wound  be  indicated,  it  is  accomplished  by  gauze  or  fine  drainage-tubing, 
brought  out  through  an  opening  made  by  biting  a  half-button  of  bone  from 
the  edge  of  the  bone-flap  with  rongeur  forceps  or  through  a  drill-opening,  Fig. 
466.  If  intracranial  drainage  be  used,  it  is  brought  out  through  this  half- 
button  opening  or  drill-opening — and  then  serves  as  an  extra-dural  and  extra- 
cranial drain  as  well. 


Fig.  465. — Osteoplastic  Exposure  of  the  Brain: — II. — The  dural  flap  is  turned  down, 

exposing  the  brain. 


Comment. — The  narrower  the  pedicle  of  the  horseshoe  flap  of  bone,  the 
easier  it  is  to  crack  it  across  at  its  base,  but  it  should  be  broad  enough  to  insure 
nutrition  of  the  osteoplastic  flap. 

The  edges  of  the  bone  of  the  osteoplastic  flap  and  the  margin  of  the  cranium 
may  be  drilled  and  the  borders  of  bone  united  (if  thought  necessary)  by 
chromic  gut  sutures.  If  the  osteoplastic  flap  be  beveled,  as  always  should 
be,  if  possible,  suturing  is  not  necessary — and  is  not  generally  necessary  any- 
how, as  the  adherent  scalp  usually  holds  the  bone  up  in  place. 


58o 


OPERATIONS    UPON    THE    HEAD. 


It  is  best  to  open  the  dura  in  all  cases  calling  for  osteoplastic  resection 
of  the  skull. 

The  application  of  the  osteoplastic  method  of  exposure  to  some  of  the 
sites  i  if  the  brain  is  shown  in  Figs.  468,  469,  470. 


Fig.  466. — Ixtra-dural  axd  Extra-dcral  Draixage: — I. — The  membranes  are  shown 
sutured,  and  through  the  lower  angles  of  the  dural  flap  a  cerebral  drain  of  catgut  strands,  or 
silkworm  gut,  is  making  its  exit  from  the  brain  and  escaping  onto  the  surface  of  the  scalp,  through 
the  drill-holes  at  the  lower  angles  of  the  bone-flap,  for  intra-dural  drainage.  A  bone-drill  is 
seen,  the  burr  in  the  act  of  making  an  opening  through  the  skull,  for  extra-dural  drainage. 


LINEAR   CRANIOTOMY. 

Description. — The  division  of  the  cranial  bones  in  one  or  more  straight 
lines  variously  placed — an  operation  sometimes  resorted  to  in  microcephalus 
for  the  purpose  of  giving  increased  room  to  the  brain.  No  portion  of  the 
bone  is  removed  except  the  buttons  of  bone  from  the  trephine-openings  made 
preliminary  to  the  use  of  the  saw.  (While  craniotomy  is  performed  in  micro- 
cephalus, partial  craniectomy,  or  the  removal  of  a  definite  piece  of  bone,  is 
probably  a  preferable  operation  for  this  purpose,  if  any  at  all  be  justifiable.) 

The  operation  of  craniotomy  is  included  under  that  of  craniectomy  (q.  v.). 


PARTIAL    CRANIECTOMY. 


58l 


PARTIAL  CRANIECTOMY. 

Description. — Removal  of  a  section  of  the  cranial  bones  from  one  or 
both  sides  of  the  head, — an  operation  sometimes  done  in  microcephalus  for 
the  purpose  of  increasing  room  for  the  growth  of  the  brain. 

(Strictly,  in  trephining  and  other  cranial  operations  where  the  button  or 
part  of  bone  is  not  returned,  the  operation  becomes  a  Partial  Craniectomy 
though  the  term  is  not  here  used  in  that  sense.) 

Preparation  and  Position. — See  under  General  Surgical  Considerations 
in  Cranio-cerebral  Operations  (page  554). 

Landmarks. — Nasion  and  inion,  and  the  general  bony  landmarks  of 
the  skull. 


Fig.  467. — Intra-dural  and  Extra-dural  Drainage: — II. — The  strands  of  the  intra- 
dural drain  are  seen  at  their  exit  through  the  drill-holes  of  the  osteoplastic  flap; — and  the  rubber- 
tube  of  the  extra-dural  drain  at  its  exit  through  the  burr-opening  in  the  center  of  the  flap.  The 
soft  parts  are  in  the  act  of  being  sutured,  after  turning  back  the  composite  flap. 

Control  of  Hemorrhage. — By  means  of  a  flat  rubber  tourniquet  wound 
several  times  around  base  of  skull,  small  compresses  having  been  placed 
over  the  main  arteries  of  the  scalp  and  held  in  place  by  the  tourniquet — as 
described  under  General  Surgical  Considerations  in  Cranio-cerebral  Opera- 
tions. This  method  of  control  is  generally  indicated,  as  hemorrhage  is  apt 
to  be  marked. 

Incision. — From  the  junction  of  the  skin  of  the  forehead  with  the  hair, 
to  the  inion — passing  slightly  external  to  the  median  line. 

Operation. — (1)  The  incision  of  the  soft  parts  passes  through  the  skin, 


582 


OPERATIONS    UPON    THE    HEAD. 


fascia,  muscle,  aponeurosis,  and  periosteum  to  bone.  Clamp  all  bleeding 
vessels  uncontrolled  by  constrictor  and  ligate  the  chief  ones  with  gut.  (2) 
The  soft  parts  are  raised  from  the  bone  by  periosteal  elevator  and  turned 
downward,  being  held  out  of  the  way  by  retractor,  or  a  stitch  or  two.  The 
flap  thus  turned  back  will  be  represented  by  practically  the  soft  parts  of  one 
entire  side  of  the  skull.  (3)  Having  exposed  a  large  area  upon  one  side  of 
the  skull,  and  having  controlled  all  further  hemorrhage,  the  amount,  posi- 
tion, and  shape  of  bone  section  are  determined.  An  area  of  bone  in  the  form 
of  a  narrow  parallelogram  represents  the  section  of  bone  most  usually  removed, 


Fig.  468. — Exposure  of  the  Cerebellum  through  an  Osteoplastic  Flap: — A  correspond 
ing  dural  flap,  together  with  double  ligature  of  the  occipital  sinus,  is  shown. 

though  other  forms  of  bone-section  are  used.  Supposing  the  parallel  lines 
representing  this  figure  to  be  1.2  cm.  (\  inch)  or  1.9  cm.  (f  inch)  apart,  a 
trephine-opening  is  made  at  either  end  of  this  figure  with  a  diameter  of  1.2 
cm.  or  1.9  cm.  (\  or  §  inch)  accordingly.  If  the  distance  between  the  trephine- 
openings  be  too  long  for  a  dural  separator  and  guide  to  travel,  one  or  more 


PARTIAL    CRANIECTOMY.  583 

intermediate  trephine-openings  should  be  made.  A  pliable  dural  separator 
is  then  passed  from  opening  to  opening  between  bone  and  dura  and  traveling 
in  two  parallel  lines  corresponding  with  the  upper  and  lower  margins  of  the 
circumference  of  the  trephine-openings.  A  grooved  guide  is  then  passed  in 
the  tracks  cleared  by  the  dural  separator  to  protect  the  brain,  and  the  bone 
then  divided  in  two  parallel  lines  with  an  electric  motor  saw  (the  Powell 
electric  saw  answering  the  purpose  well)— first  in  a  line  with  the  upper  mar- 
gins of  the  trephine-openings  and  then  in  a  line  with  the  lower  margins 
of  these  openings.  By  properly  directing  the  saw  both  ends  of  the  section 
may  be  pointed,  going  beyond  the  trephine-openings  at  both  ends.  The 
bone  section  is  best  made  with  a  motor  saw— it  may  be  made  with  rongeur 
forceps — but  preferably  not  with  chisel,  as  chiseling  causes  too  much  jarring. 
In  using  an  ordinary  motor  saw  a  trephine-opening  is  necessary  wherever 
the  direction  is  changed.     A  Gigli  saw  passed  between  the  openings  also 


Fig.  469. — Hartley's  Double  Osteoplastic  Flaps  for  Exposing  the  Frontal  Con- 
volutions:— Having  their  bases  over  the  temporal  regions.  (Modified  from  Hartley  and  Ken- 
yon.) 


answers  well.  (4)  If  there  be  no  special  indication  for  exploration,  the  dura 
is  not  opened.  If  opened,  it  is  so  incised  as  to  admit  of  subsequent  suturing. 
(5)  The  bone,  of  course,  is  not  replaced.  The  soft  parts  are  sutured  into 
position.     No  drainage  is  ordinarily  used. 

Comment. — (1)  Hemorrhage  from  the  diploe  is  apt  to  be  great  and  may 
have  to  be  controlled  by  plugging  with  catgut  or  aseptic  wax,  by  crushing 
together  the  walls  of  the  bony  canals,  or  by  gauze  pressure.  (2)  Probably 
it  is  best  to  operate  upon  the  second  side  of  the  head  at  a  subsequent  date. 
(3)  A  grooved  director  for  the  saw  can  be  used — or  the  dural  separator  may 
be  grooved.  (4)  Where  craniotomy  is  done  instead  of  craniectomy  the  saw- 
travels  only  once  between  the  trephine-openings,  which  are  merely  large 
enough  to  allow  of  separation  of  dura  and  passage  of  a  guide — and  no  bone 
(other  than  the  trephine-buttons)  is  removed.  A  crescent-shaped  piece  of 
bone  may  be  removed,  instead  of  a  piece  of  the  above-described  shape. 


5§4 


OPERATIONS    UPON   THE    HEAD. 


EXPLORATORY  PUNCTURE  OF  THE  BRAIN. 

Description. —  For  the  purposes  of  exploration,  the  needle  of  an  aspira- 
torv  syringe  may  be  thrust  into  the  brain  substance,  especially  where  pus 
and  fluid  tumors  or  hemorrhage  are  suspected — the  brain  having  been  ex^ 
posed  through  a  small  trephine-opening.  A  solid  needle,  or  special  probe, 
may  be  used  for  the  detection  of  solid  bodies. 


Fig.  470. — Osteoplastic  Exposure  of  the  Antero-superior  Aspect  of  the  Frontal 
Lobes  of  the  Brain: — The  superior  longitudinal  sinus  is  doubly  ligated.  (Modified  from 
Kiliani.) 

Preparations  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  454). 

Landmarks. — Position  of  some  lesion  and  localization  symptoms,  taken 
in  connection  with  the  special  structures  to  be  avoided. 

Incision. — That  for  ordinary  trephining. 

Operation. — (1)  Is  the  same  as  that  for  trephining,  up  to  the  raising  of 
the  dural  flap  and  the  exposure  of  the  brain.  (2)  The  needle  is  then  steadily 
thrust  into  the  brain  in  a  straight  line  in  any  direction  indicated  by  the  phe- 


OPERATION    FOR    INTRACRANIAL    HEMORRHAGE    IN    GENERAL.       585 

nomena  present,  avoiding  the  venous  sinuses,  large  vessels,  basal  ganglia), 
and  ventricles  (unless  puncture  of  the  latter  be  indicated).  The  needle 
should  be  withdrawn  after  each  puncture.  Whenever  it  is  desired  to  explore 
in  another  direction,  the  needle  is  reinserted  and  always  carried  in  a  straight 
line,  without  side  to  side  movement.  (3)  Having  accomplished  the  obi'ect 
of  the  operation,  or  after  meeting  with  a  negative  result,  the  wound  is  closed 
as  after  trephining. 

Comment. — For  further  data  as  to  exploratory  puncture  of  the  intra- 
cerebral structures,  see  Operations  for  Cerebral  and  Cerebellar  Abscess 
(pages  595  and  596),  Tumor  (pages  597-599),  and  Hemorrhage  (page  585). 

OPERATION  FOR  INTRACRANIAL  HEMORRHAGE  IN  GENERAL. 

Varieties  of  Intracranial  Hemorrhage. — (i)  Epidural  (Extra-dural) ; 
between  cranial  bones  and  dura — may  be  arterial  or  venous.  If  arterial — 
generallv  from  middle  meningeal  or  its  branches.  If  venous — generally  from 
the  superior  longitudinal,  lateral,  or  occipital  sinus.  (2)  Intrameningeal;  if 
arterial,  generallv  from  middle  meningeal  or  branches.  If  venous,  fre- 
quentlv  from  veins  connected  with  longitudinal  or  other  sinus.  If  capillary, 
generallv  due  to  traumatism,  and  site  dependent  upon  trauma.  If  subdural 
(into  subdural  space),  it  may  be  caused  either  by  rupture  of  dura,  and  is 
then  generallv  from  the  middle  meningeal  vessels;  or  by  a  vessel  of  the  pia 
rupturing  through  the  arachnoid.  If  subarachnoidean  (between  arachnoid 
and  pia  mater),  it  is  due  either  to  rupture  of  vessels  of  pia  into  the  pia-arach- 
noid,  or  to  rupture  of  middle  meningeal  through  dura  and  arachnoid.  (3) 
Intracerebral:  generally  from  middle  cerebral  or  one  of  its  branches, 
especially  the  lenticulo-striate. 

Onlv  the  general  features  of  intracranial  hemorrhage  will  be  here  con- 
sidered. For  specific  operations  for  hemorrhage  from  the  middle  meningeal 
arterv  and  its  anterior  and  posterior  branches,  and  from  longitudinal  and 
lateral  venous  sinuses,  see  ligations  of  those  structures  (pages  47,  48,  49 
and  586). 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Craniocerebral  Operations  (page  554). 

Landmarks. — Determined  by  circumstances  of  particular  case  and  by 
general  cranio-cerebral  topography.  Site  of  hemorrhage  may  be  determined 
by  external  injury  or  by  localization  symptoms. 

Incision. — As  for  trephining  or  osteoplastic  resection  (according  to  size 
of  opening  required),  and  placed  in  accordance  with  nature  of  case. 

Operation. — (I)  Having  exposed  the  area  involved,  either  by  a  trephine- 
opening  or  osteoplastic  section  (the  steps  of  the  operation  up  to  this  point 
1  icing,  in  all  essential  features,  those  of  one  or  the  other  of  these  procedures), 
the  site  of  the  blood-clot,  if  any,  is  located  and  the  source  of  the  hemorrhage 
traced.  (2)  The  clot  is  carefully  turned  out  with  such  an  instrument  a-  the 
handle  of  a  thin  silver  spoon — the  bleeding  vessel  is  sought  and  doubly  ligated 
with  gut.  The  dura  must,  of  course,  be  opened  if  hemorrhage  be  subdural 
— and  it  is  even  best  to  open  it  though  hemorrhage  appear  to  be  only  epidural, 
for  the  sake  of  verification.  Where  the  hemorrhage  comes  from  the  middle 
cerebral  an  attempt  should  be  cautiously  made,  when  possible,  to  reach  the 
site  of  hemorrhage,  by  carefully  separating  the  lips  of  the  sylvian  fissure 
and  doubly  tying  the  artery  with  gut.  If  site  of  hemorrhage  cannot  be 
accuratelv  ascertained  and  still  continues,  all  that  can  be  done  is  to  carefully 
pack  the  region  with  gauze.     (3)  Finally,  carefully  irrigate  with  warm  normal 


5^6  OPERATIONS    UPON    THE    HEAD. 

salt  solution    (except  where  packing  is  used) — drain   if   necessary — closing 
wound  as  after  simple  trephining  or  osteoplastic  resection. 

Comment. — If  no  accurate  data  lead  to  source  of  hemorrhage,  it  is  best 
to  seek  first  in  the  position  of  the  anterior  branch  of  middle  meningeal  artery 
- — then  in  the  position  of  the  posterior  branch. 

LIGATION  OF  TRUNK  OF  MIDDLE  MENINGEAL  ARTERY. 
See  under  Ligation  of  Arteries  (page  47). 

LIGATION  OF  ANTERIOR  BRANCH  OF  MIDDLE  MENINGEAL  ARTERY. 
See  under  Ligation  of  Arteries  (page  48). 

LIGATION  OF  POSTERIOR  BRANCH  OF  MIDDLE  MENINGEAL 

ARTERY. 

See  under  Ligation  of  Arteries  (page  49). 

LIGATION  OF  LONGITUDINAL  OR  LATERAL  SINUS. 

Description. — The  longitudinal  and  lateral  sinuses  are  sometimes 
accidentally  injured  in  operation,  or  otherwise,  or  lie  directly  in  the  course 
of  some  operation — under  which  circumstances  it  becomes  necessary  to 
control  hemorrhage  from  them,  which,  when  possible,  should  be  done  by 
ligation.     (See  Figs.  471  and  472.) 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — Determined  by  site  of  sinus  involved. 

Incision. — Often  determined  by  a  preceding  injury  or  local  condition 
— or  circumstances  calling  for  ligation  may  accidentally  arise  during  the 
course  of  some  other  cranio-cerebral  operation.  If  deliberately  planned  to 
tie  the  longitudinal  or  lateral  sinus  in  the  path  of  an  operation  (as,  for  example, 
preliminarily  to  exposing  a  surface  of  brain  more  or  less  covered  by  a  sinus), 
two  small  trephine-openings  are  made  on  either  side  and  very  near  the  borders 
of  the  sinus,  after  having  exposed  the  site  of  both  trephine-openings  by  turning 
back  a  single  oval  flap.  For  course  and  deviations  of  the  sinuses,  see  Surgical 
Anatomy  of  the  Cranio-cerebral  Region  (page  536). 

Operation. — (1)  Complete  the  operation,  up  to  the  removal  of  the  two 
buttons  of  bone,  as  an  ordinary  trephining.  (2)  The  dura  and,  with  it,  the 
sinus  are  detached  from  the  cranium  by  passing  a  dural  separator  between 
the  bone  and  dura,  from  one  to  the  other  of  these  two  small  trephine-openings 
immediately  adjacent  to  the  outer  borders  of  the  sinus.  The  bridge-work 
of  bone  between  the  two  openings  is  then  cut  away,  preferably  with  Gigli  saw 
(cutting  pliers  or  rongeur  forceps).  A  limited  longitudinal  incision  of  the 
dura  is  made  safely  to  the  outer  aspect  of  each  side  of  the  sinus,  which  enables 
a  more  intelligent  and  safer  passage  of  the  ligature  than  if  it  were  simply 
carried  blindly  beneath  the  supposed  lower  limit  of  the  sinus.  The  sinus  is 
thereby  fully  exposed  and  is  doubly  ligated  transversely  with  chromic  gut,  by 
passing  a  fully  curved  needle  beneath  the  sinus  and  through  the  falx  cerebri, 
and  divided  between  the  ligatures.  If  the  sinus  be  wounded  to  a  limited 
degree,  it  is  often  possible  to  either  laterally  ligate  the  rent,  or  suture  \t — as 
described  under  the  ligation  of  veins.  (3)  The  operation  is  completed  as 
indicated  by  the  special  circumstances  attending  it — the    button    of    bone 


LIGATION    OF    LONGITUDINAL    OR    LATERAL    SINUS. 


53; 


being  replaced,  or  nut,  according  to  the  judgment  of  the  operator.  Drain- 
age would  be  used  or  not,  as  indicated  (generally  not,  if  all  bleeding  be  con- 
trolled and  wound  be  clean).     The  flap  of  soft  parts  is  sutured  into  place. 


litis.  471  and  472.— Ligation  of  the  Longitudinal  Sinus  : — A,  Exposure  of  longitudinal  sinus 
by  means  of  two  trephine-openings  on  either  side,  followed  by  cutting  away  the  intervening  bridge  of 
bone;  B.  Scalp-flap  turned  back;  C,  Two  trephine-openings  made  near  the  outer  borders  of  the 
longitudinal  sinus,  with  intervening  bone  cut  away;  D,  Incisions  through  dura,  on  either  side  of 
sinus,  for  passage  of  needle  and  ligature  ;  E,  Longitudinal  sinus  ;  F,  Cross-section  of  head,  showing 
position  of  sinuses. 


588  OPERATIONS   UPON   THE    HEAD. 

OPERATION  FOR  THROMBOSIS  OF  LATERAL  SINUS. 

Description. — As  a  result  of  otitis  media,  the  adjacent  sigmoid  and 
transverse  portions  of  the  lateral  sinus  frequently  become  infected  and  undergo 
sinus  phlebitis  and  thrombosis,  requiring  their  exposure,  the  removal  of 
thrombosed  contents  and  their  obliteration  by  ligature  or  otherwise.  The 
operation  is  intimately  connected  with  that  for  the  exposure  of  the  mastoid 


Fig.  473. — Operation  for  Infection  and  Thrombosis  of  the  Lateral  Sinus  and 
Internal  Jugular  Vein: — I. — The  lateral  sinus  and  membranes  of  the  brain  exposed  through 
a  chiselled  opening  in  the  skull.  The  internal  jugular  vein  exposed  in  the  neck  and  doubly 
ligated. 

antrum  and  cells,  which  should  be  reviewed  in  this  connection  (pages  600- 
608).     The  internal  jugular  vein  may  also  be  involved  and  require  exposing. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — Lines  for  sigmoid  and  transverse  portions  of  the  lateral 
sinus.     (See  Surgical  Anatomy,  pages  536  and  542,  and  also  Fig.  479,  L  M.) 


OPERATION    FOR    THROMBOSIS    OF    LATERAL    SINUS. 


589 


Incision. — Where  this  sinus,  at  junction  of  transverse  and  sigmoid 
portions,  is  independently  exposed,  a  horseshoe  flap  is  turned  down,  with 
pedicle  below,  so  planned  as  to  expose  an  area  with  its  center  about  2.5  cm. 
(1  inch)  behind  and  6  mm.  (\  inch)  above  the  center  of  the  external  auditory 
meatus.  Where  the  opening-up  of  the  neighboring  sinus  is  simply  a  con- 
tinuation of  the  mastoid  operation  (which  is  usually  the  case)  the  incision 
for  the  exposure  of  the  sinus  is  prolonged  from  the  original  incision. 


Fig.  474. — Operation*  for  Infection  and  Thrombosis  of  the  Lateral  Sinus  and 
Internal  Jugular  Vein: — II. — The  lateral  sinus  has  been  incised,  the  clot  removed,  its  cere- 
bral end  packed  with  gauze,  and  its  cervical  end  left  open  for  irrigation.  The  internal  jugular 
vein  has  been  ligated  below  the  thrombosis  and  its  upper  end  opened  and  brought  out  for  drainage 
through  the  otherwise  closed  wound  in  the  neck. 


Operation. — (1)  Proceeding  as  in  the  operation  of  trephining,  a  trephine 
having  a  diameter  of  about  2.5  cm.  (1  inch)  is  applied  over  this  center  and  a 
button  of  bone  carefully  removed,  without  injury  to  dura  and  without  pre- 
mature  opening   of   sinus  (Figs.  415  and  473).     Whatever   additional  room 


590  OPERATIONS  UPON  THE  HEAD. 

may  be  required  can  be  gotten  by  biting  out  the  circumference  of  the  trephine- 
opening  by  means  of  rongeur  forceps.  (2)  Thrombosis  having  been  deter- 
mined by  palpation  and  exploratory  needle,  the  thrombosed  sinus  is  now  laid 
open  longitudinally  and  the  contents  carefully  turned  out  with  a  special  scoop, 
as  far  as  accessible  in  both  directions,  or  until  a  patulous  condition  is  reached, 
when  the  flow  is  controlled  by  gut  ligature  of  the  sinus,  if  possible,  or  by  gauze 
packing.  (3)  The  mastoid  antrum  and  cells,  the  usual  source  of  the  original 
infection,  are  generally  opened  up  into  continuity  with  the  sinus  by  means  of 
a  gouge,  sharp  spoon,  or  chisel.  (4)  The  internal  jugular  vein  is  often  exposed 
in  the  neck  (page  474),  when  found  in  a  condition  of  thrombosis,  and  ligated. 
The  thrombosed  vein  may  then  be  opened  above  the  ligature  and  the  vein 
irrigated  from  the  lateral  sinus,  and  vice  versa.  (5)  The  wound  is  packed, 
and  closed  only  in  part,  room  being  left  for  drainage. 

Comment. — If  contents  of  lateral  sinus  be  fluid,  the  sinus,  if  possible, 
should  be  ligated  prior  to  opening  the  thrombosed  part.  A  firm,  healthy 
clot,  about  to  undergo  organization,  may  sometimes  be  left  on  the  distal  side 
of  a  ligature. 


TREPHINING  FOR  FRACTURE  OF  SKULL. 

Description. — The  seat  of  fracture  is  exposed,  the  depressed  pieces  of 
bone  are  elevated  to  the  common  level,  and  any  spicuke  of  bone  which  may 
be  exercising  pressure  upon  the  brain  are  removed. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — Determined  by  the  nature  and  site  of  the  fracture  ami 
general  cranio-cerebral  topography. 

Incision. — Where  a  skin  wound  exists,  this  is  usually  enlarged,  or  used 
as  a  part  of  the  incision  for  the  exposure.  Where  the  skin  is  unbroken,  the 
site  of  fracture  is  best  exposed  through  a  U-shaped  flap,  as  in  trephining. 

Operation. — (1)  The  soft  parts,  including  the  periosteum,  are  turned 
back,  in  the  same  manner  as  in  trephining,  and  site  of  fracture  thus  exposed 
— hemorrhage  being  controlled  as  in  that  operation.  Even  where  the  bones 
of  a  depressed  fracture  can  be  raised  by  being  levered  back  into  position 
without  exposing  the  brain  (which  often  can  be  done),  it  is  always  best  to 
expose  the  dura  at  least — and  safer  still  to  open  the  dura  and  examine  the 
surface  of  the  underlying  brain.  (2)  The  following  steps  of  the  operation  are 
conducted  very  much  as  in  ordinary  trephining.  The  point  of  the  trephine 
is  placed  upon  sound  bone  that  will  resist  pressure,  avoiding  the  site  of  vessels 
and  sinuses,  and  in  a  position  from  which  the  fractured  bone  can  be  best 
raised — with  the  major  portion  of  the  circle  (which  should  be  from  1.2  to 
1.8  cm.,  or  \  to  f  inch)  generally  lying  over  sound  bone,  and  the  inner  portion 
overlapping  or  coming  in  line  with  the  fractured  margin.  When  the  button 
of  bone  is  removed,  if  more  room  be  needed,  it  can  be  gotten  by  biting  out 
portions  of  bone  with  rongeur  forceps.  (3)  A  blunt  elevator  (an  osteotome 
answers  well)  is  now  carefully  inserted  beneath  the  fractured  bone,  resting 
upon  the  sound  margin  of  bone,  or  upon  an  instrument  or  a  finger  stretched 
across  the  area  as  a  fulcrum,  and  the  fractured  bone  levered  back  into  place, 
without  disconnecting  it  from  its  natural  attachments  (Fig.  475).  (4)  Some- 
times judicious  use  of  chisel  or  saw  will  aid  in  freeing  the  fragments.  All 
sharp  edges  are  rounded  off.  All  pieces  likely  to  become  detached  are  removed. 
(5)  The  dura,  if  deliberately  opened  by  the  operator,  is  repaired  as  after 


OPERATION    FOR    BULLET    WOUND    OF    BRAIN. 


591 


trephining — if  wounded  by  fragments,  is  repaired  by  catgut  suturing  as  fully 
as  possible.  (6)  The  manner  of  treating  bone  space  left  by  trephining  for 
fracture  is  the  same  as  after  simple  trephining.  Drainage  is  used,  if  indicated 
— and  the  wound  entirely  or  partially  closed  in  accordance. 


Fig.  475. — Operations  for  Fractures  of  the  Skull: — A,  A  loosened  fragment  of  bone 
being  pried  out  by  an  instrument  introduced  beneath  its  border  through  a  trephine-opening  made 
immediately  adjacent  to  and  continuous  with  one  of  the  lines  of  fracture.  B,  Levering  out  a 
bony  fragment  from  an  adjacent  margin  of  sound  bone  as  a  fulcrum.  C,  The  removal  of  a 
fragment  by  means  of  bone-holding  forceps. 


OPERATION  FOR  BULLET  WOUND  OF  BRAIN. 

Description. — For  the  purpose  of  seeking  the  bullet,  removing  spiculas 
of  bone  and  foreign  material,  and  for  providing  drainage. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — Determined  by  position  of  wound  and  position  of  im- 
portant underlying  structures  and  areas. 

Incision. — An  oval  (or  reversed  U-shaped)  flap,  with  pedicle  downward, 
and  center  corresponding  with  wound. 

Operation. — (1)  The  soft  parts  are  incised  to  the  bone,  the  vessels  clamped 
and  tied,  and  the  flap  raised  and  turned  back.  If  trephining  were  not  con- 
templated, the  periosteum  need  not  be  raised  with  the  flap — but  as  the  use 


592 


OPERATIONS    UPON    THE    HEAD. 


of  the  trephine  or  that  of  the  rongeur  is  practically  always  indicated,  the 
bone  should  be  completely  bared.  (2)  Access  to  the  brain  may  be  gotten 
by  biting  out  the  circumference  of  the  wound-opening  with  rongeur  forceps, 
or,  better,  by  trephining  with  a  trephine  whose  diameter  is  sufficiently  large 
to  make  a  cut  extending  around  the  wound  1.2  to  1.8  cm.  (h  to  f  inches), 
according  to  accompanying  circumstances,  and  with  the  precautions  observed 
in  trephining  for  fracture  (q.  v.).  All  fragments  of  bone  are  removed  or 
elevated  into  position — and  all  foreign  material  is  picked  out  with  forceps 
as  encountered.  (3)  Having  thus  enlarged  the  bullet  wound,  the  bullet  is 
sought  along  its  track  with  such  instruments  as  a  long,  delicate  needle,  Fluhrer's 


Fig.  476. — Operations  for  Bullet-wounds  of  Skull  and  Brain  : — Above,  the  bullet- 
wound  in  the  skull  has  been  trephined  and  a  button  of  bone,  whose  center  is  the  bullet-hole, 
is  being  removed.  Below,  the  bullet-hole  in  the  bone  is  being  enlarged  by  biting  out  its  mar- 
gin with  special  rongeur  forceps. 

aluminium  probe,  or  Girdner's  telephone  probe.  If  the  bullet  can  be  reached 
with  special  forceps,  it  may  be  withdrawn  by  that  means  through  the  original 
wound,  especially  if  near  it.  If  the  bullet  be  near  the  far  end  of  the  wound- 
track,  it  is  generally  more  readily  and  safely  removed  through  a  counter- 
opening.  Such  a  counter-opening  may  be  made  at  a  point  determined  by 
thrusting  a  probe  along  the  track  of  the  wound,  directly  in  the  line  of  the 
bullet-track,  to  the  inner  wall  of  the  opposite  side  of  the  skull — passing  the 
bullet  if  it  lie  on  the  way — followed  by  tying  a  piece  of  silk  to  the  outer  end 
of  the  probe  and  carrying  the  silk  across  the  shaved  scalp  at  different  points 


OPERATION    FOR    EXPOSURE    OF    A    MOTOR    CENTER.  593 

upon  its  contour — the  common  point  at  which  these  lines  all  intersect  will 
indicate  the  point  on  the  exterior  of  the  skull  opposite  which  the  inner  end 
of  the  probe  has  come  into  contact  with  the  inner  wall  of  the  skull.  At  this 
point  a  trephine-opening  is  made.  The  counter-opening  is  made  with  a 
trephine  of  3.8  to  5  cm.  (i^  to  2  inches)  in  diameter,  as  the  bullet  is  apt  to 
lie  an  inch  or  more  below  the  point  of  striking  the  inner  wall,  and  room  is 
often  necessary  for  manipulation  and  exploration.  Upon  a  probe,  a  grooved 
director  is  carried  down  to  the  bullet,  and  upon  the  director  a  pair  of  bullet- 
forceps,  with  which  the  bullet  is  grasped  and  removed.  When  the  region 
does  not  admit  of  a  counter-opening,  as  toward  the  base  of  the  brain,  the 
bullet  must  be  removed  through  a  single  opening.  (4)  Thorough  drainage 
may  be  instituted  by  drawing,  upon  a  long  probe,  a  few  strands  of  silk,  silk- 
worm-gut, or  rubber  drainage-tube.  (5)  The  wound  is  carefully  irrigated, 
and  then  closed  up  to  the  points  of  drainage. 

Comment. — The  bullet  may  sometimes  be  located  by  placing  the  patient 
so  that  the  bullet-track  is  vertical,  and  then  letting  the  probe  drop  into  the 
wound  as  far  as  possible.  It  may  also  sometimes  be  located  by  means  of 
x-ray  shadows  taken  in  two  directions. 


OPERATION  FOR  EXPOSURE  OF  A  MOTOR  CENTER. 

(ILLUSTRATED  BY  OPERATION  FOR  FOCAL  EPILEPSY.) 

Description. — The  operation  performed  for  Focal  Epilepsy  consists  in 
the  exposure  of  an  area  to  which  attention  has  been  called  by  convulsive 
movements  beginning  in  those  parts  controlled  by  that  area — or  in  connection 
with  which  some. injury  has  been  received — the  object  being  to  remove  the 
source  of  irritation,  which  may  be  some  form  of  pressure  or  an  adhesion,  or 
a  part  of  the  motor  center  itself  may  be  removed  to  a  limited  extent — the  area 
usually  being  exposed  by  trephining.  It  will  be  supposed,  in  the  present 
case,  that  the  epileptic  seizures  are  preceded  by  muscular  twitchings  of  the 
muscles  of  the  right  fingers,  hand  and  forearm.  The  exposure  of  the  cortical 
center  presiding  over  these  structures  will  be  indicated,  namely,  the  lower 
posterior  part  of  the  middle  third  of  the  sensori-motor  area  of  the  left  side. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554 1. 

Landmarks. — Site  of  the  motor  center  (here,  for  example,  the  center 
for  the  right  fingers,  hand  and  forearm)  is  determined  by  some  form  of  local- 
ization method  (in  this  instance,  by  Chipault's  method,  page  546). 

Incision. — An  oval  flap  (U-shaped),  with  convexity  above  and  base 
below,  is  outlined,  having  its  center  about  1  cm.  (f  inch)  posterior  to  the 
junction  of  the  lower  third  and  fourth  tenths  of  Chipault's  rolandic  line 
(see  Chipault's  method).  For  the  bone-section,  a  trephine  of  at  least  3.8, 
cm.  (ij  inches)  should  be  used. 

Operation. — (1)  The  steps  of  the  operation,  up  to  the  removal  of  the 
button  of  bone,  are  the  same  as  for  trephining.  (2)  Open  the  aura  in  the 
form  of  a  small  flap,  as  heretofore  described.  As  soon  as  the  brain  is  exposed 
carefully  examine  for  abnormal  adhesions  between  dura  and  brain,  and,  if 
detected,  free  by  cautiously  sweeping  a  bent  probe  between  these  structures. 
If  bony  growths  be  found  pressing  upon  brain,  remove  them  by  bone-section. 
(3)  If  part  of  a  motor  center  is  to  be  removed,  incise  the  brain  substance 
38 


594  OPERATIONS    UPON    THE    HEAD. 

in  the  direction  of  the  commissural  fibers,  making  the  incision  carefully  with 
delicate  knife  or  scissors.  (4)  Tie  all  bleeding  meningeal  and  cerebral  vessels 
with  fine  gut — dividing  them  in  advance,  where  possible,  between  double 
ligatures.  Harm  pia  mater  as  little  as  possible,  and  replace  if  pushed  aside. 
(5)  To  avoid  readhesion,  if  previous  adhesion  existed,  or  to  avoid  new  adhe- 
sion, plates  of  very  thin  celluloid,  gold  leaf,  gutta-percha,  decalcified  bone- 
plate,  india-rubber,  etc.,  are  sometimes  placed  over  the  pia  mater.  (6)  The 
dura  is  carefully  sutured  with  fine  gut.  The  button  of  bone  is  replaced  or 
not,  according  to  the  surgeon's  judgment.  The  scalp-flap  is  sutured,  without 
drainage,  and  speedy  union  especially  sought. 


PUNCTURE  AND  DRAINAGE  OF  LATERAL  VENTRICLES. 

Description. — Puncture  of  the  lateral  ventricle  and  withdrawal  of  cerebro- 
spinal fluid  by  aspiration,  simple  drainage  by  cannula,  or  by  capillary  drainage. 
Indications;  acute  hydrocephalus  (to  withdraw  excess  of  fluid  and  relieve 
tension) ;  chronic  hydrocephalus  (to  withdraw  excess  of  fluid  and  relieve 
tension,  or  to  inject  medicated  fluid);  meningitis  (for  drainage). 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — Junction  of  the  third  and  fourth  tenths  of  Chipault's 
temporo-sphenoidal  line  represents  the  posterior  part  of  the  body  of  the 
lateral  ventricle.  (For  this,  as  well  as  for  the  descending  and  posterior 
horns,  see  Chipault's  Cranio-cerebral  Localization  Method,  page  548.) 

Incision. — An  oval  or  inverted  U-shaped  flap  with  its  center  at  the  above 
point  is  outlined.  The  bone-section  should  be  made  by  a  trephine  of  at 
least  2.5  cm.  (1  inch)  in  diameter. 

Operation. — (1)  Having  made  and  turned  down  the  flap  of  soft  parts — 
controlled  hemorrhage  by  clamps  and  ligature — applied  trephine  and  removed 
disc  of  bone — the  dura  is  exposed  and  a  small  dural  flap  turned  down.  (2) 
The  needle  of  the  aspiratory  syringe,  or  trocar  and  cannula,  is  then  thrust 
directly  into  the  substance  of  the  brain,  opposite  the  point  indicated  above, 
avoiding  all  visible  vessels — and  is  made  to  penetrate  horizontally  inward  for 
one-third  of  the  transverse  diameter  of  the  brain  itself  (as  determined  after 
subtracting  the  thickness  of  the  scalp  and  skull  of  both  sides  from  the  total 
thickness  of  the  head  on  the  line  of  puncture).  (See  Chipault's  Method,  Other 
Points  and  Lines,  page  547 .)  Through  the  needle  (or  cannula)  introduced  fluid 
is  withdrawn.  (3)  Subsequently,  before  withdrawal  of  instrument,  medicated 
fluid  may  be  injected,  if  indicated.  Where  it  is  desired  to  introduce  drain- 
age, silk,  silkworm-gut,  wick,  gauze,  or  a  drainage-tube  may  be  introduced 
through  the  cannula,  if  a  trocar  and  cannula  have  been  used — or  by  means  of 
special  forceps  alongside  an  ordinary  aspiratory  needle  before  its  withdrawal. 
(4)  If  no  drainage  be  instituted,  the  wound  is  closed  as  after  simple 
trephining.  If  drainage  be  used,  the  dura  and  soft  parts  are  only  partially 
sutured,  and  the  button  of  bone  is  either  not  returned,  or  only  a  part  of  it 
is  returned. 

Comment. — While  it  is  more  satisfactory  to  open  the  dura,  thus  exposing 
the  condition  of  the  brain  and  the  position  of  the  vessels,  yet  where  drainage 
is  not  indicated,  the  lateral  ventricles  may  be  aspirated  through  the  unopened 
dura. 


OPERATION    FOR    CEREBRAL    ABSCESS.  595 


INCISION    OF    THE    CEREBELLAR    SUBARACHNOID    SPACE    FOR 

DRAINAGE. 

PARKINS  OPERATION. 

Description. — The  exposure,  by  trephine,  of  the  membranes  in  the 
cerebellar  fossa,  followed  by  the  incision  of  the  subarachnoid  space  below 
the  tentorium  cerebelli.  Sometimes  performed  for  the  relief  of  intracranial 
pressure  by  dependent  drainage  of  the  cerebrospinal  fluid  in  acute  and  chronic 
meningitis  and  in  hydrocephalus. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — Lines  of  lateral  and  occipital  sinuses. 

Incision. — An  oval  (or  reversed  U-shaped)  flap  is  outlined,  with  con- 
vexity upward  and  base  downward  toward  the  neck,  and  its  center  over  the 
center  of  the  right  or  left  cerebellar  fossa. 

Operation. — (I)  The  incision  outlining  the  above  flap  is  carried  to  the 
bone,  the  vertical  portions  of  the  incision  passing,  at  this  site,  through  con- 
siderable thickness  of  muscular  tissue,  and  rather  free  bleeding  may  occur. 
All  vessels  are  clamped  and  tied  with  catgut.  The  flap  is  retracted  down- 
ward and  the  occipital  bone  exposed.  (2)  A  trephine  of  about  1.2  cm.  (1 
inch)  diameter  is  so  applied  as  to  be  safely  below  the  lateral  sinus,  and  safely 
to  the  outer  side  of  the  occipital  sinus,  and  away  from  the  thickness  of  the 
external  occipital  protuberance.  The  button  of  bone  thus  defined  is  removed, 
and  the  dura  exposed.  (3)  The  dura  is  seized  with  delicate  forceps  and 
incised  with  knife  or  scissors  sufficiently  to  make  a  satisfactory  opening  for 
drainage — and  the  subarachnoid  space  thus  entered.  (4)  Drainage  is  accom- 
plished by  strands  of  silk,  silkworm-gut,  wick,  gauze,  or  tubing.  (5)  The 
button  of  bone  is  not  returned.  The  wound  is  sutured  in  part,  leaving  open 
only  enough  space  for  drainage. 


OPERATION  FOR  CEREBRAL  ABSCESS. 

Description. — Intracranial  abscess  may  be  extradural  or  intracerebral. 
The  site  of  abscess  (when  not  directly  traceable  to  an  evident  cause)  is  deter- 
mined, in  conjunction  with  constitutional  symptoms,  by  local  compression 
symptoms  referable  to  the  part  of  the  brain  pressed  upon  by  the  collection 
of  pus — and  the  operation  is  done  over  that  area  determined  by  these  symp- 
toms. 

The  most  frequent  causes  of  cerebral  abscess  are  otitis  media,  first  of 
all,  and  conditions  of  suppuration  in  the  orbital  and  nasal  cavities.  Abscess 
occurs  more  frequently  on  the  right  side. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — The  site  of  abscess,  if  not  otherwise  fixed,  is  determined 
by  pressure  symptoms,  and  localized  by  known  position  of  center  pressed 
upon. 

Incision. — An  oval  (or  reversed  U-shaped)  flap  is  outlined  for  the  appli- 
cation of  a  trephine  of  about  3.8  cm.  (1^  inches)  diameter — the  center  of 
the  trephine  to  be  placed  over  the  site  determined  as  above  described.     A 


596  OPERATIONS    UPON    THE    HEAD. 

trephine-opening  will  generally  suffice,  though  an  osteoplastic  (lap  is  some- 
times raised.     (See  Comment.) 

Operation. — (1)  The  ordinary  steps  of  a  trephining  (or  the  raising  of 
an  osteoplastic  flap)  are  carried  out,  up  to  the  exposure  of  the  dura.  (2) 
If  an  abscess  be  found  between  the  cranium  and  dura,  it  is  evacuated  (pro- 
tecting the  diploe  as  much  as  possible),  irrigated,  and  loosely  packed  with 
gauze,  a  portion  of  the  gauze  serving  as  a  drain.  The  scalp-flap  is  sutured 
back  in  place  throughout  its  greater  part,  room  being  left  for  drain.  The  but- 
ton of  bone  is  usually  not  replaced — if  used  at  all,  only  a  part  of  the  button 
is  returned,  the  rest  being  bitten  off  for  drain-opening.  (3)  If  pus  be  not 
thus  found  outside  of  dura,  a  flap  of  dura  is  raised,  as  in  trephining,  and  the 
brain  exposed  and  explored  in  various  directions  with  a  needle  (see  Exploratory 
Puncture  of  the  Brain,  page  584).  Wherever  found,  especially  if  deep,  the 
needle  is  left  in  situ  and  serves  as  a  guide.  The  dura  over  the  site  is  divided 
by  a  crucial  incision  (to  provide  free  exit),  a  linear  incision  tending  to  close. 
If  dura  be  divided  before  the  presence  of  abscess  is  assured,  a  straight  inci- 
sion of  the  membrane  is  made,  admitting  of  subsequent  suture  if  indicated. 
Before  freeing  the  pus,  the  cut  diploe  should  be  protected  from  infection  as 
well  as  possible,  by  a  strip  of  thin  rubber  tissue,  or  by  smearing  the  bone- 
section  with  sterile  vaseline.  The  abscess  cavity  may  be  cut  into  by  a  punc- 
ture-like thrust  of  a  knife — or,  probably  better,  a  pair  of  special  forceps 
(or  ordinary  dressing  forceps)  may  be  inserted  closed,  guided  by  the  needle 
left  in  situ,  and  then  opened  to  a  limited  extent,  allowing  the  pus  to  drain 
along  the  handles,  or  a  grooved  director  may  be  used.  Two  parallel  pieces 
of  small-calibered  rubber  drainage-tubes  are  then  inserted,  one  serving  for 
inflow  of  irrigant,  the  other  for  the  outflow  of  pus — the  tubes  being  held 
in  place  by  transfixing  them  with  a  safety-pin  resting  upon  the  gauze  which 
has  been  packed  around  them.  (4)  The  dural  and  scalp  flaps  are  partly 
sutured  into  place,  leaving  room  for  drainage. 

Comment. — As  the  most  general  cause  of  cerebral  abscess  is  otitis  media, 
the  most  usual  site  for  the  abscess  is  in  the  temporo-sphenoidal  lobe,  in  the 
middle  fossa  of  the  skull,  adjacent  to  the  antero-superior  aspect  of  the  petrous 
portion  of  the  temporal  bone — and  the  landmark  for  the  operation  is,  there- 
fore, generally  taken  as  a  point  1.8  to  2.5  cm.  (f  to  1  inch)  above  Reid's 
base-line  (see  Reid's  Method  of  Cranio-cerebral  Localization,  page  551, 
also  Fig.  415,  S),  on  a  line  drawn  vertically  upward  along  the  posterior  border 
of  the  external  auditory  meatus,  at  right  angle  to  the  base-line — and  this 
point  is  used  as  the  point  at  which  first  to  explore,  where  uncertainty  exists. 
This  site  having  been  exposed,  if  evidence  of  pus  be  not  found,  explore  with 
needle,  of  fair  calibre,  and  preferably  first  through  the  unopened  dura — 
first  inward,  forward,  and  downward  toward  the  apex  of  the  petrous  por- 
tion of  the  temporal — then  upward  and  forward,  and  backward  and  inward, 
and  in  other  directions — but  guarding  the  basal  ganglia  and  the  petrosal 
sinuses.     When  pus  is  located,  the  dura  is  always  incised. 


OPERATION  FOR  CEREBELLAR  ABSCESS. 

Description. — Like  cerebral  abscess,  cerebellar  abscess  may  be  extra- 
dural or  intracerebellar.  As  the  cause  of  abscess  is  generally,  as  in  the  case 
of  the  cerebrum,  otitis  media,  the  abscess  is  usually  found  in  the  vicinity 


OPERATION    FOR    CEREBRAL    TUMOR.  592 

of  the  posterior  or  postero-superior  aspect  of  the  petrous  portion  of  the 
temporal  bone.     The  site  is  usually  exposed  by  a  trephine-opening. 

Preparation  and  Position. — See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks. — The  external  auditory  meatus  and  the  lines  of  the  sigmoid 
and  transverse  portions  of  the  lateral  sinus. 

Incision. — Draw  a  line  from  the  external  occipital  protuberance  to  the 
center  of  the  external  auditory  meatus.  To  allow  for  an  unusually  low  trans- 
verse portion  of  lateral  sinus,  trephine  1  cm.  (fy-  inch)  below  this  line.  And 
to  avoid  the  sigmoid  portion  of  the  lateral  sinus,  and  also  the  occipital  artery 
trephine  posterior  to  a  vertical  line  placed  3.5  cm.  (if  inches)  behind  the 
center  of  the  external  auditory  meatus.  Outline  an  oval  (or  reversed  U- 
shaped)  flap  with  its  center  calculated  to  be  over  the  center  of  the  above 
indicated  area — the  limbs  of  the  incision  running  well  into  the  neck,  as 
the  occipital  fossa  is  to  be  opened  below  the  nuchal  furrow. 

Operation. — (1)  Carry  the  incision  outlining  the  flap  to  the  bone — 
control  hemorrhage,  which  is  apt  to  be  marked,  by  clamp  and  ligature. 
Retract  this  thick  muscular  flap  downward,  exposing  the  occipital  bone 
below  the  superior  curved  line.  (2)  Apply,  in  the  site  indicated  under 
Incision,  a  trephine  of  at  least  2.5  cm.  (1  inch)  diameter  and  remove  the 
button  of  bone,  exposing  the  cerebellar  dura.  (3)  The  abscess  is  now  sought 
in  a  direction  forward,  upward,  and  outward;  or  forward,  upward,  and 
inward,  in  the  same  general  manner  as  in  cerebral  abscess — and,  if  found, 
dealt  with  in  the  same  fashion — and  the  wound  finally  similarly  treated. 

Comment. — Cerebellar  abscess  is  often  encountered,  when  it  exists,  in 
the  course  of  an  operation  upon  the  mastoid  region — during  an  operation 
where  the  inner  wall  of  the  mastoid  process  has  been  exposed  and  removed, 
laving  bare  the  lateral  sinus  and  the  dura  anterior  and  posterior  to  it.  Where 
the  abscess  follows  disease  of  the  inner  mastoid  wall,  it  generally  lies  behind 
the  lateral  sinus  and  in  contact  with  the  involved  bone.  Where  the  abscess 
is  connected  with  involvement  of  the  labyrinth,  it  lies  in  front  of  the  lateral 
sinus  and  in  connection  with  the  internal  meatus  or  vestibular  aqueduct. 
A  fistula  generally  leads  from  the  diseased  bone  to  the  abscess. 


OPERATION  FOR  CEREBRAL  TUMOR. 

Description. — Removal,  en  masse,  of  growths  from  surface  or  interior 
of  brain.  Those  involving  the  basal  ganglia,  internal  capsule,  and  base  of 
brain  generallv,  are  inoperable. 

Preparation  and  Position.— See  General  Surgical  Considerations  in 
Cranio-cerebral  Operations  (page  554). 

Landmarks.— Site  of  tumor  will  have  been  determined  by  localization 
symptoms — and  site  of  operation  determined  accordingly. 

Incision. — Amount  of  room  required  for  recognition  and  removal  of 
tumor  generallv  necessitates  an  osteoplastic  resection  of  the  skull,  which 
should  be  planned  with  reference  to  the  particular  case.  Or  the  overlying 
bone  may  be  totally  and  permanently  removed  by  making  several  small 
trephine-openings  and  connecting  these — or  a  large  trephine  may  be  first 
used  and  the  margins  of  the  resulting  opening  bitten  out  with  rongeurs  as 
far  as  necessarv— in  either  of  which  cases  a  horseshoe  flap  of  soft  parts  is 
temporarily  turned  down  and  then  replaced. 


59§ 


OPERATIONS    UPON    THE    HEAD. 


Operation. — (i)  The  steps  of  the  operation,  up  to  the  exposure  of  the 
dura,  are  the  same  as  for  osteoplastic  resection  of  the  skull,  hemorrhage 
being  controlled  as  during  that  operation.  (2)  The  dural  flap  is  turned 
back  as  in  osteoplastic  resection.  The  pia  mater  is  divided  in  the  direction 
of  the  length  of  the  tumor — hemorrhage  from  the  pia  being  controlled  by 
slight  tension  upon  it  or  by  ligature  en  masse.     (3)  The  situation  and  extent 


Fig.  477. — Removal  of  a  Cerebral  Tumor  through  an  Osteoplastic  Exposure: — 
The  outlying  area  has  been  previously  ligatured  off  by  the  needle  and  ligature  seen  dipping  deeply 
beneath  a  cerebral  vessel  into  the  brain  substance.  The  tumor  is  shown  partly  separated  by  a 
special  spoon. 


of  the  tumor  are  now  determined  by  palpation  and  exploration.  (4)  Having 
reasonably  settled  both  of  these  questions,  the  tumor  is  to  be  excised.  The 
incision  into  the  brain  substance  is  begun,  where  possible,  at  the  apex  of  a 
convolution  and  is  made  in  the  direction  of  its  commissural  fibers — and 
rather  over  a  convolution  than  over  a  sulcus,  as  there  is  less  hemorrhage. 
A  special  spoon  may  also  be  used  (Fig.  477).     If  the  tumor  be  encapsulated, 


OPERATIONS    UPON   THE    GASSERIAN    GANGLION.  599 

divide  the  overlying  brain  and  gently  retract  the  cerebral  substance,  cutting 
from  above  downward,  and  enucleate  with  a  spoon.  If  the  tumor  lie  beneath 
the  surface  but  not  encapsulated,  isolate  by  carefully  incising  its  connections 
and  enucleating  with  such  an  instrument  as  the  curved  handle  of  a  thin  silver 
spoon.  Cystic  tumors  sometimes  only  admit  of  draining,  cauterizing,  and 
packing.  (5)  The  cavity  left  is  lightly  packed  with  gauze  if  bleeding  occurs. 
Where  possible,  the  brain  incision  is  closed  with  catgut,  with  or  without  drain- 
age, as  indicated.  The  dura  is  sutured.  Celluloid  or  metallic  plates  are  some- 
times used  to  reinforce  the  opening.  The  osteoplastic  flap  or  flap  of  soft 
parts,  according  to  method  of  exposure  used,  is  sutured  into  place,  as  in  the 
osteoplastic  resection  or  trephining  operation  respectively. 

Comment. — If  working  in  the  motor  area,  use  of  the  faradic  electrode 
mav  corroborate  diagnosis. 


OPERATION  FOR  CEREBELLAR  TUMOR. 

Description. — The  operation  is  similar  to  that  for  cerebral  tumor,  in 
essential  details — with  the  following  modifications  (chiefly  from  the  greater 
inaccessibility  of  the  cerebellum) : — (a)  A  horseshoe  flap  of  soft  parts  alone 
may  be  used,  with  its  base  toward  the  neck — or  an  osteoplastic  flap  may  be 
raised: — (b)  In  the  former  case,  the  opening  in  the  bone  is  made  with  a 
trephine  of  as  large  a  diameter  as  feasible,  and  is  enlarged,  if  necessary,  by 
biting  out  its  circumference  with  rongeurs.  Thinness  of  the  occipital  fossa^; 
nearness  of  the  sinuses  of  the  occipital  bone  and  proximity  of  the  foramen 
magnum  require  especial  care,  and  make  the  osteoplastic  method  especially 
difficult. 


OPERATIONS  UPON  THE  MASTOID  ANTRUM  AND  CELLS. 

See  under  Operations  upon  the  Bony  (Air)  Sinuses  of  Head   and  Face 
(page  600). 


OPERATIONS  UPON  THE  GASSERIAN  GANGLION. 

See   under  Operations  upon  the    Nerves,  Plexuses,  and  Ganglia  (pages 
175  and  181). 


6oo 


OPERATIONS  UPON  THE  HEAD. 


II.  THE  BONY  (AIR)  SINUSES  OF  THE  HEAD  AND  FACE.* 

OPERATIONS  UPON  THE  MASTOID  ANTRUM  AND  CELLS. 

SURGICAL    ANATOMY  OF  MASTOID  ANTRUM  AND    CELLS. 

Muscles  of  the  Mastoid  Region. — Retrahens  aurem;  occipitofrontalis; 
sternomastoid;  splenius  capitis;  trachelomastoid ;  digastric. 


Fig. 478.— Surgical  Anatomy  of  Middle  Ear  and  Mastoid  Region  :— With  membrana  tym- 
pani  removed  and  four  windows  chiseled  into  mastoid  process  :  A,  Pinna  of  ear  stitched  to  cheek  ;  B, 
Curved  incision  of  exposure,  back  of  ear ;  C,  Soft  external  auditory  canal;  D,  Temporal  fascia  ;  E, 
Mastoid  cells  ;  F,  Mastoid  antrum  ;  G,  Lateral  sinus  ;  H,  Suprameatal  spine  ;  I,  Bony  plate  covering 
facial  nerve  ;  J,  Promontory  and  fenestrum  rotundum  ;  K,  Malleus  ;  L,  Incus  ;  M,  Stapedius  muscle  ; 
N,  Tensor  tympani  muscle  ;  O,  Chorda  tympani  nerve.  (From  drawing  made  from  cadaver,  in  De- 
partment of  Operative  Surgery,  College  of  Physicians  and  Surgeons,  by  Dr.  A.  E.  Schmitt.) 


Arteries  of  the  Mastoid  Region. — Posterior  auricular  and  occipital 
branches  of  external  carotid. 

Veins  of  the  Mastoid  Region. — Posterior  auricular  (emptying  into 
temporomaxillary  vein);  occipital  (emptying  into  internal  jugular). 

*  Among  the  Bony  (Air)  Sinuses  of  the  Head  and  Face,  will  be  considered  the  Mastoid 
Antrum  and  Cells,  the  Frontal  Sinus  and  the  Maxillary  Sinus — the  Ethmoidal  and  Sphe- 
noidal Sinuses  more  properly  belonging  to  the  special  surgery  of  the  Nose. 


SURGICAL  ANATOMY  OF  MASTOID  ANTRUM  AND  CELLS. 


601 


Nerves  of  the  Mastoid  Region. — Posterior  auricular  branch  of  facial; 
auricularis  magnus  from  cervical  plexus;  occipitalis  minor  from  cervical 
plexus;  auricular  branch  of  occipitalis  major;  external  branch  of  posterior 
division  of  second  cervical  nerve. 

Mastoid  Antrum. — A  retort-shaped  cavity  situated  in  mastoid  portion 
of  temporal  bone,  communicating  with  mastoid  cells  posteriorlv,  and  opening, 
anteriorly,  through  aditus  ad  antrum,  into  highest  part  of  tvmpanic  cavity, 
the  epitympanic  recess  (attic  of  tympanum),  thereby  communicating  with 
eustachian  tube.  The  epitympanic  recess  lies  above  the  anterior  three- 
fourths  of  the  orifice  of  the  opening  of  the  antrum  into  tvmpanic  cavity. 
The  floor  of  antrum  lies  below  the  level  of  the  entrance  into  antrum,  generally 


Fig.  479—  Surgical  Anatomy  of  Mastoid  Region  and  Middle  Ear  :— With  membrana  tym- 
pani  removed  ;  mastoid  cells,  mastoid  antrum,  and  lateral  sinus  exposed  ;  and  trephine  disc  removed 
just  above  temporal  crest  and  ear  ;  A,  Soft  auditory  canal  in  turned-back  ear  ;  B,  Temporal  muscle; 
C,  Temporal  crest ;  D,  Horizontal  semicircular  canal  ;  E,  Promontory  ;  F,  Fenestrum  rotundum ;  G, 
Stapes;  H,  Facial  nerve;  I,  Mastoid  cells  ;  J,  Arrow  passing  from  attic  to  antrum,  along  aditus  ad 
antrum;  K,  Trephine-opening  exposing  posterior  branch  of  middle  meningeal  artery;  L,  Horizontal 
limb  of  lateral  sinus  ;  M,  Descending  limb  of  lateral  sinus  ;  N,  Beginning  of  internal  limb  of  lateral 
sinus  ;  O,  Opening  of  opposite  lateral  siuns  ;  P,  Opening  of  longitudinal  sinus  ;  Q,  Opening  of  superior 
petrosal  sinus  ;  R.  Mastoid  foramen.  (  From  drawing  made  from  cadaver,  in  Department  of  Operative 
Surgery.  College  oi  Physicians  and  Surgeons,  by  Dr.  A.  E.  Schmitt.) 


corresponding  with  level  of  center  of  auditory  meatus,  or  even  higher.  The 
communication  between  antrum  and  epitympanic  recess  is  triangular  in 
shape,  with  base  upward  and  rounded  angle  below;  its  lower  portion  being 
on  level  with  superior  wall  of  external  auditory  meatus;  its  measurement 
being  about  4  mm.  (T\  inch)  both  transversely  and  vertically.  The  antrum 
lies  from  7  to  14  mm.  (y\-  to  ^g-  inch)  from  surface  of  mastoid  bone;  and 
from  7  to  12  mm.  (T\  to  T8g  inch)  behind  superior  posterior  margin  of  tympanic 
ring — the  outer  portion  of  overlying  bone  being  hard,  the  inner  portion  more 
spongy.  The  antrum  measures,  longitudinally,  10  to  15  mm.  (T6g  to  Tf  inch) ; 
vertically,  10  mm.  (y6^  inch);  transversely,  4  to  6  mm.  (f\  to  T\  inch).  In 
infancy  and  childhood  the  antrum  is  nearly  full  size,  but  the  mastoid  cells 
rarely  develop  before  twelve  years  of  age.  The  overlying  bone  is  relatively 
thin  in  the  young. 


602 


OPERATIONS  UPON  THE   HEAD. 


Mastoid  Cells. — Situated  within  mastoid  process  of  temporal  bone; 
opening,  anteriorly,  into  mastoid  antrum;  and  extending,  postero-inferiorly, 
sometimes  to  tip  of  mastoid  process. 

Relations  of  Mastoid  Antrum. — (I)  Superiorly;  antrum  is  separated 
from  middle  cranial  fossa  of  skull  by  a  thin,  bony  plate,  the  tegmen  tympani, 
sometimes  partially  deficient,  a  fibrous  membrane  and  vascular  tissue  then 
intervening.  Roof  of  antrum  generally  corresponds  to  supramastoid  crest, 
though  sometimes  being  upon  a  higher  level  than  crest,  in  which  latter  cases 
the  inferior  temporal  convolution  of  the  cerebral  hemisphere  may  overlap 
upper  part  of  antrum.  (2)  Inferiorly;  floor  of  antrum  is  formed  by  mastoid 
portion  of  petrosal  bone.  (3)  Anteriorly;  a  thin  wall  of  bone  comes  between 
antrum  and  deep  portion  of  auditory  meatus.  (4)  Posteriorly,  extends 
backward  and  outward,  lying  nearer  surface  posteriorly  than  anteriorly, 
approaching  sigmoid  portion  of  lateral  sinus,  sometimes  but  a  thin  bony 
lamina  intervening,  though  distance  between  the  two  generally  averaging 
5  to  10  mm.  (T3g-  to  j's  inch)  and  usually  consisting  of  mastoid  cells;  the  lateral 
sinus  ordinarily  lying  nearer  the  surface  than  the  antrum.  (5)  Externally; 
outer  wall  is  formed  by  squamous  portion  of  temporal  below  supramastoid 
crest.     (Figs.  478  and  479.) 


Fig.  480. — Incision  for  Exposing  the  Antrum  and  Mastoid  Cells  and  the  Neighbor- 
ing Intracranial  Structures: — B  D,  Incision  for  exposing  mastoid  antrum  and  cells  (antrum 
operation  of  Schwartze);  B  A  and  B  E,  Incisions  for  exposing  brain  abscess;  C  F,  Incisions  for 
exposing  lateral  sinus;  G  H,  Incision  for  tympano-mastoid  exenteration  (radical  operation  of 
Schvvartze-Stacke);  L,  Auricle  drawn  forward;  I,  Suprameatal  crest;  J,  Suprameatal  spine; 
K,  Position  of  mastoid  antrum;  M,  Lateral  sinus;  N,  Occipital  artery. 


SURFACE   FORM   AND   LANDMARKS   OF   MASTOID   ANTRUM   AND 

CELLS. 

External  auditory  meatus — varying  in  shape,  size,  and  in  the  direction 
of  its  longest  diameter.  Separated  from  mastoid  process  by  the  concha 
of  the  ear. 

External  auditory  canal — corresponds  with  general  direction  of  approach 
to  antrum  through  mastoid  process. 

Mastoid  process  of  temporal  bone — contour  generally  capable  of  being 
outlined  through  the  skin. 


SURGICAL    CONSIDERATIONS    IN    MASTOID    OPERATIONS.  603 

Supramastoid  crest  (linea  temporalis) — continuation  of  zygomatic  ridge 
backward. 

Suprameatal  triangle — site  of  approach  to  mastoid  antrum;  having  follow- 
ing boundaries;  Superiorly,  supramastoid  crest;  Inferiorly  and  Anteriorly, 
outer  margin  of  posterior  superior  quadrant  of  bony  external  auditory  meatus; 
Posteriorly,  vertical  line  drawn  upward  along  most  posterior  margin  of  bony 
external  auditory  meatus.     (Fig.  480.) 

Suprameatal  fossa  (fossa  mastoidea) — depression  in  upper  posterior  angle 
of  suprameatal  triangle. 

Suprameatal  spine — crest  of  bone  separating  suprameatal  fossa  from 
external  auditory  meatus. 

Suprameatal  line — line  continuing  level  of  suprameatal  spine  backward. 

Remains  of  masto-squamosal  suture — sometimes  exists,  with  small  canals 
occupied  by  connective  tissue  and  veins. 


GENERAL  SURGICAL  CONSIDERATIONS  IN  OPERATIONS  UPON  MAS- 
TOID ANTRUM  AND  CELLS. 

Site  and  Direction  of  Operation  for  Opening  Antrum. — (i)  Site  lies 
in  suprameatal  fossa,  directly  within  suprameatal  triangle,  or  immediately 
behind  it.  This  generally  brings  upper  edge  of  opening  about  3  mm.  (y% 
inch)  below  suprameatal  line,  and  about  5  mm.  (T3g-  inch)  behind  bony  external 
auditory  meatus.  (2)  Direction  of  opening  passes  inward  and  slightly  upward 
and  forward,  following  general  direction  of  bony  external  auditory  canal. 
This  will  open  into  anterior  part  of  antrum,  at  distance  of  from  7  to  14  mm. 
(tV  t°  tV  inch)  (extremes,  especially  in  disease,  from  3  to  18  mm.,  or  -f^  to  Cl- 
inch) from  surface  of  mastoid  process. 

General  Precautions  in  Operating. — (i)  Keep  below  supramastoid 
crest — to  avoid  middle  cerebral  fossa  of  skull.  Middle  cranial  fossa  some- 
times dips  down  to  quite  a  low  level  between  petrous  and  squamous  portions 
of  temporal  bone,  and  the  roof  of  antrum  and  tympanum  form  part  of  floor 
of  this  fossa.  The  level  of  floor  of  fossa  may  vary  as  much  as  2  cm.  (-^-f  inch) 
but  is  never  as  much  as  1  cm.  (f^  inch)  below  supramastoid  crest.  Where 
supramastoid  crest  cannot  be  felt,  keep  3  mm.  (T2g-  inch)  below  horizontal 
line  running  backward  from  upper  edge  of  bony  external  auditory  meatus, 
in  order  to  avoid  middle  fossa.  To  further  avoid  the  possibility  of  entering 
middle  cranial  fossa,  make  opening  at  first  directly  inward,  penetrating  from 
5  to  8  mm.  (y3g-  to  j\  inch)  before  taking  an  upward  direction.  (2)  Do  not 
go  more  than  2  mm.  (between  TV  and  T2g-  inch)  behind  posterior  limit  of 
suprameatal  triangle — to  avoid  lateral  sinus.  (3)  Check  instrument  as  soon 
as  antrum  is  entered — to  avoid  external  semicircular  canal  and  facial  nerve. 

Special  Structures  to  be  Avoided. — (i)  At  inferior  aspect  of  entrance 
into  antrum,  inner  wall  of  antrum  bulges  slightly  over  external  semicircular 
canal,  which  lies  on  median  side  of  aditus,  superior  to  and  separated  from 
fallopian  canal  by  thin  lamina  of  bone.  It  may  form  the  antero-median 
wall  of  antrum,  if  it  project  backward.  To  avoid  injury  to  external  semi- 
circular canal,  check  instrument  as  soon  as  cavity  of  antrum  is  reached. 
The  inner  wall  of  antrum  lies  about  17  to  20  mm.  (y^-  to  T§  inch)  from  surface 
of  mastoid.  (2)  On  inner  side  of  epitympanic  recess,  inferiorly  and  anteriorly 
to  the  bulging  marking  external  semicircular  canal,  is  the  arching  osseous 


604  OPERATIONS    UPON    THE    HEAD. 

canal  of  the  facial  nerve.  The  wall  toward  antrum  is  thin  and  partly  wanting. 
Avoid  facial  nerve  by  not  directing  the  opening  too  far  forward.  The  per- 
pendicular portion  of  fallopian  canal,  with  contained  nerve,  may  be  3  mm. 
(A-  inch)  internal  to  posterior  periphery  of  ear-drum,  or  its  position  may  be 
almost  immediately  opposite  this  posterior  periphery.  (3)  Between  external 
semicircular  canal  anteriorly,  and  lateral  sinus  posteriorly,  the  air-cells  are 
separated  from  posterior  fossa  of  skull  by  bony  wall  from  1  to  9  mm.  (from 
less  than  yg-  to  T6g-  inch)  thick.  (4)  Extreme  curvature  of  sigmoid  portion 
of  lateral  sinus  may  occur.  'Where  this  exists,  the  sigmoid  sinus  may  be  in 
almost  direct  contact  with  outer  cortex  of  mastoid,  and  it  may  come  to  within 
3  mm.  (3%  inch)  of  posterior  wall  of  bony  auditory  meatus.  As  its  course 
cannot  be  known  in  advance,  it  is  best  avoided  by  careful  use  of  gouge  or 
chisel  (which  are  preferable  to  all  instruments  which  approach  by  boring 
their  way). 

Manner  of  Making  Bone-section. — Bone  is  divided  either  by  chisels 
and  mallet,  aided  by  hand  gouges  and  curettes;  or  by  a  burr  driven  by  an 
engine  or  worked  by  hand,  followed  by  use  of  gouges  and  curettes. 


INSTRUMENTS. 

(i)  For  incision  and  repair  of  soft  parts,  see  instruments  used  in  cranio- 
cerebral operations  (page  557).  (2)  Special  instruments  used  upon  mastoid 
process,  auditory  canal,  and  tympanic  cavity,  are  the  following:  small  mallet; 
chisels;  gouges;  guard  for  gouge;  scoops;  curettes;  elevators;  small  trephine; 
forceps;  burr  driven  by  hand  or  by  engine;  bradawl;  two  or  three  centi- 
meters of  a  metallic  millimeter  measure.  (3)  Special  instruments  for  intra- 
tympanic  work;  straight  and  angled  knives;  tenotomy  knives;  synechia  knives; 
ear-drum  knives;  incus  hooks;  fine  forceps. 


OPERATION  FOR  EXPOSING  MASTOID  ANTRUM  AND  CELLS. 

ANTRUM  OPERATION  OF  SCHWARTZE. 

Description. — In  this  operation  only  the  antrum  and  cells  of  the  mastoid 
process  are  opened  up,  without  invading  the  cavity  of  the  tympanum.  Indi- 
cated in  such  conditions  as  empyema,  osteitis,  or  osteomyelitis  occurring  in 
the  mastoid  process  alone.  In  the  following  account  the  description  of  J. 
Orne  Green  is  largely  followed.     (See  Fig.  481.) 

Preparation. — The  ear  is  irrigated  with  antiseptic  solution  and  packed 
with  sterile  cotton.  The  hair  of  the  neighborhood  is  shaved,  and  the  head 
and  neck  enveloped  in  sterile  dressings. 

Position. — Patient  rests  upon  side,  with  head  elevated  and  so  placed 
upon  its  opposite  side  as  to  make  mastoid  region  prominent,  resting  upon  a 
firm  cushion  to  prevent  jarring.  Surgeon  stands  behind  patient.  Assistant 
stands  opposite  and  to  one  side  of  surgeon. 

Landmarks. — External  auditory  meatus;  supramastoid  crest;  mastoid 
process. 

Incision. — Slightly  curvilinear,  placed  behind  ear — beginning  1  cm. 
(Tfig-  inch)  above  level  of  upper  edge  of  auditory  meatus  and  passing  down- 
ward at  a  distance  of  0.5  to  1  cm.  (yg-  to  T6T  inch)  behind  insertion  of  auricle, 
and  ending  at  tip  of  mastoid  process.     (See  Fig.  480,  B,  D.j 


ANTRIM  OPERATION  OF  SCHWARTZE. 


6o  = 


Operation. — (1)  Incision  passes  through  skin,  overlying  muscles,  and  peri- 
osteum directly  to  bone  (Fig.  481).  (2)  The  soft  parts  are  elevated  from  the 
bone  with  periosteal  elevator — anteriorly,  until  the  supra meatal  spine  is  ex- 
posed— posteriorly,  until  the  mastoid  process  is  bared.  (3)  From  the  supra- 
meatal  spine,  draw  a  line  horizontally  backward.  Make  an  opening  with  its 
upper  edge  3  mm.  (y2^  inch)  below  this  suprameatal  line,  and  its  anterior  edge 
5  mm.  (y3^  inch)  behind  the  auditory  meatus — which  position  will  correspond 
with  the  suprameatal  fossa  (fossa  mastoidea)  when  that  depression  is  suffi- 
ciently marked  for  recognition.  The  area  of  operation,  bounded  as  above, 
will  extend  over  a  surface  7  to  10  mm.  (T4(T  to  T6-g  inch)  in  diameter.     (4)  By 


Fig. 48 1.— Exposure  of  Mastoid  Antrum  and  Cells  (Operation  of  Schwaktze  j:— A,  Auricle 
drawn  forward  ;  B,  Mastoid  antrum;  C,  Mastoid  Cells ;  D,  Periosteum  drawn  aside;  E,  Sternomas- 
toid  muscle  ;  F,  Temporal  muscle  ;  G,  Posterior  branch  of  posterior  auricular  artery. 


means  of  gouge  and  mallet  the  bone  is  removed  in  thin  chips,  always  keeping 
the  process  of  excavation  in  a  line  parallel  with  the  auditory  canal.  The 
amount  of  bone  to  be  removed  varies  from  a  thin  lamina  up  to  1  cm.  (j^  inch) 
before  the  mastoid  cells  are  reached.  (5)  As  soon  as  the  air-cells  are  opened, 
explore  with  probe — upward,  to  locate  the  roof  of  the  mastoid — inward  and 
backward,  to  locate  the  posterior  fossa  of  the  skull.  (6)  Break  down  the 
intervening  wall  between  the  cells,  working  directly  inward  for  5  to  8  mm. 
(f(T  to  y%  inch).  Thence  work  in  a  slightly  upward  and  forward  direction, 
with  curette,  until  the  antrum  is  reached,  at  a  distance  from  the  surface  of 
7  to  14  mm.  (y4^-  to  y9^-  inch).  The  excavation  should  not  extend  beyond  14 
or  15  mm.  (y9-^  or  T¥  inch)  from  the  surface,  which  is  as  far  as  it  is  safe  to 
go.  (7)  Carious  bone  should  be  removed  wherever  found,  even  if  it  be  neces- 
sary to  expose  the  dura — and  whether  the  roof  of  the  mastoid  lie  imme- 
diately beneath  the  cerebrum;  or  the  inner  wall,  with  the  lateral  sinus  and 
cerebellum,  lie   just  to  the  inner  side.     The  dura   is   displaced  with  a  dural 


606  OPERATIONS  UPON  THE  HEAD. 

separator  and  the  bone  is  removed  with  a  curette.  (8)  The  interior  of  the 
mastoid  process  must  be  dealt  with  according  to  indications.  Pus  should 
be  evacuated — granulations  removed  and  cell-walls  broken  down.  In  in- 
flamed diploe,  the  cancellated  structure  should  be  curetted  away.  In  osteitis, 
curette  away  softened  bone  short  of  harming  the  labyrinth  and  facial  nerve. 
The  entire  external  aspect  of  the  mastoid  process  may  be  removed  to  the  tip 
of  the  process.  (9)  In  completing  the  operation,  pack  the  cavity  left  in  the 
mastoid  with  gauze.  Suture  the  periosteum  partially,  and  the  soft  parts  also 
in  part,  leaving  room  for  drainage. 

Comment. — (i)  Where  the  interior  of  the  mastoid  is  partly  or  wholly 
diploetic,  proceed  with  greater  care,  using  curette  or  hand  gouge.  Pass 
directly  inward  parallel  with  auditory  canal,  for  5  to  8  mm.  (T\  to  ^g-  inch) — 
if  no  air-cells  are  reached  by  this  time,  pass  slightly  forward,  upward  and 
inward  to  the  antrum — but  do  not  go  beyond  15  mm.  (T\-  inch)  from  the 
external  surface  of  the  anterior  edge  of  the  osseous  opening,  lest  the  facial 
nerve  or  horizontal  semicircular  canal  be  injured.  (2)  In  a  mastoid  affected 
with  osteosclerosis  (from  long  suppuration  or  previous  disease)  the  usual 
landmarks,  gotten  with  a  probe  as  one  advances,  are  not  so  available.  Proceed 
carefully  in  the  same  directions  and  for  the  same  distances  as  in  the  diploetic 
tissue  just  mentioned,  but  working  with  a  chisel  and  mallet,  instead  of  a 
hand  gouge.  Diploetic  bone  may  be  met  after  passing  through  7  to  10  mm. 
(tit  t0  tt  mch)  of  sclerosed  bone.  Sometimes,  though  rarely,  the  antrum  may 
be  obliterated  by  osteosclerosis.  (3)  Where  fistula?  exist,  these  should  be 
exposed  and  followed  up,  rather  than  to  make  another  opening  through 
healthy  bone;  or  the  fistulous  tracks  may  be  used  in  conjunction  with  the 
ordinary  opening.  An  externally  placed  fistula  is  exposed  by  reflecting  the 
periosteum  from  the  external  surface  of  the  mastoid  process.  An  anteriorly 
placed  fistula  is  exposed  by  reflecting  the  periosteum  from  the  posterior  wall 
of  the  auditory  canal.  An  inferiorly  placed  fistula  is  exposed  by  reflecting 
the  periosteum  from  the  tip  of  the  mastoid  process,  toward  the  digastric 
groove. 


OPERATION    FOR    EXPOSING    MASTOID    ANTRUM    AND    CELLS,    TO- 
GETHER WITH  INTERIOR  OF  TYMPANUM  AND  MEATUS, 
AND  THE  EXENTERATION  OF  THE  MIDDLE- 
EAR  CAVITIES. 

THE  TYMPANOMASTOID  EXENTERATION,  OR  RADICAL  OPERATION,  OF 
SCHWARTZE-STACKE  (OR  SCHWARTZE-ZAUFAL). 

Description. — This  operation,  much  more  extensive  than  the  last,  con- 
sists in  the  opening  up  of  the  mastoid  antrum,  mastoid  cells,  tympanum,  and 
meatus,  and  of  the  complete  exenteration  (evisceration)  of  the  middle-ear 
cavities.  The  whole  interior  of  the  mastoid  antrum,  aditus,  epitympanum, 
tympanum,  and  meatus  are  thereby  converted  into  a  single  large  and  continu- 
ous cavity — the  smooth  walls  of  which  are  made  to  heal  throughout  by  epider- 
mization — the  epidermis  growing  in  from  the  meatus  and  the  edges  of  the 
wound.  Indicated  in  empyema,  osteitis  or  osteomyelitis  of  mastoid  process 
occurring  in  connection  with  osteitis  of  the  aditus,  epitympanum,  tympanum, 
and  meatus;  and  also  in  cholesteatomatous  collections  in  those  parts.  In 
the  following  account  the  description  of  J.  Orne  Green  is  largely  followed. 

Preparation — Position — Landmarks. — Same  as  in  the  Antrum  Opera- 
tion (page  604). 


TYMPANO-MASTOID  EXENTERATION.  607 

Incisions  and  Operation. — 

A.  Formation  of  Skin-flap  and  Periosteal  Flap,  and  exposure  of  Operation 
Site: — -(i)  Skin-flap — incision  begins  3  mm.  (T2g-  inch)  above  the  anterior 
superior  insertion  of  the  auricle — passes  downward  about  3  mm.  (y\  inch), 
posterior  to  and  parallel  with  the  auricle,  to  the  tip  of  the  mastoid  process — 
thence  about  12  mm.  (yg-  inch)  backward — thence  upward  and  slightly 
backward  over  the  posterior  aspect  of  the  mastoid  to  its  upper  part.  (See 
Fig.  480,  B.)  The  skin  over  this  triangle  is  dissected  off  from  the  remaining 
soft  parts  and  displaced  upward.  (2)  Partial  separation  of  auricle — dissect 
off  the  auricle,  without  the  periosteum,  up  to  the  postero-superior  margin  of 
the  meatus  and  displace  it  forward.  (3)  Periosteal  Flap — incise  horizontally- 
backward  through  the  periosteum  to  bone  along  the  supramastoid  crest,  from 
near  the  meatus  to  the  upper  end  of  the  posterior  skin  incision — and  also 
perpendicularly  downward  near  to  meatus.  Displace  downward  the  triangular 
flap  of  periosteum  thus  made. 

Sometimes  this  order  of  raising  the  flaps  is  reversed,  the  skin-flap  being 
turned  downward  and  the  periosteal  flap  upward.  Hemorrhage  is  controlled 
as  encountered. 

B.  Extirpation  of  lining  of  Superior  and  Posterior  aspects  of  Osseous 
Auditorv  Meatus — (1)  Detach  the  cartilaginous  meatus  from  the  osseous 
meatus,  with  periosteal  elevator,  along  its  superior  and  posterior  aspects  and 
displace  it  forward  and  downward  with  the  auricle.  (2)  Incise  the  lining 
of  the  meatus  along  the  antero-superior  and  postero-inferior  walls,  beginning 
at  the  drum-membrane  and  ending  at  the  free  margin — dicsarding  the  excised 
triangular  portion  of  periosteum. 

C.  Exposure  of  Antrum,  with  Removal  of  posterior  wall  of  Osseous  audi- 
tory canal,  together  with  Membrana  and  Malleus — (1)  Expose  the  antrum  as 
in  the  ordinary  antrum  operation  (q.  v.).  (2)  Chisel  out  a  wedge  of  bone  be- 
tween the  anterior  edge  of  the  mastoid  opening  and  the  posterior  edge  of  the 
meatus.  As  the  lower  chisel-cuts  approach  the  floor  of  the  meatus  and 
grow  deeper,  they  are  directed  somewhat  upward,  finally  opening  into  the 
osseous  auditory  canal.  (3)  Dissect  out  the  fibrous  tympanic  ring  by  means 
of  a  special  knife,  and  remove  the  membrana  tympani  and  the  malleus,  if 
still  present.  (4)  Pass  a  bent  probe,  or  special  guide,  by  the  tympanic  route, 
through  the  aditus  into  the  antrum,  and,  upon  this  as  a  guide,  chisel  away 
the  remaining  wedge  of  bone  between  the  antrum  and  aditus — making  as 
wide  an  opening  as  the  position  of  the  facial  nerve  will  allow. 

D.  Extirpation  of  Epitympanum  and  Removal  of  Incus: — (1)  Chisel  away 
the  outer  wall  of  the  epitympanum  with  a  specially  curved  chisel,  exposing 
the  entire  epitympanum.  (2)  Disarticulate  the  incus  from  the  stapes  with  a 
special  knife,  and  remove  the  incus  with  forceps. 

E.  Exenteration  of  entire  Mastoid  Antrum,  Aditus,  and  Epitympanum: 
— (1)  Chisel  away  most  of  the  outer  cortex  of  the  mastoid  and  its  cancellated 
portion.  (2)  So  chisel  away  the  posterior  wall  of  the  osseous  auditory  meatus 
as  to  leave  a  ridge  of  firm  bone  between  mastoid  and  meatus,  sloping  outward 
and  downward  from  the  floor  of  the  aditus.  The  fallopian  canal  lies  inside 
this  ridge,  none  of  which  is  to  be  removed  on  the  median  side  of  the  tympanic 
ring.  (3)  Smooth,  by  curette  or  surgical  engine,  all  bony  irregularities  in  the 
walls  of  the  mastoid,  antrum,  epitympanum,  and  roof  of  tympanum.  Espe- 
ciallv  search  for  caries  upon  the  posterior  and  interno-inferior  aspects  of 
antrum,  lateral  sinus,  and  roof  of  tympanum — exposing  the  dura  if  required. 
(4)  Guard  the  horizontal  part  of  the  fallopian  canal  through  the  tympanum, 


608  OPERATIONS  UPON  THE  HEAD. 

and  the  perpendicular  part  running  down  from  the  aditus — also  the  horizontal 
semicircular  canal  in  the  inner  wall  of  the  aditus. 

F.  Splitting  of  Membranous  Meatus  and  Suturing: — (i)  Slit  the  car- 
tilaginous meatus  throughout  its  posterior  wall,  from  near  the  concha  out- 
ward. Two  triangular  flaps  are  thus  formed,  whose  corners  are  to  be  sutured 
with  catgut  to  the  external  tissues,  one  being  stretched  upward,  the  other 
downward.  (2)  Suture  the  auricle  back  into  its  former  position  as  far  down 
as  the  supramastoid  crest.  (3)  Turn  the  skin-flap  and  periosteal  flap  into 
the  cavity  made,  after  cleansing  and  draining  it — and  tampon  them  with 
gauze.  (4)  Suture  the  skin  over  the  lower  part  of  the  mastoid.  (5)  Apply 
a  voluminous  protective  dressing. 

G.  After-treatment: — Keep  evefy  crevice  of  cavity  well  packed  with 
gauze,  until  the  cavity  fills  with  granulations,  and  until  granulations  are 
covered  with  epidermis — which  epidermis  is  gotten  partly  from  epidermization 
of  granulations,  partly  from  the  skin-flap  turned  in — and  may  also  be  gotten 
from  grafts. 

Comment. — The  middle  ear  is  sometimes  first  exposed  by  removing  the 
upper  and  posterior  wall  of  the  osseous  canal,  and  then,  by  means  of  a  probe 
in  the  aditus  ad  antrum,  the  aditus  and  antrum  are  expcsed.  Thus  antra 
lying  further  forward  than  usual  would  be  exposed  with  less  danger  to  the 
cranial  cavity  (Stacke). 


OPERATIONS   UPON   THE   FRONTAL   SINUSES. 
SURGICAL  ANATOMY  OF  THE  FRONTAL  SINUSES. 

Description. — Two  more  or  less  triangular  air-spaces  of  variable  size, 
with  bases  anteriorly  and  apices  posteriorly,  situated  chiefly  in  antero-inferior 
portions  of  frontal  bones,  on  either  side  of  median  line,  anterior  to  ethmoidal 
notches,  and  separated  from  each  other  by  an  intervening  bony  septum. 
They  lie  at  the  antero-internal  junction  of  horizontal  and  vertical  portions 
of  frontal  bones,  immediately  internal  to  internal  angular  processes,  lying 
above  root  of  nose  and  more  or  less  beneath  inner  portions  of  superciliary 
ridges.  The  sinuses  begin  to  develop  at  two  years,  but  are  insignificant  in 
size  until  after  seven  years. 

Muscles  in  Relation  with  Frontal  Sinuses. — Frontal  portion  of  occipito- 
frontalis;  orbicularis  palpebrarum;  corrugator  supercilii;  sometimes  the  an- 
terior part  of  temporal. 

Arteries  in  Neighborhood  of  Frontal  Sinuses.  — Angular;  termination 
of  facial;  frontal  branch  of  ophthalmic;  supraorbital  branch  of  ophthalmic. 

Veins  in  Neighborhood  of  Frontal  Sinuses. — Frontal  (emptying  into 
nasal  arch  and  supraorbital);  supraorbital  (forming,  with  frontal,  the  angular 
vein);  angular  (becoming  the  facial);  anterior  temporal  (emptying  into 
common  temporal). 

Nerves  in  Neighborhood  of  Frontal  Sinuses. — Supraorbital  and 
supratrochlear  branches  of  frontal  division  of  ophthalmic;  sometimes  the 
lachrymal  branch  of  ophthalmic. 

Walls  and  Their  Relations. — (1)  Anterior  Wall:  formed  by  vertical 
portion  of  frontal;  extends  from  supraorbital  arch  below,  a  variable  distance 
upward  (v.  i.);  contains  diploe;  thickness  of  wall  varies  from  1  to  6  mm. 
(from  less  than  Jg-  to  yV  inch)  in  different  places,  average  being  from  2  to 
3  mm.  (from  about  yg-  to  T2¥  inch) ;  has,  in  relation,  the  soft  parts  mentioned 
above  (see  muscles,  arteries,  veins,  and  nerves).     (2)  Postero-superior  Wall 


GENERAL  SURGICAL  CONSIDERATIONS.  609 

(or  roof):  forms  part  of  anterior  boundary  wall  of  anterior  cranial  fossa; 
dense  and  brittle;  has,  in  relation,  the  frontal  lcbe  of  brain  and  the  olfactory 
lobe.  (3)  Inferior  Wall  (or  floor):  (a)  Orbital  Portion:  forms  part  of  roof 
of  orbit;  of  variable  extent;  marked  by  depression  for  pullev  of  superior 
oblique  muscle  of  eye;  (b)  Nasal  Portion:  (the  part  of  greater  surgical  im- 
portance) ;  articulates  with  anterior  ethmoidal  cells,  nasal  process  of  superior 
maxillary  and  nasal  bones;  infundibulum  opens  through  this  portion  of 
inferior  surface  from  frontal  sinus  into  middle  meatus  of  nose.  (4)  Internal 
Wall:  formed  by  the  antero-posterior  septum  between  the  sinuses,  which 
generally  deviates  from  median  line. 

Extent. — (1)  Laterally;  Average  of  two  hundred  cases  gave  an  extension 
outward  from  median  line  of  from  2  to  2.8  cm.  (};:  to  iT2y  inches) — Extremes, 
from  mere  slits  in  nasal  part  of  frontal,  to  cavities  extending  from  median 
septum  into  external  angular  process  of  frontal.  (2)  Vertically;  averages, 
from  base  to  apex  above,  along  its  inner  border  (its  highest  part),  from  1.8 
to  2.5  cm.  (f-f  to  1  inch) — extremes,  from  nasofrontal  suture  to  frontal  eminence. 
(3)  Floor,  frequently  extends  back  as  far  as  anterior  ethmoidal  foramen — 
rarely  back  to  lesser  wing  of  sphenoid. 

The  size  of  the  frontal  sinuses  is  not  determined  by  neighboring  bony 
prominences  and  depressions,  as  they  may  be  largely  formed  at  the  expense 
of  the  inner  table  of  the  skull.  It  is  also  often  said  that  one  sinus  may  be 
absent  or  rudimentary,  the  opposite  one  extending  across  the  median  line,  but 
in  Lothrop's  examination  of  two  hundred  and  fifty  sinuses  the  orbital  portion 
of  the  sinus  was  not  once  missing. 

Septum. — A  thin  bony  septum  separates  the  two  sinuses,  which  may 
deviate  slightly  or  considerably  to  one  side.  Septum  generally  does  deviate 
to  one  side,  and  this  deviation  may  amount  to  5  mm.  (j^  inch)  or  more. 
When  deviation  is  very  marked,  one  sinus  partly  overlaps  the  other,  an  im- 
portant surgical  fact.  The  septum  is  rarely  absent.  Perforation  of  septum 
is  very  exceptionally  found  (once  in  one  hundred  and  eighty  cases). 

Communication  with  Nose. — By  infundibulum,  which  passes  downward 
and  backward  behind  the  nasal  process  of  superior  maxillary  bone,  through 
anterior  portion  of  lateral  mass  of  ethmoid,  and  opens  into  middle  meatus 
of  nose,  under  anterior  end  of  middle  turbinated  bone,  and  on  a  level  with 
the  palpebral  fissure. 

SURFACE  FORM  AND  LANDMARKS. 

No  external  guide  exists  as  to  the  extent  of  the  frontal  sinuses — though, 
generally,  the  more  prominent  and  larger  the  supraorbital  area,  inclusive  of 
the  superciliary  ridges  and  nasal  eminences,  the  greater  the  extent  of  the 
sinuses. 


GENERAL  SURGICAL  CONSIDERATIONS. 

It  is  not  safe  to  make  an  opening  for  the  exposure  of  the  frontal  sinus 
at  any  point  external  to  the  supraorbital  notch — the  site  at  which  the  sinus 
is  most  surely  encountered  being  just  above  the  antero-inferior  aspect  of  the 
internal  angular  process  of  the  frontal  bone,  at  a  position  to  one  side  of  the 
median  line  sufficiently  far  to  miss  the  average  position  of  the  septum. 

39 


6io  OPERATIONS  UPON  THE  HEAD. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  FRONTAL  SINUSES. 

See  those  mentioned    under   the  Cranio-cerebral  and    Mastoid    regions 
(pages  557  and  604). 


EXPOSURE  AND  DRAINAGE  OF  THE  FRONTAL  SINUSES. 

Description. — The  frontal  sinus  is  exposed  through  its  anterior  wall — 
and  subsequently  drained  either  through  the  original  wound — or,  where 
possible,  through  the  infundibulum  into  the  middle  meatus  of  the  nose,  after 
closing  the  original  wound — or  through  both  routes. 

Preparation. — Shave  eyebrow.  Close  eyelid  and  place  a  sterile  pad 
over  it. 

Position. —  Patient  supine;  shoulders  elevated;  head  extended.  Surgeon 
on  side  of  operation,  or  behind  head.     Assistant  opposite. 

Landmarks. — Supraorbital  ridge;  supraorbital  notch  (generally  detectable 
through  the  skin,  at  the  junction  of  the  inner  and  middle  thirds  of  the  supra- 
orbital ridge) ;  sagittal  suture  (middle  line  of  head) ;  nasofrontal  suture  (de- 
tectable when  soft  parts  are  retracted). 

Incision. — A  horizontal  incision  is  made,  beginning  to  the  outer  side  of 
the  center  of  the  supraorbital  ridge,  and  continued  inward  to  the  median  line, 
just  above  the  supraorbital  margin  (Fig.  482).  If  more  room  be  needed, 
this  incision  may  cross  the  median  line,  or  be  curved  upward  or  downward  at 
the  median  line.  (Instead  of  the  horizontal,  a  vertical  incision  is  some- 
times made  in  the  median  line,  between  the  superciliary  ridges — but  leaves 
more  of  a  scar  than  an  incision  through  the  eyebrow. 

Operation. — (1)  The  incision  passes  directly  to  the  bone,  through  the 
skin,  the  fascia,  transversely  through  the  frontal  portion  of  the  occipito- 
frontalis,  longitudinally  between  some  fibers  of  the  orbicularis  palpebrarum 
and  through  periosteum  to  bone.  The  supraorbital  vessels  and  the  supra- 
orbital and  supratrochlear  nerves  are  cut — but  the  more  important  branches 
of  the  facial  nerve  to  the  occipitofrontalis,  corrugator  supercilii,  and  orbicu- 
laris palpebrarum  are  not  cut.  (2)  The  periosteum  is  elevated  and,  together 
with  the  soft  parts,  is  displaced  upward  and  downward  by  retractors.  (3) 
The  bone  having  been  well  exposed,  and  bleeding  controlled,  an  opening  is 
made  with  a  small  trephine  or  burr  (or,  less  desirably,  with  chisel  and  mallet). 
The  opening  is  placed  just  above  the  antero-inferior  aspect  of  the  internal 
angular  process  of  the  frontal  bone — the  inner  margin  of  the  opening  should 
be  external  to  the  median  line,  to  allow  for  deviation  of  the  septum — the 
outer  margin  should  never  extend  beyond  the  supraorbital  foramen — and 
the  lower  margin  should  be  above  the  nasofrontal  suture.  (4)  After  pene- 
trating the  anterior  bony  wall,  with  its  diploe,  the  mucous  membrane  of  the 
frontal  sinus  is  encountered  and  divided.  (5)  Pass  a  probe  through  the 
trephine-opening  into  the  sinus — thence  through  the  infundibulum  (which 
first  runs  downward  and  backward  a  short  way,  then  sharply  forward  and 
downward)  into  the  middle  meatus  of  the  nose,  which  it  enters  under  the 
anterior  end  of  the  middle  turbinated  bone.  (6)  The  interior  of  the  cavity, 
if  necessary,  may  be  curetted.  The  infundibulum  may  be  forcibly  dilated. 
Drainage,  at  least  temporary,  is  generally  indicated — and  may  be  accomplished 
in  one  of  the  following  ways — (a)  by  drawing  a  rubber  tube  through  the 
infundibulum  into  the  middle  meatus  of  the  nose,  with  entire  closure  of  the 


SURGICAL  ANATOMY  OF  THE  MAXILLARY  SINUSES.  611 

external  wound — or  (b)  by  combined  external  drainage  through  the  lower 
part  of  the  external  wound  (the  upper  part  of  the  wound  being  sutured)  and 
drainage  into  the  middle  meatus  of  the  nose  by  rubber  tube  or  strands  of 
silkworm-gut  or  silk.  It  is  better  to  adopt  the  latter  method  at  first — and 
the  former  may  be  adopted  later,  when  external  drainage  can  be  abandoned. 
The  first  method  alone  is  preferable  if  the  matter  of  scarring  from  a  granu- 
lating wound  be  of  importance.  Suture  all  of  the  external  wound  except 
that  portion  required  for  drainage.  The  transversely  divided  muscle  tissue 
should  be  repaired  with  catgut. 

Comment. — (')    Avoid   passing   the   probe  through   the  ethmoidal  cells 
into  the  brain.     (2)  It  is  well  to  remove  the  anterior  end  of  the  middle  tui- 


Fig.482.— Exposure  of  Frontal  Sinus  by  Transverse  Supraorbi  iai.  Incision  : — A,  Remains 
of  frontal  suture  ;  B,  Nasofrontal  suture;  C,  Supraorbital  foramen,  artery,  and  nerve;  D,  Trephine- 
opening  through  internal  angular  process  of  frontal  bone  ;  E,  Orbicularis  palpebrarum  divided  longi- 
tudinally ;  F,  Occipitofrontalis  divided  transversely  ;  G,  Supratrochlear  nerve  ;  H,  Periosteum  drawn 
aside  ;  I,  Nasal  suture. 

binated  bone,  as  freer  access  to  and  from  the  infundibulum  is  thereby  given. 
(3)  Where  possible,  the  lips  of  the  wound  through  the  eyebrow  should  be 
very  carefully  approximated  and  sutured,  that  the  eyebrows  may  grow  out 
in  their  proper  axes. 


OPERATIONS  UPON  THE  MAXILLARY  SINUSES. 

SURGICAL  ANATOMY  OF  THE  MAXILLARY  SINUSES. 

Description. — A  somewhat  pyramidal  air-cavity  generally  occupying 
chief  portion  of  body  of  superior  maxillary  bones.  Dimensions  variable — 
may  be  contracted — may  extend  into  malar  bone.  Small  with  thick  walls 
in  young — larger  with  thinner  walls  in  old.  Communicates  by  an  irregular 
opening  with  middle  meatus  of  nose — sometimes  more  than  one  communi- 
cating opening  may  exist.  Infraorbital  canal,  for  infraorbital  nerve,  pene- 
trates its  superior  and  anterior  walls.  Posterior  dental  canals  groove  its 
posterior  wall.  Bony  septa  may  divide  interior  of  cavity.  Floor  of  antrum 
uneven  from  upward  projection  of  roots  of  teeth.     Teeth  in  contact  with 


612  OPERATIONS  UPON  THE  HEAD 

the  antrum  are  the  molars,  and  especially  the  first  and  second  molars — 
sometimes  the  roots  of  all  the  teeth  of  one  side  may  be  in  contact  with  floor 
of  antrum  of  that  side. 

Muscles  in  Relation. — (i)  In  Relation  with  Anterior  or  Facial  Wall; 
levator  labii  superioris  alaeque  nasi;  levator  labii  superioris;  levator  anguli 
oris;  zygomaticus  major;  zygomaticus  minor;  orbicularis  oris;  buccinator; 
risorius.  (2)  In  Relation  with  Posterior  or  Zygomatic  Wall;  masseter; 
temporal;  external  pterygoid. 

Arteries  in  Relation. — (1)  In  Relation  with  Anterior  Wall;  facial  of 
external  carotid;  transverse  facial  branch  of  temporal  branch  of  external 
carotid.  (2)  With  Posterior  Wall;  internal  maxillary  of  external  carotid; 
posterior  dental  (alveolar)  of  internal  maxillary;  descending  palatine  of 
internal  maxillary.  (3)  With  Internal  Wall;  sphenopalatine  of  internal 
maxillary.     (4)  With  Superior  Wall;  infraorbital  of  internal  maxillary. 

Veins  in  Relation. — Correspond  with  arteries. 

Nerves  in  Relation. — (1)  In  Relation  with  Anterior  Wall;  middle  supe- 
rior dental  branch  of  superior  maxillary;  anterior  superior  dental  branch  of 
superior  maxillary;  malar  branches  of  facial;  infraorbital  branches  of  facial; 
buccal  branches  of  facial.  (2)  With  Posterior  Wall;  posterior  superior  dental 
branches  of  superior  maxillary;  anterior  or  large  palatine  nerve  from  Meckel's 
ganglion;  posterior  or  small  palatine  nerve  from  Meckel's  ganglion.  (3) 
With  Superior  Wall;  infraorbital  division  of  superior  maxillary  (emerges  on 
anterior  wall).  (4)  With  Internal  Wall;  nasopalatine  nerve  of  Meckel's 
ganglion. 

Walls  and  Their  Relations. — (1)  Base  or  Internal  (Nasal)  Wall;  pre- 
sents the  very  irregular  opening  of  antrum  of  Highmore,  at  its  posterior  part, 
communicating  with  middle  meatus  of  nose — and  is  partly  filled  in  by  vertical 
plate  of  palate,  unciform  process  of  ethmoid,  maxillary  process  of  inferior 
turbinated,  part  of  lachrymal  and  by  mucous  membrane.  (2)  Apex;  formed 
by  malar  process  of  superior  maxillary.  (3)  Superior  Wall;  orbital  plate  of 
superior  maxillary.  (4)  Inferior  Wall;  alveolar  ridge.  (5)  Anterior  Wall; 
facial  surface  of  superior  maxillary.  (6)  Posterior  Wall;  zygomatic  surface 
of  superior  maxillary. 


SURFACE  FORM  AND  LANDMARKS. 

The  antero-external  and  postero-external  walls  of  the  sinus,  together  with 
the  alveolar  ridge,  which  are  the  aspects  where  openings  are  usually  made, 
are  best  exposed  by  upward  and  backward  traction  of  the  upper  lip  and 
cheek  of  that  side,  sufficiently  to  obliterate  the  fold  of  mucous  membrane 
reflected  from  cheek  to  gums. 


GENERAL  SURGICAL  CONSIDERATIONS. 

The  maxillary  sinus  may  be  approached  by  enlarging  its  natural  opening 
into  the  middle  meatus  of  the  nose;  by  making  an  opening  through  its  ex- 
ternal wall;  or  by  going  through  a  socket  of  one  of  the  molar  teeth.  The 
best  site  for  the  opening,  upon  the  facial  aspect  of  the  bone,  is  in  the  interval 
between  the  first  and  second  molar  teeth,  upon  the  posterior  aspect  of  the 
malar  ridge  of  the  superior  maxillary  bone,  sufficiently  high  to  avoid  the 
roots  of  the  teeth.  Above  the  second  molar  might  be  better,  but  the  malar 
ridge  makes  it  difficult  to  get  high  enough  up  to  avoid  the  root  of  the  tooth 


OPENING  OF  MAXILLARY  SINUS  THROUGH  THE  FACE. 


613 


— but  this  site  would  be  better  if  the  tooth  were  absent.  Where  the  opening 
is  made  through  the  alveolar  ridge  the  second  molar  tooth  is  drawn  and  the 
socket  penetrated  by  a  burr  or  drill. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  MAXILLARY 

SINUSES. 

See   those  mentioned    under   the  Cranio-cerebral   and    Mastoid  regions 
(pages  557  and  604). 


OPENING  OF  MAXILLARY  SINUS  (ANTRUM  OF  HIGHMORE)  THROUGH 
ITS  FACIAL  ASPECT,  ABOVE  THE  ALVEOLAR  MARGIN. 

Description. — The  upper  lip  and  cheek  are  displaced  upward  and  back- 
ward, and  the  antrum  entered  above  the  fangs  of  the  molar  teeth,  preferably 


Fig. 483.— Exposure;  of   Maxillary  Antri  m  : — Through  the  malar  ridge  of  the  superior  maxilla, 
above  the  interval  between  fust  and  second  molar  teeth  fangs. 


in  the  interval  between  the  first  and  second  molars,  upon  the  postero-external 
aspect  of  the  malar  ridge  of  the  superior  maxilla.     (See  Fig.  483.) 

Preparation. — Mouth  cleansed;  sponge  so  placed  as  to  absorb  blood  and 
prevent  its  reaching  throat. 

Position. — Patient  supine;  head  elevated,  resting  upon  sound  side. 
Surgeon  on  side  of  operation.     Assistant  opposite. 

Landmarks. — Alveolar  margin;  first  and  second  molars;  malar  ridge  of 
superior  maxilla. 


6l4  OPERATIONS  UPON  THE  HEAD. 

Incision. — Having  retracted  upward  and  backward  the  upper  lip  and 
cheek,  a  vertical  incision  is  made  above  the  roots  of  the  first  and  second  molars 
and  as  nearly  over  the  interspace  between  them  as  is  accessible,  being  guided 
in  the  placing  of  the  incision  by  the  prominent  ridge  of  the  superior  maxilla 
leading  up  to  the  malar  process. 

Operation. — (I)  Carry  the  incision  through  mucous  membrane  and 
periosteum  to  the  bone — free  the  periosteum  from  the  bone  by  periosteal 
elevator — retract  soft  parts  anteriorly  and  posteriorly.  (2)  Apply  a  small 
trephine  just  above  the  back  part  of  the  root  of  the  first  molar  and  high 
enough  to  avoid  its  fangs,  directing  it  upward,  inward,  and  backward  — 
until  it  is  felt  to  have  entered  the  cavity.  (3)  Remove  diseased  tissue  of 
antrum  with  scoop  or  curette.  By  tilting  head  forward,  irrigation  may  be 
made  from  artificial  opening  through  middle  meatus  of  nose.  The  opening 
should  be  plugged  during  meals,  or  a  tube  with  an  adjustable  plug  should 
be  worn. 

Comment. — (1)  Avoid  injury  to  infraorbital  vessels  and  nerves  by  keeping 
below  and  to  outer  side  of  infraorbital  foramen.  (2)  Avoid  entering  the 
orbit.  (3)  This  operation  is  probably  better  than  entering  through  the 
socket  of  a  tooth — while  the  latter  gives  better  drainage,  the  former  better 
protects  from  entrance  of  food  into  the  sinus  from  the  mouth. 


OPENING  OF  MAXILLARY  SINUS  (ANTRUM  OF  HIGHMORE)  THROUGH 
THE  SOCKET  OF  THE  SECOND  MOLAR  TOOTH. 

Description. — The  removal  of  the  tooth  alone  may  accomplish  sufficient 
drainage,  as  the  fangs  may  open  directly  into  the  antrum,  save  for  their 
thin  bony  covering,  which  is  easily  broken  down.  If  the  opening  made  by 
the  simple  withdrawal  of  the  tooth  be  insufficient  (which  is  usually  the  case) 
it  may  be  deepened  and  enlarged. 

Preparation  and  Position. — Same  as  in  last  operation. 

Landmarks. — Second  molar  tooth. 

Operation. — Draw  second  molar  tooth.  If  fangs  leave  opening  com- 
municating with  the  antrum,  deepen  and  enlarge  it  with  a  bone-drill.  If  no 
opening  be  found,  drill  through  the  intervening  bone.  Drain  and  treat  as  in 
the  above  operation. 

Comment. — This  operation  gives  better  drainage  than  the  preceding, 
but  is  more  apt  to  be  contaminated  from  the  mouth,  unless  the  opening  be 
closed  artificially  by  some  form  of  plug,  except  during  irrigation.  The  loss 
of  the  tooth  is  entailed.  The  operation  is  especially  indicated  when  the 
tooth  is  already  absent. 


III.  THE  EYEBALL  AND  THE  ORBIT.* 

OPERATIONS  UPON  THE  EYEBALL. 

SURGICAL  ANATOMY  OF  THE  ORBIT. 

Fibrous  Tissues  of  the  Orbit. — (1)  Orbital  periosteum.  (2)  Fascia 
ensheathing  muscles,  vessels,  optic  and  other  nerves,  and  enclosing  lobules 
of  fat.     Posteriorly,  it  blends  with  periosteum  (where  the  fascia  is  thinner 

*  Only  the  removal  of  the  eye  will  be  here  considered,  most  of  the  operations  upon  the 
contents  of  the  orbit  belonging  to  the  special  field  of  ophthalmology. 


ENUCLEATION  OF  THE  EYEBALL.  615 

and  looser).  Anteriorly,  it  is  thicker  and  firmer,  accompanying  the  muscles 
nearly  to  the  equator  of  eyeball,  where  it  divides  into  an  anterior  lamina, 
forming  a  complete  investment  and  passing  forward  to  eyelids, — and  a  poste- 
rior lamina,  turning  backward  and  covering  the  hinder  third  of  the  globe. 
(3)  Tenon's  capsule,  a  serous  membrane  (whose  layers  are  separated  by 
Tenon's  lymph-space) — surrounding  the  hinder  two-thirds  of  the  eyeball. 
The  visceral  layer  follows  the  convexity  of  the  sclerotic,  from  the  ciliary 
margin  of  the  cornea  to  entrance  of  optic  nerve,  where  it  is  reflected  from  the 
eyeball  and,  becoming  the  parietal  layer,  blends  with  the  posterior  lamina  of 
the  muscle-fascia  (v.  s.).  Anteriorly,  Tenon's  capsule  is  continued  into  the 
conjunctiva.  Posteriorly,  it  is  continued  with  the  subarachnoid  space  through 
the  sheath  of  the  optic  nerve.  Tenon's  capsule  is  pierced  by  the  ocular 
muscles,  which  are  surrounded  by  sheaths  from  Tenon's  capsule. 

Muscles  of  the  Orbit. — Recti  superior,  inferior,  external  and  internal; 
obliquus  oculi  superior  and  inferior;  levator  palpebral  superioris. 

Arteries  of  the  Orbit. — Ophthalmic  and  its  branches — lachrymal; 
supraorbital;  posterior  ethmoidal;  anterior  ethmoidal;  palpebral;  frontal; 
nasal;  muscular;  anterior  ciliary,  short  ciliary;  long  ciliary;  arteria  centralis 
retinas. 

Veins  of  the  Orbit. — Superior  muscular;  anterior  and  posterior  ciliary; 
anterior  and  posterior  ethmoidal;  lachrymal;  central  vein  of  retina; — all  form 
superior  ophthalmic  vein.  Inferior  muscular  and  lower  posterior  ciliary 
form  inferior  ophthalmic.  Superior  and  inferior  ophthalmic  veins  unite  to 
form  the  common  ophthalmic  vein. 

Nerves  of  the  Orbit. — Optic;  motor  oculi;  trochlear;  lachrymal,  frontal 
and  nasal  branches  of  the  ophthalmic  division  of  the  fifth;  ophthalmic  (ciliary; 
ganglion. 


ENUCLEATION  OF  THE  EYEBALL. 

Description. — Consists  of  the  removal  of  the  eyeball  intact,  after  incising 
the  conjunctiva,  severing  the  attachment  of  the  ocular  muscles  to  the  globe 
and  dividing  the  optic  nerve  at  its  entrance  into  the  eyeball.  Indicated 
chiefly  in  malignant  disease  and  in  extensive  injury. 

Special  Instruments  Required. — Eye-speculum;  toothed  fixation  for- 
ceps; strabismus  hook;  blunt-pointed  scissors  curved  on  the  flat. 

Position. — Patient  supine;  head  elevated.  Surgeon  on  side  of  operation. 
Assistant  opposite. 

Landmarks. — Reflection  of  the  conjunctiva  on  to  the  globe. 

Operation. — (1)  Insert  a  spring  eye-speculum,  an  arm  passing  between 
the  globe  and  each  lid,  holding  the  latter  out  of  the  way.  (2)  Catch  up  the 
ocular  conjunctiva  with  toothed  forceps  and  snip  it  with  blunt-pointed  scissors 
all  around,  near  to  the  cornea.  (3)  Having  opened  Tenon's  capsule,  catch 
up  each  rectus  tendon — generally  beginning  with  the  external,  then  the 
superior  and  inferior,  ending  with  the  internal — with  a  strabismus-hook, 
drawing  them  forward  and  dividing  them  with  scissors  close  to  their  sclerotic 
attachment.  (4)  Press  upon  the  speculum  slightly  so  as  to  push  it  behind 
the  equator  of  the  eye,  which  will  cause  the  ball  to  start  forward.  Pass 
curved  scissors  backward,  on  the  outer  side  of  and  behind  the  globe,  and 
divide  the  optic  nerve  close  to  the  eyeball.  Draw  the  eyeball  forward  and 
tut  the  superior  and  inferior  oblique  muscles  near  the  sclerotic — and  remove 
the  eye.     (5)  The  ophthalmic  artery  is  immediately  clamped  and  tied.    Other 


616  OPERATIONS  UPON  THE  HEAD. 

bleeding  vessels  are  controlled  by  ligature  or  by  pressure  maintained  by 
dressing. 

Comment. — (I)  Where  the  globe  has  collapsed,  or  collapses  during  the 
operation,  seize  it  with  forceps  and  dissect  it  out.  (2)  In  disease  it  is  often 
indicated  to  remove  all  the  soft  tissues  of  the  orbit,  as  well  as  the  eye  proper. 


EVISCERATION  OF  THE  EYEBALL. 

Description. — Consists  in  the  removal  of  the  contents  of  the  eyeball, 
leaving  a  stump  composed  of  the  tissues  of  the  globe  for  the  better  reception 
of  an  artificial  eye  within  the  original  sclerotic.  Indicated  chiefly  in  suppura- 
tion of  the  eyes  and  in  limited  lesions. 

Special  Instruments. — Those  given  under  Enucleation,  together  with 
the  following  in  addition — Beer  knife;  sharp  scoop;  needle-holder;  curved 
needles;  silk;  glass  globes  of  various  sizes,  with  globe-introducers. 

Position  and  Landmarks. — Same  as  for  Enucleation. 

Operation. — (1)  Introduce  eye-speculum  as  for  Enucleation.  (2)  Steady 
eye  by  grasping  conjunctiva  with  fixation  forceps.  Remove  cornea  by 
incising  sclerotic  with  a  Beer  knife  a  little  outside  of  the  sclero-corneal  junction 
— continuing  the  incision  a  short  distance  into  the  sclerotic  on  each  side,  at 
the  mid-lateral  aspects  of  the  opening — to  provide  for  the  insertion  of  the 
artificial  eye  and  an  easy  coming  together  of  the  wound.  Remove  from 
the  sclerotic  the  entire  contents  of  the  globe  with  a  scoop,  especially  from  the 
uveal  tract.  (3)  Control  hemorrhage  by  hot  or  cold  irrigation.  Insert  a 
glass  eye  of  appropriate  size  and  appearance — suturing  the  edges  of  the 
wound  over  it,  the  sutures  passing  through  the  conjunctiva  and  sclerotic, 
around  the  circumference  and  uniting  the  lips  of  the  two  lateral  incisions. 


EXENTERATION  OF  THE   ORBIT. 

Description. — Removal  of  the  entire  contents  of  the  orbit— indicated 
chiefly  in  malignant  disease. 

Position. — As  in  the  preceding  operations. 

Landmarks. — Margin  of  the  orbit;  external  tarsal  ligament. 

Incision. — An  incision  is  made  from  the  external  canthus  outward  through 
the  external  tarsal  ligament — to  allow  the  lids  to  be  fully  separated.  The 
conjunctiva  is  cut  through  down  to  the  bone,  around  the  entire  circumference 
of  the  bony  orbit — to  subperiosteal^  expose  the  cavity  of  the  orbit. 

Operation. — The  soft  parts  having  been  thus  freed,  the  periosteum  of  the 
orbit  is  raised  by  means  of  an  appropriate,  curved  periosteal  elevator.  The 
structures  within  the  orbit  are  not  disturbed  separately — but  are  freed,  en 
masse,  within  the  surrounding  periosteum,  toward  the  apex  of  the  orbit.  The 
mass  of  soft  parts  is  then  drawn  forward  and  divided  close  to  the  apex  of  the 
orbital  cavity  by  means  of  a  pair  of  curved  scissors  inserted  deeply  behind  the 
mass  of  tissues.  The  orbital  cavity,  and  especially  its  apex,  is  then  tamponed 
firmly.  This  tamponade  may  be  allowed  to  remain — or  it  may  be  withdrawn 
and  the  ophthalmic  artery  clamped  and  ligated. 

The  manner  of  completing  the  operation  will  be  determined  by  the  special 
object  for  which  it  was  performed.  Grafting  by  means  of  the  lids  may  be 
at  once  resorted  to — or  may  be  subsequently  done  from  adjacent  tissues.  The 
incision  through  the  outer  canthus  is  sutured. 


EXPOSURE    OF    IXTRA-ORBITAL    AND    RETRO-BULBAR    STRUCTURES.    617 
EXPOSURE  OF   INTRA-ORBITAL   AND   RETRO-BULBAR  STRUCTURES. 

KROENLEIN'S     OPERATION. 

Description. —The  outer  wall  of  the  orbit,  consisting  of  bony  and  soft 
parts,  is  osteoplastically  turned  outward — and  subsequently  replaced.  The 
procedure  is  indicated  in  retro-bulbar  diseases  and  intra-orbital  injuries. 

Position. — The  patient's  head,  resting  upon  its  back,  is  turned  slightly 
toward  the  operator. 

Landmarks. — External  angular  process  of  the  frontal  bone;  margin  of 
the  orbit;  outline  of  the  malar  and  zygoma. 


Fig.  484. — Kroenlein's  Operation  for  the  Exposure  of  the  Intra-orbital  Structures: — 
A  B,  Skin-incision;  C  and  D,  Bone  sections. 


Incision. — The  skin-incision  begins  in  the  temporal  region,  about  1  cm. 
(about  J  inch)  above  the  supra-orbital  margin — runs  thence  downward  and 
forward,  with  anterior  convexity,  along  the  external  orbital  margin,  to  the 
upper  edge  of  the  zygoma — where  it  turns  backward  and  ends  over  the  center 
of  the  zygomatic  arch. 

Operation. — Incise  through  skin,  superficial  fascia,  aponeuroses,  muscles, 
and  periosteum  to  the  bone  throughout.  By  means  of  a  curved  periosteal 
elevator  the  periosteum  is  then  raised  from  the  outer  wall  of  the  orbit,  carrying 
with  it  the  intra-orbital  structures  as  far  as  the  spheno-maxillary  fissure.  The 
external  angular  process  of  the  frontal  bone  is  then  sawn  or  chiselled  through 
in  the  direction  indicated  by  the  line  A,  Fig.  484,  the  section  beginning  just 
above  the  fronto-malar  suture-line.  The  malar  is  then  divided,  from  its 
outer  margin  into  the  anterior  end  of  the  spheno-maxillary  fissure,  as  indicated 


618  OPERATIONS    UPON    THE    HEAD. 

by  the  line  B,  Fig.  484.  The  bony  outer  wall  of  the  orbit  is  now  turned  out- 
ward, with  the  adherent  and  undisturbed  overlying  soft  parts — thus  exposing 
the  structures  within  the  orbit.  When  the  object  of  the  exposure  has  been 
accomplished,  the  composite  flap  is  turned  back  into  position — the  bone,  if 
indicated,  being  sutured  through  previously  drilled  holes. 

Comment. — Eventration  may  also  be  performed  after  exposing  the  orbital 
cavity  by  means  of  Kroenlein's  operation. 


IV.  THE  EAR  AND  EUSTACHIAN  TUBE.* 

SURGICAL  ANATOMY  OF  THE  MEMBRANA  TYMPANI. 

Description. — The  membrana  tympani  is  an  ellipsoidal  disc  (with  slight 
central  depression)  about  10  mm.  (between  y%-  and  y7^  inch)  in  length,  9  mm. 
(between  f5^  and  y\  inch)  in  width,  and  about  0.1  mm.  in  thickness.  It 
extends  obliquely  from  above  downward,  its  circumference  being  lodged  in 
the  groove  of  the  tympanic  ring,  at  the  inner  end  of  the  external  auditory 
meatus — forming  the  boundary  between  external  and  middle  ear.  It  con- 
sists of  three  layers — the  cuticular  covering  without,  the  fibrous  layer,  and 
the  mucous  lining  within.  The  handle  of  the  malleus  descends  downward 
and  backward  between  its  two  inner  layers  and  is  attached  to  the  membrana 
tympani  a  little  below  its  center,  at  the  umbo.  The  short  process  of  the  mal- 
leus and  long  process  of  the  incus  are  visible  through  the  membrana  tympani 
at  its  upper  part.  A  cone  of  light  is  generally  visible  extending  from  the 
umbo  (end  of  manubrium  or  handle  of  malleus)  downward  and  forward 
toward  the  circumference. 


INTRODUCTION    OF    EAR    SPECULUM    FOR    EXAMINATION    OF   MEM- 
BRANA TYMPANI. 

Seat  patient  upright  in  chair,  with  a  good  natural  light  (other  than  sun- 
light) or  artificial  illumination  available — the  patient  occupying  such  a  position 
as  to  enable  the  light  to  be  reflected  by  a  head-mirror,  worn  by  the  operator, 
into  the  auditory  canal.  Warm  and  moisten  a  speculum  (Gruber's  silver 
speculum,  or  other) — grasp  the  upper  free  portion  of  the  auricle  between  the 
bent  knuckles  of  the  index  and  middle  fingers  of  the  left  hand — draw  the 
ear  upward,  backward,  and  outward  (suggested  by  the  letters  u,  b,  o),  to 
straighten  the  canal — insert  the  speculum,  held  lightly  between  right  index 
and  thumb,  by  twirling  it  forward  and  backward  in  a  small  arc  until  it  has 
sunk  to  the  right  depth  in  the  proper  axis  of  the  external  auditory  canal, 
when  it  is  steadied  by  the  left  thumb  placed  upon  its  rim.  It  may  then 
be  manipulated  in  different  directions  to  expose  all  portions  of  the  depth  of 
the  auditory  canal  and  the  surface  of  the  membrana  tympani — noticing  par- 
ticularly the  color  and  position  of  the  drum  as  to  whether  normally  re- 
tracted, or  abnormally  bulging  from  a  collection  of  fluid  in  the  tympanum. 

*Only  the  introduction  of  the  ear-speculum  and  the  eustachian  catheter  and  the  punc- 
ture of  the  ear-drum  will  be  here  considered,  most  of  the  operations  upon  the  ear  belonging 
to  the  special  field  of  Otology. 


SURGICAL    AX  ATOMY.  619 


PARACENTESIS  TYMPANI. 

Description. — Incision  of  tympanic  membrane  for  the  purpose  of  drainage 
of  the  tympanic  cavity  and  for  irrigation.     Indicated  chiefly  in  otitis  media. 

Instruments  Required. — Ear-speculum;  double-edged  paracentesis 
needle. 

Preparation. —  Cleansing  of  auditory  canal  by  antiseptic  irrigation. 

Position. — Patient  sits  upright.     Surgeon  sits  opposite  the  involved  ear. 

Landmarks. — Handle  of  malleus  showing  through  the  membrana  tym- 
pani. 

Operation. — (1)  Insert  the  ear-speculum — expose  the  membrana  tympani 
in  the  field  of  the  speculum — and  recognize  the  handle  of  the  malleus.  (2) 
Incise  the  ear-drum,  making  the  incision  in  the  posterior  half  of  the  mem- 
brane, between  the  handle  of  the  malleus  and  the  posterior  border  of  the 
membrana  tympani,  and  enlarge  the  opening  vertically — taking  care  not  to 
wound  the  middle  ear. 


INTRODUCTION  OF  THE  EUSTACHIAN  CATHETER. 

Place  the  patient  in  a  chair  opposite  the  operator,  with  head  thrown  back 
and  supported  upon  the  back  of  the  chair  or  upon  a  rest.  The  surgeon, 
standing  or  sitting,  places  the  fingers  of  his  left  hand  upon  the  patient's  fore- 
head, while  his  left  thumb  pushes  the  tip  of  the  patient's  nose  upward  (to 
bring  the  nostril  on  a  level  with  the  floor  of  the  nose).  Warm  and  lubricate 
the  eustachian  catheter,  having  atomized  the  nasal  cavity  with  a  local  anes- 
thetic, if  necessary — push  the  tip  of  the  catheter,  pointing  downward,  along 
the  floor  of  the  nose,  until  it  touches  the  posterior  wall  of  the  pharynx — turn 
the  point  obliquely  outward  but  not  quite  horizontal — withdraw  the  instru- 
ment until  the  point  is  felt  to  glide  over  the  projecting  posterior  border  of 
the  eustachian  tube — now  turn  the  tip  further  outward,  until  the  guide-ring 
at  the  posterior  end  of  the  catheter  points  to  the  outer  canthus  of  the  eye  of 
the  same  side — when  the  direction  of  the  beak  will  generally  coincide  with 
the  axis  of  the  eustachian  tube. 


V.  THE  NOSE  AND  NASAL  CAVITIES. 

For  operations  exposing  the  Nasal  Cavities,  see  Excisions  and  Osteoplastic 
Resections  (pages  473,  474).  Most  of  the  other  operations  upon  the  Nose 
and  Nasal  Cavities  belong  to  the  special  field  of  Rhinology. 


VI.  THE  TONGUE. 

SURGICAL  ANATOMY. 

Connections  of  the  Tongue. — (1)  With  Os  Hyoides;  by  hyoglossi  and 
geniohvoglossi  muscles,  and  hyoglossal  membrane.  (2)  With  Styloid  Process; 
by  styloglossi  muscles.  (3)  With  Inferior  Maxilla ;  by  geniohvoglossi  muscles. 
(4)  With  Pharvnx;  by  superior  constrictors  and  mucous  membrane.  (5) 
With  Epiglottis;  by  median  and  two  lateral  glosso-epiglottic  folds  of  mucous 
membrane.     (6)   With  Soft  Palate;  by  anterior  pillars  of  the  fauces  {i.e., 


620  OPERATIONS    UPON   THE   HEAD. 

the  palatoglossi  muscles  covered  by  mucous  membrane).  (7)  With  Gums 
and  Floor  of  Mouth;  by  mucous  membrane  and  fraenum  linguae. 

Muscles  Entering  into  Formation  of  Tongue. — (1)  Extrinsic  Muscles 

(arising  externally  and  terminating  in  tongue);  styloglossi,  hyoglossi,  genio- 
hyoglossi,  palatoglossi,  pharyngeoglossal  portion  of  superior  constrictors, 
chondroglossi.  (2)  Intrinsic  Muscles  (entirely  within  tongue  and  forming 
its  chief  bulk);  superior,  transverse,  vertical  and  inferior  linguales. 

Arteries  of  Tongue. — (1)  Lingual  (for  its  surgical  anatomy,  see  Liga- 
tions) ;  dorsalis  lingiue  branch  of  Lingual  (arises  beneath  hyoglossus  and 
passes  to  dorsum  of  tongue) ;  sublingual  branch  of  lingual  (arises  at  anterior 
border  of  hyoglossus  and  passes  forward  between  geniohyoglossus  and  sub- 
lingual gland);  ranine  branch  of  lingual  (arises  at  anterior  border  of  hvo- 
glossus  and  passes  forward  beneath  under  surface  of  tongue).  (2)  Tonsillar 
branch  of  facial;  muscular  branch  of  facial  to  styloglossus.  (3)  Branches  of 
ascending  pharyngeal  branch  of  external  carotid. 

Veins  of  Tongue. — Correspond  with  arteries. 

Nerves  of  Tongue. — Lingual  branch  of  trifacial  (to  papilla?  of  front  and 
sides  of  tongue) ;  lingual  branch  of  glossopharyngeal  (to  mucous  membrane 
of  base  and  sides  and  to  papilla?  circumvallata?) ;  hypoglossal  (to  muscular 
substance  of  tongue) ;  chorda  tympani  (to  lingualis) ;  sympathetic  filaments. 


GENERAL  SURGICAL  CONSIDERATIONS  IN  THE  REMOVAL  OF  PART 
OR  THE  WHOLE  OF  THE  TONGUE. 

Indications. — Chiefly  removed  for  malignant  growth. 

Varieties  of  Operation  and  Manners  of  Operating. — (1)  Small  por- 
tions of  tongue  may  be  excised  by  a  V-shaped,  or  other,  incision.  One  half 
of  tongue,  transversely  or  longitudinally,  may  be  removed.  The  entire 
organ  may  be  excised.  (2)  The  tongue  may  be  removed  through  the  un- 
altered mouth;  through  an  incision  in  the  neck;  through  the  mouth  after 
splitting  the  cheek,  or  temporarily  dividing  the  inferior  maxilla;  or  after 
excision  of  the  inferior  maxilla.  (3)  It  may  be  removed  with  or  without 
previous  ligation  of  the  lingual  arteries,  either  beneath  the  hyoglossi  or  at 
their  origin — and  with  or  without  previous  tracheotomy — dependent  upon  the 
difficulties  and  circumstances  of  the  case.  (4)  It  may  be  removed  by  scissors; 
by  knife;  by  some  form  of  ecraseur,  applied  through  mouth  or  neck;  by 
ligature;  or  by  galvano-cautery. 

General  Observations. — Where  the  involvement  is  strictly  limited  to 
the  tongue  alone,  it  should  be  removed  through  the  mouth.  Where  the  floor 
of  the  mouth  or  the  cervical  glands,  and  especially  both  are  involved,  the 
tongue  should  be  removed  through  the  neck,  together  with  the  simultaneous 
removal  of  all  the  diseased  tissues.  Where  but  a  limited  portion  of  the 
tongue  is  involved,  especially  where  the  involvement  is  at  or  toward  the 
anterior  end  of  the  organ,  a  limited  portion  of  tissue,  or  a  transverse  or  longi- 
tudinal half  may  be  removed.  The  natural  separation  of  the  two  halves  of 
the  tongue  by  a  fibrous  septum  makes  it  possible  to  remove  one  half  alone 
comparatively  easy.  The  tongue  is  readily  split  by  placing  a  stout  silk 
retractor  in  each  half,  about  2.5  cm.  (1  inch)  behind  the  tip  and  about  1.2 
cm.  (\  inch)  from  the  median  line — while  these  are  drawn  in  different  direc- 
tions, the  tongus  is  split  down  the  median  fibrous  raphe  with  blunt-pointed 
scalpel  or  scissors.  In  removing  one  half  or  the  entire  tongue,  it  is  readily 
drawn  out  of  the  mouth  after  dividing;  the  frcenum  and  mucous  membrane 


EXCISION    OF    LIMITED    PORTIONS    OF   THE   TONGUE.  621 

of  the  floor  of  the  mouth  in  front,  and  the  anterior  pillars  of  the  fauces  laterally. 
The  chief  difficulties  of  operating  are  the  narrow  working-room  and  hemor- 
rhage. A  good  light  is  necessary  in  all  cases.  In  exceptional  cases  the 
extraction  of  two  or  three  of  the  lower  teeth  to  give  fuller  working-room  is 
indicated — the  teeth  being  subsequently  replaced  upon  a  dental  splint. 

Control  of  Hemorrhage  in  Operations  upon  the  Tongue. — The  chief 
hemorrhage  is  from  the  lingual  arteries,  divided  in  the  floor  of  the  mouth, 
anterior  to  the  hyoglossi  (where  they  are  called  the  ranine) — the  position  of 
the  cut  vessels  being  the  chief  difficulty  encountered — the  hemorrhage  being 
apt  to  flood  the  field  of  operation  and  get  into  the  air-passages.  The  head 
is  to  be  held  so  as  to  direct  the  flow  of  blood  away  from  the  back  of  the  throat. 
If  the  mouth  be  kept  well  open,  the  cut  arteries  are  inclined  to  spurt  out  of 
the  mouth.  By  firm  pressure  applied  without  upon  the  neck,  between  the 
inferior  maxilla  and  hyoid  bone,  the  stump  of  the  tongue  can  be  brought 
into  view,  and  the  hemorrhage  also  temporarily  arrested  by  that  pressure. 
The  same  thing  may  also  be  accomplished  by  hooking  a  finger  or  an  instru- 
ment around  the  base  of  the  stump  and  drawing  it  forward.  Hemorrhage 
can  be  thus  temporarily  controlled  until  the  vessels  can  be  clamped  and  tied. 
If  only  the  anterior  half  or  two-thirds  of  the  tongue  is  to  be  removed,  a  double 
ligature  may  be  passed  through  the  center  of  the  organ,  well  behind  the 
growth  and  temporarily  tied  on  either  lateral  aspect  of  the  tongue,  thereby 
controlling  hemorrhage.  Preliminary  ligation  of  the  lingual  arteries  in  the 
neck  insures  a  comparatively  dry  field,  and  therefore  more  thorough  work. 


INSTRUMENTS  USED  IN  REMOVAL  OF  THE  TONGUE. 

Special  mouth-gags;  cheek  retractors;  blunt  hooks;  tongue  depressors; 
tenacula;  tongue  forceps;  sponges  in  holders;  scalpels,  various;  dissecting 
forceps;  toothed  forceps;  artery  clamp  forceps,  long  and  short;  scissors, 
straight  and  curved,  long  and  short;  aneurism-needles,  various;  ligature 
carriers;  needles,  various;  ligatures,  silk  and  chromic  gut;  sutures,  silk  and 
gut;  needle-holder;  silk-retractors  for  tongue;  curved  needle  in  handle  to 
carry  silk-retractors  through  tongue;  volsella;  tracheotomy  tubes;  tampon 
cannula;  thermocautery;  Gigli  or  chain  saw;  bone-holding  forceps;  bone- 
cutting  forceps;  drill;  wire;  wire-cutters  (in  case  lower  maxilla  is  to  be  divided) ; 
hare-lip  pins,  sometimes  used  if  cheek  be  split. 


EXCISION  OF  LIMITED  PORTIONS  OF  THE  TONGUE. 

Description. — Limited  portions  of  the  tongue  are  best  excised,  where 
possible,  by  a  V-shaped  incision.  Where  it  is  possible  to  do  so,  the  resulting 
edges  of  the  wound  are  brought  together  and  sutured  with  silk — otherwise 
the  margins  must  heal  by  granulation.  This  method  is  generally  applicable 
to  limited  involvement  of  the  free  portion  of  the  tongue. 

Preparation  and  Position. — As  in  the  removal  of  the  entire  organ. 
(See  the  following  operation.) 

Landmarks. — The  known  attachments  of  the  tongue  to  the  structures 
of  the  mouth,  and  the  position  of  its  vessels. 

Operation. — Gag  the  mouth  open,  as  in  the  complete  operation.  Place 
a  thread  retractor  on  each  side  of  the  area  to  be  removed.  An  assistant,  with 
a  retractor  in  each  hand,  draws  the  tongue  forward  out  of  the  mouth.     The 


622  OPERATION'S  UPON  THE  HEAD. 

operator  seizes  the  part  to  come  away  with  toothed  forceps  held  in  his  left 
hand — and  taking  a  knife  in  his  right  hand,  he  enters  it  behind  the  center 
of  the  growth  to  be  removed,  allowing  a  fairly  wide  area,  and  cuts  forward 
on  one  side  of  the  area.  The  knife  is  then  entered  at  the  same  spot  and 
made  to  cut  its  way  out  on  the  opposite  side  of  the  area,  thus  removing  a 
V-shaped  piece.  The  bleeding  vessels  are  ligatured  with  gut,  or  twisted — 
and  the  lips  of  the  incision,  if  practicable,  are  sutured,  otherwise  they  are  left 
to  granulate. 

Comment. — For  removal  of  one  half  of  the  tongue  longitudinally,  see  the 
following  operation.  For  removal  of  one  half  of  the  tongue  transversely, 
hemorrhage  may  be  controlled  as  mentioned  under  General  Surgical  Con- 
siderations— the  tongue  is  then  drawn  out  of  the  mouth  by  thread  retractors 
and  the  anterior  portion  removed  by  curved  scissors,  cutting  transversely 
just  anterior  to  the  temporary  ligatures.  The  lingual  arteries  are  then 
clamped  and  tied  with  chromic  gut  or  silk,  the  smaller  ones  being  twisted, 
and  the  stump  left  to  heal  by  granulation. 


EXCISION  OF  THE  TONGUE  THROUGH  THE  MOUTH,  WITHOUT  PRE- 
LIMINARY LIGATION  OF  THE  LINGUAL  ARTERIES. 

WHITEHEAD'S  OPERATION. 

Description. — The  tongue  is  drawn  forward  with  a  double  silk  retractor 
— its  connections  with  the  floor  of  the  mouth  and  the  anterior  pillars  of  the 
fauces  are  divided  with  scissors — its  base  is  similarly  divided  transversely — 
the  lingual  arteries  being  seized  just  before  division,  divided,  clamped,  and 
then  twisted. 

Preparation. — Thorough  cleansing  of  the  mouth  and  teeth. 

Position. — Patient  lies  near  right  edge  of  table,  shoulders  and  head 
raised  almost  to  the  sitting  position  (preferably  until  his  head  is  nearly  on  a 
level  with  the  surgeon's  axilla) — his  head  being  turned  to  the  right  side  and 
slightly  forward,  so  that  blood  gravitates  out  of  the  mouth.  A  gag  is  placed 
in  position  upon  the  left  side  of  the  mouth  and  held  firmly  pressed  to  the  left 
side  of  the  face.     Surgeon  stands  to  the  right.     Assistant  opposite. 

Landmarks. — The  known  attachments  of  the  tongue,  and  the  position 
of  its  vessels. 

Operation. — (i)  Having  gagged  the  mouth  wide  open,  pass  a  heavy 
double  ligature  through  the  anterior  portion  of  the  tongue,  in  the  median 
line,  and,  by  means  of  this  retractor,  draw  the  tongue  out  of  the  mouth. 
(See  Fig.  485.)  (2)  Separate  the  tongue  from  the  floor  of  the  mouth  and 
the  anterior  pillars  of  the  fauces  by  cutting  boldly  through  the  fraenum  linguae, 
connective  tissues  and  the  anterior  pillars,  while  the  tongue  is  drawn  well 
forward  by  the  thread  retractors,  freeing  the  tongue  first  horizontally  to  a  point 
behind  the  focus  of  disease  (or  as  far  as  practicable)  and  then  dividing  it  trans- 
versely across  its  base — cutting  not  in  little  snips,  but  in  decided  cuts  carried 
boldly  on  until  near  the  known  position  of  the  lingual  arteries  upon  the  lingualis, 
just  to  the  outer  side  of  the  geniohyoglossi — sponging  away  all  blood  promptly 
as  the  division  progresses.  (3)  Just  prior  to  dividing  the  Unguals,  they  are 
seized,  together  with  the  tissue  immediately  surrounding,  by  artery  forceps 
and  clamped — the  tissues  including  the  arteries  are  then  cut — after  which 
the  arteries  are  caught  by  a  second  pair  of  clamp  forceps,  twisted,  and  let  go. 
(4)  Before  finally  severing  the  last  attachments  of  the  tongue,  pass  a  stout 


EXCISION    OF    THE    TONGUE    THROUGH    THE    MOUTH. 


623 


silk  retractor  through  the  glosso-epiglottidean  fold,  to  enable  the  base  of 
the  tongue-stump  to  be  drawn  forward  in  case  of  hemorrhage  or  difficulty  of 
respiration.  Allow  this  ligature  to  remain  attached  for  about  twenty-four 
hours,  in  case  of  need.  (5)  The  stum])  receives,  at  the  hands  of  the  author 
of  the  operation,  an  immediate  coating  of  a  special  antiseptic,  styptic  varnish. 
Other  surgeons  merely  dust  the  stump  with  some  form  of  powder.  Others 
make  no  special  form  of  application,  merely  frequently  washing  the  mouth 
with  an  antiseptic  solution. 


Fig.485.— Whitehead's  Excision  of  the  Tongue  through  the  Mouth  :— A,  Tongue  partly 
split  in  the  median  raphe  and  draw  n  out  of  the  gagged  mouth  by  thread  retractors;  B,  Scissors  free- 
ing the  attachments  of  the  tongue  from  the  floor  of  the  mouth  ;  C,  Scissors  dividing  the  anterior  pillar 
of  the  fauces  and  base  of  the  tongue  ;  D,  Catch-forceps  clamping  the  lingual  artery  in  situ  prior  to  its 
division  by  scissors  ;  E,  Suture  through  the  glosso-epiglottidean  fold,  placed  before  its  division,  for 
drawing  the  base  of  the  tongue  forward. 


Comment. — (1)    The  operation   is   rapidly  and   boldly  done,  until  the 
tongue  is  removed  and  the  arteries  and  the  stump  are  in  view  and  in  control. 

(2)  The  thread  retractor  in  the  glosso-epiglottidean  fold  may  be  omitted,  as 
the  tongue  may  be  hooked  forward  with  a  finger  or  an  instrument  if  necessary. 

(3)  Jacobson  first  splits  the  tongue  in  the  middle  line  and  removes  each  half 
separately.  He  also  cuts  a  transverse  groove  through  the  side  and  dorsum 
of  the  tongue  nearly  to  the  artery,  and  then  tears  through  with  the  finger  and 
closed  scissors  until  the  artery  is  reached  and  clamped.  (4)  If  necessary  to 
remove  but  one  half  of  the  tongue,  a  thread  retractor  is  placed  through  the 


624  OPERATIONS  UPON  THE  HEAD. 

tip  of  the  sound  side — the  tongue  is  then  split  through  the  median  fibrous 
raphe  (while  the  opposite  side  is  held  by  forceps  or  another  thread  retractor) 
— the  connections  with  the  floor  of  the  mouth  and  the  anterior  pillars  of  the 
fauces  are  separated  on  that  side  alone — and  the  operation  completed  as 
above.  (5)  Preliminary  tracheotomy  is  not  generally  done,  but  may  be  done 
if  indicated.  (6)  The  lingual  arteries  may  be  tied,  when  exposed  in  the 
above  way,  instead  of  being  merely  twisted. 


EXCISION   OF   THE    TONGUE   THROUGH   THE   MOUTH,    AFTER   PRE- 
LIMINARY LIGATION  OF  THE  LINGUAL  ARTERIES  IN 
THE  NECK. 

Description. — The  two  Unguals  are  first  tied  in  the  neck,  and  the  tongue 
is  then  removed  through  the  mouth  by  means  of  scissors. 

Preparation,  Position,  and  Landmarks. — As  in  the  preceding  opera- 
tion. 

Operation. — The  two  lingual  arteries  are  first  tied  in  the  neck,  beneath 
the  hyoglossi — precisely  as  in  the  simple  ligation  of  those  vessels  (see  Liga- 
tions, page  38) — and  the  wounds  closed  and  dressed.  The  tongue  is  then 
removed  through  the  gagged  mouth  by  means  of  scissors,  just  as  in  the  White- 
head operation  previously  described.  Thus  comparatively  slight  hemorrhage 
occurs — from  the  dorsalis  linguae  branch  of  the  lingual  and  from  branches  of 
the  facial  and  ascending  pharyngeal  of  the  external  carotid. 


EXCISION  OF  THE  TONGUE  BY  MEDIAN  INCISION  THROUGH  LOWER 

LIP,   CHIN,    AND    NECK,   WITH    OSTEOPLASTIC    DIVISION    OF 

INFERIOR  MAXILLA. 

kocher's    operation. 

Description. — This,  the  more  modern  form  of  Kocher's  operations  for 
the  removal  of  the  tongue,  is  especially  indicated  where  the  growth  involves 
the  adjacent  intra-oral  structures,  particularly  those  rather  posteriorly  placed, 
and  hence  difficult  to  reach,  and  where,  at  the  same  time,  the  glandular 
structures  lying  along  the  large  cervical  vessels  are  not  involved  (unless  these 
latter  be  removed  by  separate  operation) . 

Preparation. — The  teeth,  mouth,  and  pharynx  are  to  be  thoroughly 
cleansed  to  guard  against  aspiration  pneumonia. 

Position. — The  patient  is  in  the  half-sitting  position — no  preliminary 
tracheotomy  is  done — and  complete  anaesthesia  is  used. 

Landmarks. — Median  line  of  lower  lip,  inferior  maxilla,  and  hyoid  bone. 

Incision. — Carry  a  median  incision  through  the  structures  of  the  lower 
lip  and  the  structures  of  the  chin  down  to  the  bone — thence  the  incision  is 
prolonged  in  the  median  line  through  the  soft  structures  of  the  neck  to  the 
center  of  the  hyoid  bone  (Fig.  486,  A) . 

Operation. — Having  carried  the  incision  through  the  soft  parts,  the  vessels 
are  clamped  or  tied.  The  inferior  maxilla  is  now  sawn  through  in  the  middle 
line  by  means  of  a  Gigli  saw  conducted  around  and  behind  it,  coming  out 
above  between  two  teeth,  or  through  the  space  made  by  extracting  a  central 
incisor  (Fig.  487).  It  is  rather  better  to  divide  the  jaw  obliquely  backward 
in  the  direction  of  the  involved  side,  thus  keeping  the  insertions  of  the  genio- 
hyo-glossi  and  genio-hyoids  of  both  sides  attached  to  the  healthy  side — the 


EXCISION    OF    TONGUE    THROUGH    LOWER    LIP. 


625 


bevelling  also  making  subsequent  displacement  less  likely.  Previous  to 
division  of  the  bone,  drill-holes  may  be  made  for  subsequent  sutures.  Whether 
the  muscles  attached  to  the  tubercles  near  the  symphysis  menu'  be  exposed  so 
as  to  leave  half  of  them  or  all  of  them  attached  to  one  side  of  the  divided  bone 
or  not,  the  two  sides  of  the  divided  jaw  are  now  firmly  retracted  to  opposite 
sides  by  means  of  toothed  retractors.  The  tongue  is  drawm  well  out  of  the 
mouth  by  a  thread  or  special  retractor — and  displaced  to  the  side  opposite 
to  that  involved.  The  mucous  membrane  of  the  floor  of  the  mouth  is  divided 
posteriorly — under  which  is  exposed  the  lingual  vein,  which  is  ligated  as  it 
crosses  the  side  of  the  hyo-glossus  muscle.  The  lingual  nerve,  coming  forward 
just  under  the  mucous  membrane,  is  also  divided.  The  hypoglossal  nerve  is 
found  crossing  the  outer  surface  of  the  genio-glossus.  The  lingual  artery  is 
well  in  the  field,  between  the  hyo-glossus  and  the  genio-hyo-glossus,  and  can  be 


V 


Fig.  486. — Lines  of  Incision  for  Kocher's  Excisions  of  the  Tongue: — A,  By  median 
straight  incision  through  lower  lip,  chin,  and  neck,  with  osteoplastic  division  of  inferior  maxilla; 
B,  By  lateral  angular,  or  curved,  incision  raising  a  flap  upon  the  side  of  the  neck. 

ligated  at  once  or  later.  The  hyo-glossus  is  divided  outside  the  growth  and 
cauterized.  The  tongue  is  drawn  forcibly  forward  and  its  mucous  membrane 
is  divided  far  back  with  the  actual  cautery,  away  from  the  growth.  The 
stylo-glossus  muscle  and  the  glosso-pharyngeal  nerve  lying  near  it  are  also 
divided. 

If  the  mucous  membrane  is  divided  in  front  of  the  tonsil,  the  tonsil,  if 
involved,  can  be  separated  by  passing  a  curved,  blunt  dissector  around  its 
outer  aspect — thus  baring  the  internal  pterygoid  muscle.  Divide  with  the 
cautery  as  much  of  the  soft  palate  as  is  involved.  The  tensor  and  levator 
palati  are  divided,  and  the  posterior  pharyngeal  mucous  membrane  down  to 
the  longus  colli  and  in  front  of  the  root  of  the  tongue. 

The  tongue  is  now  divided  with  the  cautery  where  it  is  normal  in  structure — 

and  the  muscles,  nerves,  and  vessels  (previously  tied)  are  divided  on  the  under 

40 


626 


OPERATIONS    UPON    THE    HEAD. 


surface  before  entering  the  new  growth — the  nerves  and  muscles  of  deglutition 
being  left  as  long  as  possible. 

The  two  halves  of  the  lower  jaw  are  then  united  by  wire  sutures  introduced 
through  the  previously  drilled  holes.  Gauze  drainage  is  established  through 
the  posterior  end  of  the  opening,  just  above  the  hyoid  bone.  Kocher  rubs 
xeroform  into  the  cut  surfaces  and,  after  suturing  the  median  wound,  smears 
the  suture  line  with  bismuth  paste. 

Comment. — (i)  Damage  as  little  as  possible  the  muscles  and  nerves  of 
the  mouth,  tongue,  and  pharynx.  (2)  Provide  ample  escape  of  wound  fluids. 
(3)  Let  the  patient  occupy  a  half-sitting  posture  in  bed  from  the  time  of  the 
operation,  during  convalescence.  (4)  Division  of  the  muscles  by  the  actual 
cautery  limits  the  initial  infection  of  the  soft  parts  at  the  time  of  operation. 
(5)   No   preliminary   tracheotomy   is   done.     (6)   If   the   cervical   glands  are 


Fig.  487. — Kocher's  Excision  of  the  Tongue  by  Median  Incision  through  Lower 
Lip,  Chin,  and  Neck,  with  Osteoplastic  Resection  of  Inferior  .Maxilla: — A,  K,  Two 
halves  of  jaw  drawn  apart  by  retractors;  C,  Divided  mucous  membrane  of  mouth;  D,  Lingual 
nerve;  E,  Lingual  vein;  F,  Lingual  artery;  G,  Hypoglossal  nerve;  H,  Hyoglossus  muscle;  B, 
Tongue,  retracted  to  non-diseased  side;  I,  Right  genio-hyoglossus  muscle;  J,  Left  genio-hyo- 
glossus  muscle;  L,  Genio-hyoid  muscle.     (Redrawn  from  Kocher.) 


involved,  they  are  removed  by  a  subsequent  separate  operation.  (7)  Very  little 
hemorrhage  should  occur — and  but  limited  functional  disability,  movements 
usually  being  possible  at  once  without  pain,  and  swallowing  the  following  dav. 
The  lip  wound  leaves  but  little  scarring  if  properly  sutured.  (8)  Non-inter- 
ference with  deglutition  is  usually  accomplished  in  this  operation  and  is  the 
chief  safeguard  against  deglutition  pneumonia.  (9)  The  operation  may  be 
done  with  the  patient  in  Trendelenburg's  position.  (10)  The  access  to  the 
involved  structures  is  especially  full,  as  far  back  as  the  isthmus  of  the  fauces. 
(ii)  In  passing  in  between  the  genio-hyo-glossi  the  room  given  is  not  so  free 
as  in  making  the  bone-section  to  one  side  of  their  attachment.  The  genio-hyo- 
glossus, however,  is  only  detached  from  the  jaw  (as  pictured  in  the  illustration) 
if  adherent  upon  the  involved  side,  thereby  preventing  the  separation  of  the 
two  halves  of  the  jaw.     The  mylo-hyoid  is  stretched  to  its  limit. 


EXCISION    OF    THE    TONGUE   THROUGH   THE    NECK.  627 


EXCISION  OF  THE  TONGUE,  TOGETHER  WITH  THE  CERVICAL  AND 

SUBMAXILLARY  GLANDS,  BY  AN  INCISION  IN  THE  NECK, 

AFTER  PRELIMINARY  TRACHEOTOMY  AND  LIGATION 

OF  THE  LINGUAL  AND  FACIAL  ARTERIES. 

KOCHER'S  OPERATK  >N. 

Description. — After  a  preliminary  tracheotomy  and  the  ligation  of  the 
lingual  and  facial  arteries  in  the  neck,  upon  both  sides,  followed  by  the  removal 
of  the  cervical  and  submaxillary  glands  (and  the  sublingual,  if  necessary) 
of  both  sides,  the  tongue  is  drawn  through  an  incision  made  through  one 
side  of  the  floor  of  the  mouth,  from  the  wound  in  the  neck,  and  removed 
bv  division  transversely  at  its  base.  The  preliminary  tracheotomy  is  prefer- 
ablv  done  a  few  days  in  advance,  that  the  patient  may  have  become  accustomed 
to  breathe  through  the  tube  at  the  time  of  the  operation.  Thus  several 
distinct  operations  are  done — tracheotomy;  ligation  of  both  lingual  and 
both  facial  arteries  at  their  origin;  excision  of  the  cervical  and  submaxillary, 
and  probablv  sublingual,  glands;  and  the  removal  of  the  tongue. 

Preparation. — Thorough  cleansing  of  mouth  and  teeth.  A  preliminary 
tracheotomv  done  several  days  in  advance  of  the  main  operation. 

Position. — Patient  supine,  at  right  edge  of  table;  shoulders  elevated; 
head  thrown  back  and  turned  to  one  side;  neck  prominent.  Surgeon  on  side 
of  operation.  Assistant  opposite.  (The  positions  of  the  principals  will  differ 
somewhat  with  the  various  steps  of  the  complex  operation.) 

Landmarks. — Those  of  the  following  operations  (q.  v.),  tracheotomy, 
ligation  of  lingual  and  facial  arteries  in  the  neck,  excision  of  submaxillary, 
sublingual,  and  cervical  glands,  together  with  the  following; — the  anterior 
border  of  the  sternomastoid,  the  hyoid  bone,  and  the  anterior  belly  of  the 
digastric  muscle. 

Incision. — See  step  No.  3  of  the  Operation. 

Operation. — (1)  A  tracheotomy  is  first  performed  in  the  usual  way — 
and,  where  possible,  several  days  in  advance.  (See  page  704.)  (2)  The 
pharynx  is  plugged  with  a  sterile  sponge  attached  to  a  piece  of  silk — to  prevent 
the  ingress  of  blood  into  the  trachea  or  esophagus.  (3)  The  incision  is  now 
made  along  the  anterior  border  of  the  sternomastoid,  from  the  mastoid  process 
to  about  the  center  of  the  muscle — thence  transversely  forward  in  the  crease 
between  the  floor  of  the  mouth  and  the  neck,  to  the  hyoid  bone — thence  along 
the  anterior  belly  of  the  digastric  to  the  symphysis  menti.  (See  Fig.  486.) 
(4)  Having  divided  skin  and  subcutaneous  fascia,  and  ligated  the  subcu- 
taneous veins,  turn  back,  by  dissection,  the  flap  thus  marked  out,  and,  dis- 
placing it  upward,  suture  it  to  the  cheek.  (See  Fig.  488.)  (5)  Expose  the 
anterior  border  of  the  sternomastoid,  as  far  down  as  the  great  cornu  of  the 
hyoid  bone,  also  the  anterior  belly  of  the  digastric  muscle — and  remove,  en 
masse,  all  enlarged  glands  from  the  upper  end  of  the  sternomastoid  and  from 
beneath  the  angle  and  body  of  the  inferior  maxilla  (see  page  150).  The  veins 
are  ligated  as  encountered  and  the  mass  of  involved  glands  and  connective  tissue 
are  raised  together,  exposing  the  posterior  belly  of  the  digastric  and  stylohyoid 
muscles  posteriorly.  (6)  The  submaxillary  gland  is  dissected  up,  working 
from  behind,  and  removed  simultaneously  with  the  cervical  glands.  (See 
page  725.)  The  sublingual  gland  is  similarly  removed,  if  involved.  (See 
page  726.)  (7)  The  facial  artery  is  tied  near  its  origin  from  the  external 
carotid,  as  soon  as  exposed  in  the  process  of  raising  the  submaxillary  gland 
(see  page  41).  The  lingual  artery  is  also  tied  near  its  origin,  before  passing 
under  the  hyoglossus  (see  page  39).     All  veins  encountered  are  ligated.     (8) 


6a8 


OPERATIONS    UPON    THE    HEAD. 


Steps  (3),  (4),  (5),  and  (7)  are  repeated  on  the  opposite  side,  if  the  entire 
tongue  is  to  be  removed — and  also  (6)  if  the  submaxillary  and  sublingual, 
as  well  as  the  lymphatic  glands,  be  involved.  (9)  The  mylohyoid  muscle  is 
now  exposed  and  divided  as  far  as  necessary.  The  mucous  membrane  is 
then  cut  close  to  and  parallel  with  the  inferior  maxilla — and  the  mouth  thus 


Fig.  48S. — Kocher's  Excision  of  Tongue,  together  with  the  Cervical  and  Sub- 
maxillary. Glands,  by  a  Curved  or  Angular  Lateral  Cervical  Incision,  after  Pre- 
liminary Tracheotomy  and  Ligation  of  Lingual  and  Facial  Arteries: — B,  Flap  raised 
from  neck  and  stitched  to  cheek:  A,  Submaxillary  gland  being  dissected  out;  C,  External  jugular 
vein  ligated;  D,  Internal  jugular  vein;  E,  Facial  artery  ligated  near  origin  from  external  carotid: 
H,  Hypoglossal  nerve  crossing  hyoglossus  muscle;  F,  External  carotid  artery;  G,  Lingual  artery, 
ligated  near  origin;  I,  N,  Retractors  retracting  digastric  and  stylohyoid  muscles;  O,  Ranine 
vein;  J,  Scissors,  introduced  through  mouth,  cutting  base  of  tongue  away  from  hyoid  bone  and 
its  remaining  attachments;  K,  Flap  of  skin,  fascia,  and  platysma;  L,  Incision  in  mylohyoid 
muscle;  M,  Tongue  being  drawn  through  incision  in  mylo-hyoid  muscle. 

entered.  (10)  The  tongue  is  seized  and  drawn  through  the  floor  of  the  mouth 
and  the  wound  in  the  neck.  While  under  tension  it  is  cut  away  from  the  hyoid 
bone,  by  means  of  blunt  scissors  introduced  through  the  mouth.  The  stump 
is   then  drawn  forward  in  the  mouth  and  a  few  remaining  arterial  twigs 


EXCISION    OF    THE    TONGUE    THROUGH    THE    NECK.  629 

which  bleed  are  twisted.  (11)  The  wound  is  not  sutured — but  is  allowed  to 
close  by  granulation,  with  the  freest  possible  drainage.  (12)  The  tracheot- 
omy tube  remains  in  until  the  wound  is  granulating  well — the  entrance  to  the 
larynx  being,  in  the  mean  time,  plugged  to  prevent  lung  infection.  Feeding 
is  carried  on  by  the  introduction  of  fluids  through  an  esophageal  tube.  The 
mouth  is  frequently  washed  with  an  antiseptic  solution. 

Comment. — If  but  one  half  of  the  tongue  is  to  be  removed,  an  incision 
is  made  only  upon  the  corresponding  side  of  the  neck — the  tongue  is  then 
split  down  its  center,  from  within  the  mouth,  and  the  diseased  half  drawn 
through  the  wound  in  the  neck  and  divided  at  its  base  by  blunt,  curved 
scissors  introduced  through  the  mouth. 


NOTE. 

Operations  upon  the  Teeth;  Hard  Palate;  Lips;  Gums;  Soft  Palate;  and 
Uvula,  will  not  be  separately  considered. 

Operations  upon  the  following  structures  of  the  Head  will  be  found  under 
those  structures  among  the  Operations  of  General  Surgery,  namely,  Bones; 
Joints;  Ligaments;  Fasciae;  Muscles;  Arteries;  Veins;  Lymphatics;  Nerves, 
Plexuses,  and  Ganglia. 


CHAPTER  II. 

OPERATIONS  UPON  THE  SPINE  AND  SPINAL 

CORD. 

SURGICAL  ANATOMY  OF  THE  SPINE  AND  SPINAL  CORD. 

Muscles  in  Relation  with  the  Spine. — (i)  Cervical  Region:  Ante- 
riorly; rectus  capitis  amicus  major;  rectus  capitis  anticus  minor;  rectus 
lateralis;  longus  colli.  Laterally;  scalenus  anticus,  medius  and  posticus. 
Posteriorly;  trapezius;  levator  anguli  scapula?;  rhomboideus  minor;  serratus 
posticus  superior;  splenius  capitis;  splenius  colli;  cervicalis  ascendens;  trans 
versalis  colli;  trachelomastoid ;  spinalis  colli;  complexus;  biventer  cervicis; 
semispinalis  dorsi;  semispinalis  colli;  multifidus  spinse;  supraspinales;  inter- 
spinales;  intertransversales;  rectus  capitis  posticus  major;  rectus  capitis 
posticus  minor;  obliquus  capitis  inferior;  obliquus  capitis  superior.  (2) 
Thoracic  Region:  Antero-laterally;  psoas  minor.  Postero-laterally;  trape- 
zius; latissimus  dorsi;  rhomboideus  minor;  rhomboideus  major;  serratus 
posticus  superior;  serratus  posticus  inferior;  splenius  capitis;  splenius  colli; 
longissimus  dorsi;  transversalis  colli;  trachelomastoid;  spinalis  dorsi;  com- 
plexus; biventer  cervicis;  semispinalis  dorsi;  semispinalis  colli;  multifidus 
spinae;  rotatores  spinas;  interspinales;  intertransversales;  levatores  costarum. 
(3)  Lumbar  Region:  Antero-laterally;  crura  of  diaphragm;  psoas  magnus; 
psoas  minor.  Postero-laterally;  latissimus  dorsi;  serratus  posticus  inferior; 
erector  spinae;  longissimus  dorsi;  spinalis  dorsi;  multifidus  spina?;  inter- 
spinales; intertransversales;  transversalis  abdominis;  quadratus  lumborum. 
Note — The  ligamentum  nuchas  extends  from  external  occipital  protuberance 
to  spinous  process  of  seventh  cervical  vertebra.  The  supraspinous  ligament 
is  a  continuation  downward  of  the  ligamentum  nuchas,  stretching  between 
the  spinous  processes. 

Arteries  of  the  Spinal  Region. — (I)  Arteries  in  the  Neighborhood  of 
the  Spine;  muscular  branches  and  arteria  princeps  cervicis  of  occipital;  pre- 
vertebral branches  of  ascending  pharyngeal;  lateral  spinal,  muscular,  anterior 
spinal,  and  posterior  spinal  branches  of  vertebral;  ascending  cervical  of 
inferior  thyroid;  superficial  cervical  of  transversalis  colli;  muscular,  anterior 
spinal,  and  profunda  cervicis  of  superior  intercostal;  muscular  and  spinal 
branches  from  the  posterior  branches  of  the  intercostals;  muscular  and  spinal 
branches  from  the  dorsal  branches  of  the  lumbar;  middle  sacral  artery  from 
abdominal  aorta;  lumbar  branch  from  ileo-lumbar;  superior  and  inferior 
branches  from  the  lateral  sacral  arteries.  (2)  Arteries  of  the  Spinal  Cord; 
anterior  spinal — from  vertebrals,  intercostals,  lumbar  and  other  arteries 
(passing  to  cord  along  anterior  roots);  posterior  spinal — from  vertebrals, 
intercostals,  and  other  arteries  (running  just  in  front  of  line  of  attachment 
of  posterior  nerve-roots) ;  anastomotic  chain — formed  by  branches  of  posterior 
spinal  running  behind  line  of  posterior  nerve-roots. 

Veins  of  the  Spinal  Region. — (i)  Extra-spinal;  anterior  spinal  plexus 
(in  front  of  bodies  of  vertebras,  emptying  into  neighboring  veins) ;  dorsal 
spinal  plexus  (around  spinous,  articular,  transverse,  and  laminar  Drocesses, 

630 


SURGICAL    ANATOMY    OF    THE    SPINE    AND    SPINAL    CORD. 


63I 


emptying   into   vertebral,  dorsal   branch   of  intercostal,   lumbar    and    lateral 
sacral).     (2)   Intra -spinal;  (a)    Meningeal   Veins;   two  anterior  longitudinal 


X.  to  rectus  lateralis 
'_to  rectus  antic,  minor 
Anastomosis  with  hypoglossal 

Anastomosis  with  pncumogastrio 

,Ar.  to  rectus  antic.major. 

N.  to  mastoid  region. 

.Qreat  auricular  n. 

■Transverse  cervical  n. 

N.  to  Trapezius,  Ang.  Scop,  and  Rhomboid- 

Supra  clavicular  n. 
Supra-acromial  n. 
Phrenic  n. 
N.  to  levator  ang.  scap* 

N.  to  rhomboid 

Subscapular  n. 

Subclavicular  n. 


JV.  topectoraliQ  major. 


Circumflex  n. 


^Musculocutaneous  n. 


Internal  cutaneous  n. 
Small  internal  cutaneous  fU 


J>~-z-ii 

0L.I 

ilJjA 

>— . rtio-nypogastrfc  rt. 

t  3    T^, 

^\..Ilic-lngutnal  n. 

^^si/A 

V^V_. External  cutaneou9 

4  T^^V 

X. Qen  ito-cru  rain. 

\v  /   \f 

^L—  Anterior  crural  n. 

Obturator  n. 

jr.  to  levator  ani. r^v." 

-V.  to  obturator  int ^ 

N.  to  sphincter  ant. 

Coccygeal  n. 

Co.I 


Superior  gluteal  n. 


A*,  to  pyriformla 

N.  to  gemellus  super. 

,N.  lo  gemellus  Infer. 

N.  to  quadratus 

Small  sciatic  n. 
Static  n. 


Fig.  489. — The  Relations  of  the  Segments  of  the  Spinal  Cord  and  Their  Nerve- 
roots  to  the  Bodies  and  Splnes  of  the  Yertebr.e.  (Dejerine  and  Thomas,  modified  by 
Starr.) 


spinal  (on  each  side  of  posterior  surfaces  of  bodies  of  vertebrae)   connected 
by  transverse  branches,  into  which  the  venae  basis  vertebrae  open   (emptying 


632  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

into  posterior  longitudinal  veins,  the  vertebral,  intercostal,  lumbar,  and 
sacral  veins);  two  posterior  longitudinal  spinal  (between  posterior  wall  of 
spinal  canal  and  dura  mater),  emptying  into  anterior  longitudinal,  dorsal, 
and  spinal  veins,  (b)  Medullary  Veins;  coming  from  substance  of  cord, 
empty  into  the  venous  ring  of  each  vertebra. 

Nerves  of  the  Spinal  Region. — Spinal  nerves  (emerging  through  the 
intervertebral  foramina  at  a  considerably  lower  level  than  their  origin  from 
the  cord) ;  posterior  divisions  of  the  cervical,  dorsal,  and  lumbar  nerves ; 
sympathetic  ganglia  and  nerves. 

Membranes  of  the  Cord. — (1)  Dura  Mater;  loose,  strong,  fibrous  sheath 
surrounding  the  cord — prolonged  in  tubular  form  around  spinal  nerves  and 
cauda  equina — separated  from  spinal  canal  by  lax  areolar  tissue  and  plexus 
of  veins  which  connect  its  rough  external  surface  to  periosteum  and  liga- 
ments— extends  from  dura  of  brain  to  second  or  third  sacral  vertebra,  and 
thence  to  base  of  coccyx  as  sheath  of  filum  terminale — its  smooth  inner  surface 
is  separated  by  subdural  space  from  arachnoid  and  is  connected  to  cord  by 
ligamentum  denticulatum  (a  special  development  of  pia  mater) — it  sends 
tubular  prolongations  around  spinal  nerves,  which  merge  into  their  epineurium, 
each  tube  being  divided  into  an  anterior  compartment  for  anterior  nerve-root 
and  posterior  compartment  for  posterior  nerve-root.  (2)  Arachnoid;  con- 
tinuous with  cerebral  arachnoid,  surrounding  cord  down  to  second  or  third 
sacral  vertebra — separated  from  dura  by  subdural  space — separated  from 
pia  mater  by  subarachnoid  tissue  (subarachnoidean  space,  for  cerebrospinal 
fluid) — sends  tubular  prolongations  along  nerve-roots — connected  to  pia  by 
incomplete  septum  posticum.  (3)  Pia  Mater;  formed  by  two  layers,  only  the 
outer,  stronger  layer  being  continuous  with  cerebral  pia  mater — outer  and 
inner  layers  pass  into  anterior  fissure  of  cord — only  inner  layer  dips  into 
posterior  fissure.  Ligamenta  denticulata — fibrous  bands  continuous  with 
pia,  attached  on  either  side  of  cord  and  externally  to  dura — not  piercing 
arachnoid  but  its  denticulations  receiving  tubular  sheaths  from  it — extending 
from  foramen  magnum  above  and  continuous  with  filum  terminale  below. 
Linea  splendens — a  linear  thickening  on  anterior  surface  of  cord.  Filum 
terminale — prolongation  of  pia-matral  covering  of  cord — attached  to  lower 
end  of  sacrum  or  first  piece  of  coccyx. 

Spinal  Localization. — The  relation  of  the  segments  of  the  spinal  cord 
and  their  nerve-roots  to  the  bodies  and  spines  of  the  vertebrae  is  shown  in 
Fig.  489 — the  distribution  of  the  sensory  nerves  in  the  skin  in  Figs.  490,  491 — 
and  the  symptoms  in  cross-lesions  of  the  spinal  cord  in  Figs.  492  to  508. 


SURFACE   FORM    AND    LANDMARKS    OF    SPINE    AND    SPINAL    CORD. 

The  spinal  cord  extends  from  the  upper  border  of  the  atlas  to  the  lower 
part  of  the  body  of  the  first  lumbar  vertebra,  and  is  thence  continued  as  the 
ilium  terminale  to  the  lower  end  of  the  sacrum  or  the  first  piece  of  the  coccyx. 
At  birth  the  cord  extends  to  the  third  lumbar  vertebra. 

The  cervical  enlargement  of  the  spinal  cord  extends  from  the  third  cervical 
to  the  second  dorsal  vertebra,  and  the  lumbar  enlargement  from  the  ninth 
to  the  twelfth  dorsal. 

The  anterior  nerve-roots  emerge  from  the  cord  along  the  antero-lateral 
fissure,  and  the  posterior  nerve-roots  along  the  postero-lateral  fissure — and 
unite  near  the  outer  part  of  the  intervertebral  foramina.  The  intrathecal 
nerve-roots  increase  in  length  as  they  descend. 


SURGICAL    ANATOMY    OF    THE    SPINE    AND    SPINAL    CORD. 


633 


Auriculotemporal  3  V, 

Great  oceipita 

Lacrimal  1  V 

Temporomalar  2  V 

Small  occipital  C.  P 

Great  auricular  C.  P. 


Supraclavicular 
*     C.  P. 
Acromial  branch 
Middle  branch 


Circumflex  E.  P. 
Interoostohumeral 

Nerve  of  Wrisberg 

B.  P. 
Exterual  cutaneous 
of  musculospiial 
B.  P. 

Internal  cutaneous 
B.  P. 

Musculocutaneous 
B.  P. 


Median 
B.  P. 


Ulnar  B.  P 
Exterual  cutaneous  L.  P 


Branches  from  external 
popliteal  S.  P. 


Musculocutaneous  S.  P. 

External  saphenous  S.  P. 
Anterior  tibial  S.  P. 


Supra-orbital  1  V. 

Supratrochlear  1  V. 
Intratrochlear  1  V. 
Nasal  1  V. 

Infra-orbital  2  V. 
Buccal  3  V. 
Mental  3  V. 

Superficial  cervical  C.  P. 


Sternal  branch 


Anterior  branches  of  intercostal 
nerves 


Lateral  branches  <>f  intercostal 
nerves 


Iliohypogastric  L.  P. 
Porsalis  penis  of  pudic  S.  P. 
Ilioinguinal  L.  P. 

Genitocrural  L.  P. 
Middle  cutaneous  L.  P. 
Internal  cutaneous  L.  P. 


Internal  saphenous  L.  P. 


Fig.  490.— Cutaneous  distribution  of  nerves  (after  Flower). 


634  OPERATIONS    UPON   THE    SPINE    AND    SPINAL    CORD. 


Great  occipital,  posterior  branch  or 
second  cervical 


Third  cervical 


Posterior  branches  of  spinal  nerves 


Lateral  branches  of  intercostal  nerves 

Iliac  branch  of  ilio-inguinal  L.  P. 
Second  lumbar 

Inferior  hemorrhoidal  of  pudic  S.  P. 

Superficial  perineal  of  pudic  and 
inferior  pudendal  of  small 
sciatic  S.  P. 

Interior  gluteal  of  small  sciatic  S.  P. 


Internal  cutaneous  L.  P. 


Internal  saphenous  L.  P. 


Auriculotemporal  3  V. 
Small  occipital  C.  P. 

Great  auricular  C.  P. 


Supraclavicular 
C.  P.,  acromial 
branch 

Second  dorsal 
Circumflex  B.  P. 


Intercostohumeral 

Internal  cutaneous 

of  niusculospiral 

B.  P. 
Nerves  of  Wrisberg 

B.  P. 
External  cutaneous 

of  musculospiral 

B.  P. 
Internal  cutaneous 

B.  P. 
Musculocutaneous 

B.  P. 


Radial  B.  P. 
Ulnar  B.  P. 


External  cutaneous  L.  P. 


Branches  from  external 
popliteal  S.  P. 


External  saphenous  S.  P. 


Posterior  tibial  S.  P. 


Fi<r.  491.— Cutaneous  distribution  of  nerves  (after  Flower). 


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641 


642  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

The  spinous  processes  of  the  vertebrae  are  found  in  the  nuchal,  dorso- 
lumbar,  and  sacral  furrows.  The  spines  of  the  more  central  dorsal  region 
overlap  each  other  considerably — those  of  the  lower  cervical  and  upper 
dorsal  but  slightly — those  of  the  lower  dorsal  slightly  or  not  at  all — and  those 
of  the  upper  cervical  and  entire  lumbar  not  at  all. 

The  spinous  process  of  the  seventh  cervical  vertebra  (vertebra  prominens) 
is  generally  easily  located,  and  from  this  the  spines  of  the  vertebras  above 
and  below  are  readily  found  by  counting — all  the  spinous  processes  being 
more  prominent  when  the  vertebral  column  is  bent  forward.  Other  less 
accurate  methods  of  locating  the  spines  are  sometimes  used.  When  the  arms 
are  at  the  side,  the  superior  angle  of  the  scapula  corresponds,  generally,  to 
the  interval  between  the  first  and  second  dorsal  spines  (and  the  upper  border 
of  the  second  rib) ; — the  root  of  the  spine  of  the  scapula  with  the  third  dorsal 
spine,  or  with  the  interspace  between  the  third  and  fourth  dorsal  spines; — 
and  the  inferior  angle  of  the  scapula  with  the  seventh  dorsal  spine,  or  with  the 
interspace  between  the  seventh  and  eighth  (and  sometimes  with  the  eighth 
rib).  The  twelfth  dorsal  spine  corresponds  with  the  head  of  the  twelfth  rib. 
The  third  lumbar  spine  is  generally  slightly  above  the  umbilicus, — and  the 
fourth  lumbar  spine  is  on  a  level  with  the  highest  part  of  the  iliac  crests. 

The  approximate  relations  of  the  origins  of  the  roots  of  the  spinal  nerves 
to  the  spinous  processes  of  the  vertebrae  are,  according  to  R.  W.  Reid,  as 
follows; — (a)  Second  Cervical  arises  opposite  the  arch  of  the  atlas, — third, 
from  opposite  the  spine  of  the  axis, — fourth,  from  opposite  the  interspace 
between  second  and  third  spines, — fifth,  sixth,  seventh,  and  eighth  arise 
opposite  the  spine  of  the  second  cervical  vertebra  above  the  intervertebra' 
foramen  of  exit  of  each  nerve,  (b)  First,  second,  third,  fourth,  fifth,  and 
sixth  Dorsal  Nerves  arise  opposite  the  spinous  processes  of  the  third  vertebra 
above  their  respective  foramina  of  exit, — seventh,  eighth,  ninth,  tenth,  eleventh, 
and  twelfth  arise  opposite  the  spines  of  the  fourth  vertebra  above  their  respec- 
tive foramina  of  exit,  (c)  Lumbar  Nerves  arise  near  the  spines  of  the  tenth 
and  eleventh  dorsal  vertebra?,  (d)  Sacral  Nerves  arise  between  the  eleventh 
dorsal  and  first  lumbar  spines. 


GENERAL   SURGICAL   CONSIDERATIONS   IN   OPERATIONS  UPON  THE 
SPINE  AND   SPINAL   CORD. 

I.  The  General  Considerations  of  the  Osteoplastic  Resection  of  the 
Spine  and  of  Laminectomy,  and  their  Relative  Values. — In  an  osteo- 
plastic resection  of  the  spine,  a  composite  flap,  consisting  of  skin,  fascia,  one 
or  more  spinous  processes,  a  set  or  more  of  corresponding  laminae,  and  con- 
necting ligaments,  is  partially  excised  en  masse,  with  the  constituent  parts 
adherent,  and  temporarily  turned  backward  and  upward,  hinging  upon  its 
own  ligaments,  thus  exposing  the  portion  of  cord  or  spine  involved,  and  is 
finally  dropped  back  into  its  normal  place  at  the  conclusion  of  the  operation, 
with  practically  all  of  its  structures  present  and  in  natural  relation.  The 
soft  parts  are  at  no  time  detached  from  the  spines,  and  only  partly  and  tem- 
porarily detached  from  the  laminae. 

In  the  operation  of  laminectomy,  or  lamnectomy,  as  it  is  variously  called, 
the  spinous  processes  and  lamina?,  with  connecting  ligaments,  of  two  or  more 
vertebrae,  are  completely  freed  from  surrounding  structures,  excised,  and  per- 
manently discarded.  Where,  as  has  occasionally  been  done,  the  spinous 
processes  and  laminae  are  temporarily  preserved  in  warm  normal  salt  solution 


SURGICAL    CONSIDERATIONS    IN    OPERATIONS    UPON    SPINE.        643 

and  replaced  in  situ  at  the  end  of  the  operation,  the  procedure  is  not,  strictly, 
a  laminectomy,  but  becomes  a  form  of  osteoplastic  resection  without  all  the 
good  points  of  the  latter  done  in  a  typical  manner. 

In  performing  laminectomy  an  attempt,  at  least,  should  always  be  made 
to  do  the  operation  subperiosteally,  unless  there  be  some  pathological  con- 
traindication. Many  surgeons,  however,  never  attempt  to  free  the  spines 
and  laminae  of  their  periosteum  before  their  excision,  and  in  the  majority  of 
cases  where  it  is  undertaken  it  may  be  safely  said  that  the  subperiosteal  feature 
of  the  operation  is  carried  out  so  imperfectly  as  to  scarcely  amount  to  a  sub- 
periosteal method  at  all,  so  great  are  the  difficulties  of  preserving  that  mem- 
brane in  clearing  these  small  and  irregular  bones.  In  the  osteoplastic  resection 
there  is  no  indication  to  work  along  subperiosteal  lines. 

The  actual  opening  in  the  spine  may  be  of  practically  the  same  size  and 
shape  in  both  operations;  but  the  tendency  is  to  form  a  narrower  bony  opening 
in  laminectomy,  and,  of  necessity,  the  field  for  manipulation  is  more  contracted 
than  in  osteoplastic  resection,  owing  to  the  much  nearer  approximation  of 
the  walls  of  the  wound  in  the  soft  parts. 

As  to  difficulty  of  execution,  when  one  has  practised  both  operations 
equally,  no  appreciable  difference  in  the  difficulty  of  technique,  worthy  of  a 
determining  consideration,  is  experienced. 

It  is  not  open  to  question  that  the  laminectomy  leaves  a  weaker  spine  than 
does  an  osteoplastic  resection,  for  the  latter  leaves,  practically,  an  intact  spine, 
while  the  former  leaves  a  spine  minus  as  many  spinous  processes  and  laminae, 
with  their  connecting  ligaments,  as  have  been  cut  out.  Just  how  much  weaker 
laminectomy  leaves  the  spine  it  would  be  hard  to  calculate;  but  it  is  self-evident 
that  a  whole  spine  is  better  than  part  of  a  spine,  even  if  only  one-quarter  or  one- 
third  of  two  or  three  vertebrae  have  been  permanently  removed,  and  although 
the  bone  thus  represented  be  replaced  by  fibrous  tissue,  or  partly  fibrous  and 
partly  bony.  It  is  known  that  patients  have  sometimes  not  been  able  to  sit 
upright,  or  to  hold  their  heads  up,  after  laminectomy,  necessitating  the  wearing 
of  a  spinal  support  for  some  time. 

Weighing  all  considerations  involved  in  the  selection  of  one  or  the  other 
method  of  approach,  the  choice  of  operation  should,  in  the  opinion  of  the  writer, 
be  unquestionably  given  to  the  osteoplastic  resection,  as  an  altogether  more 
surgical  procedure, — saving  to  the  individual,  as  it  does,  practically  all  of  his 
structures,  all  save  one  spinous  process, — leaving,  after  union,  an  almost 
intact  and  necessarily  stronger  spinal  column;  affording  a  freer  and  fuller 
field  for  inspection  and  manipulation  at  the  time  of  operation;  furnishing 
greater  subsequent  protection  to  the  spinal  cord,  and  most  probably  furnishing 
also  greater  immediate  protection  to  the  cord  by  reducing,  in  shutting  off  the 
spinal  canal,  the  chances  of  intraspinal  infection  in  the  event  of  non-primary 
healing. 

To  summarize,  it  is  safe  to  say  that  no  operator  who  is  equally  skilful 
in  performing  an  osteoplastic  resection  and  a  laminectomy  will  hesitate  in 
choosing  the  former  as  the  best  procedure  in  the  vast  majority  of  cases;  and 
that  if,  on  the  other  hand,  he  does,  it  is  likely  he  is  only  familiar  with  the  older, 
cruder  form  of  exposure  with  crushing  and  chiselling  instruments  and  un- 
familiar with,  or  unskilled  in,  the  more  modern  technics.  Whenever  laminec- 
tomy is  elected  in  preference  to  osteoplastic  resection,  there  being  no  special 
indication  for  the  former,  the  only  partial  justification  there  would  seem  to 
be  for  the  performing  of  laminectomy  would  be  that  it  be  done  subperiosteally, 
and,  as  already  mentioned,  there  are  those  who  feel  that  a  subperiosteal  laminec- 
tomy is  very  rarely  accomplished,  even  when  definitelv  undertaken  by  the 
skilful. 


644  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

Before  considering  and  illustrating  the  operations  of  osteoplastic  resection 
and  laminectomy  in  detail,  there  are  aspects  of  the  technique  which  are  common 
to  both  operations  and  of  a  fundamental  importance  to  their  performance, 
and  which  will,  therefore,  be  first  mentioned  and  pictured  as  briefly  as  con- 
sistent with  their  understanding. 

II.  The  Features  Common  to  both  Operations. — (i)  Preparation  of 
Operation-site. — The  region  is  shaved,  whether  visible  hair  be  present  or  not, 
and  is  made  aseptic  by  the  special  antiseptic  measures  of  the  individual  oper- 
ator, the  patient  coming  to  the  table  with  the  part  protected  by  dressings 
applied  after  the  preliminary  preparation,  the  final  preparation  being  made 
at  the  time  of  operation. 

(2)  Position  of  Patient,  Surgeon,  and  Assistants. — The  patient  lies  upon  a 
specially  narrow  table,  in  the  semiprone  position,  as  nearly  upon  the  front  of 
the  chest  as  the  conditions  of  anesthesia  will  allow,  being  supported  by 
cushions.  The  surgeon  stands  at  the  patient's  back  throughout  most  of  the 
operation,  passing  to  the  opposite  side  of  the  table  and  leaning  over  the  chest 
whenever  it  is  more  convenient  to  manipulate  from  that  side.  Two  assistants 
are  useful — one  at  the  surgeon's  side,  and  another  opposite  him,  on  the  other 
side  of  the  table,  bending  over  the  patient. 

(S)  Anesthesia. — Nitrous  oxide  and  ether,  unless  contraindicated  for  special 
reasons. 

(4)  Instruments  and  Accessories. — Heavy  cartilage  knife  and  medium 
knife;  artery-clamp  forceps;  dissecting  forceps;  two  pairs  of  special  retractors 
with  teeth  blunt  and  long  enough  to  reach  the  bottom  of  the  wound;  chisel 
about  two  centimeters  (about  three-quarters  of  an  inch)  wide;  Doyen  saw; 
Gigli  saw;  probe  with  thin,  flat  end;  curved,  heavy  scissors  for  interspinous 
and  interlaminous  ligaments;  small  angular  scissors  for  incising  membranes 
of  the  cord;  two  small,  toothed  forceps  for  membranes;  large  and  small  needle- 
holders;  fine,  fully  curved  needles  for  membranes;  heavy  curved  needles  for 
buried  muscle  sutures;  straight  needles  for  skin;  plain  fine  catgut  for  mem- 
branes; twenty-day  chromic  gut  for  buried  muscle  sutures;  silkworm  gut,  or 
silk,  for  skin  sutures;  horse-hair  or  catgut  for  intradural  drainage;  tubing  or 
gauze  for  extraspinal  drainage;  gauze  for  packing  wound;  hot  normal  salt 
solution  for  hemorrhage. 

(5)  Landmarks  of  Operation. — The  spinous  processes  corresponding  with 
the  lamina?  to  be  removed  should,  if  possible,  be  very  clearly  located  before 
beginning  the  incision.  This  can  always  be  done  in  backs  of  medium  thick- 
ness, and  generally  in  moderately  thick  backs  upon  deep  pressure.  The  trans- 
verse processes  in  the  dorsal  and  lumbar  regions  and  the  articular  processes 
in  the  cervical  region  should  also  be  located,  in  the  case  of  the  osteoplastic 
resection,  if  it  be  possible;  but  often  cannot  be  determined  until  after  the  skin 
and  fascia  have  been  incised  in  the  operation  last  mentioned. 

(6)  Manner  of  Incising  Muscles  and  Aponeuroses. — While  this  is  not  a 
major  point,  attention  to  the  principle  involved  will  insure  a  more  cleanly 
cut  section  in  the  case  of  osteoplastic  resection,  and  a  more  complete  clearing 
of  soft  parts  from  the  spines  in  laminectomy  than  if  the  principle  were  not 
observed.  One  is  familiar  with  the  fact  that  the  spines  of  a  feather  may  be 
more  readily  and  cleanly  stripped  from  the  quill  by  cutting  from  tip  to  base 
than  by  cutting  in  the  opposite  direction.  Therefore,  will  the  section  of 
muscles  and  aponeuroses  be  more  cleanly  and  evenly  made  if  made  by  a  stout 
knife  wielded  in  such  a  manner  as  to  cut  into,  or  toward,  the  more  acute 
angle  formed  by  the  attachment  of  the  muscular  or  aponeurotic  fibers  to  the 
parts  of  the  vertebral  column,  rather  than  toward  the  more  obtuse  angle; 


SURGICAL    CONSIDERATIONS    IN    OPERATIONS    UPON    SPINE. 


645 


and  especially  is  this  the  case  the  nearer  the  spinous  processes  one  approaches. 
This  will  sometimes  necessitate  cutting  toward  the  head,  sometimes  toward 
the  sacrum,  according  to  the  direction  of  the  fibers  at  the  site  of  operation, 
and  may  require  stepping  to  the  opposite  side  of  the  table.     Practically,  two 


\ 


m 


-■ 


Fig.  509. — Muscles  of  Dorsal  Region  of  Back,  showing  that  Muscular  axd 
Aponeurotic  Fibers  are  more  Cleanly  Divided  by  Cutting  t<  ward  the  more  Acute 
Angle  formed  by  their  Attachment  to  Bony  Structures.  (Modified  from  Gray's  "Anat- 
omy.") 


changes  in  the  direction  of  the  incision  on  either  side  of  the  median  line  will 
fulfil  these  indications.  It  will,  therefore,  be  seen  that  it  is  not  advised  to  cut 
from  skin  to  bone  or  even  from  fascia  to  bone,  at  one  stroke,  but  rather  with 
three,— one  through  skin  and  fascia  and  two  through  the  musculo-aponeurotic 


646 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


structures, — retracting  between  each  incision,  such  a  procedure  furnishing  a 
wound  with  less  raggedly  cut  walls  (Fig.  509). 

(7)  Manner  of  Clearing  Soft  Parts  from  Spines  and  Lamina;. — This,  as 
usually  done,  is  accomplished  by  the  combined  use  of  cartilage  knife,  perios- 
teal elevator,  and  raspatory,  with  more  or  less  satisfactory  result.  The  clean- 
ing of  the  bones  may,  however,  be  much  more  thoroughly  done,  and  by  a 
single  instrument,  by  using  an  ordinary  chisel.  When  the  incisions  have  been 
carried  fully  to  the  bones,  a  knife  is  no  longer  necessary.  Through  the  incision 
made  by  the  knife,  a  chisel  (about  two  centimeters,  or  about  three-quarters 
of  an  inch,  wide)  is  carried  directly  to  the  depth  of  the  wound,  guided,  if 
necessary,  by  the  surgeon's  left  index-finger,  and  so  directed  that  its  bevelled 
edge  will  be  turned  away  from  the  soft  parts  to  be  pried  from  the  bones.  In 
osteoplastic  resections  the  blade  of  the  chisel  rests  against  the  transverse  proc- 
esses in  the  dorsal  and  lumbar  regions,  and  against  the  articular  processes, 


Fig.  510. — Dorsal  Vertebra,  showing  results  of  Incisions  begun  at  Relatively 
Corresponding  Sites  and  passing  through  Lamina  in  Different  Directions: — A,  Proper 
section,  cutting  lamina  at  right  angle  to  its  surface  and  entering  spinal  canal;  B,  Improper  section 
passing  through  lamina  parallel  with  general  direction  of  spinous  process  and  entering  pedicle 
of  vertebra  and  passing  on  into  body.     (Modified  from  Quain's  "Anatomy."; 

partly  covered  by  muscles,  in  the  cervical  region,  and,  from  these  as  fulcra, 
the  soft  parts  are  levered  off  toward  the  spines  (Fig.  515,  D).  In  a  laminec- 
tomy the  chisel-blade  rests  against  the  spinous  processes,  and  from  these  as 
fulcra  the  soft  parts  are  pried  out  of  the  bony  groove  toward  the  transverse 
processes  in  the  dorsal  and  lumbar  regions,  and  articular  processes  in  the 
cervical  (Fig.  519,  C).  This  use  of  the  chisel  is  exceedingly  satisfactory, 
its  sharp  edge  easily  and  thoroughly  removing  all  the  soft  parts,  and  probably 
leaving  a  cleaner  bony  bed  for  the  saw  than  is  accomplished  in  any  other  way. 
This  result  is  not  so  well  secured  if  the  bevel  of  the  chisel  is  turned  toward  the 
parts  to  be  removed. 

(8)  Manner  of  Dividing  the  Lamina?. — This  step,  in  either  operation,  is  of 
paramount  importance,  and  the  manner  of  its  performance,  as  far  as  the  actual 
making  of  the  saw-cut  is  concerned,  is  the  same,  whether  the  operation  be 


SURGICAL    CONSIDERATIONS    IN    OPERATIONS    UPON    SPINE.         647 

osteoplastic  resection  or  laminectomy.  And  the  principle  is  also  the  same, 
as  far  as  the  direction  of  the  section  is  concerned,  no  matter  with  what  form 
of  instrument  the  division  of  bone  be  made.  This  important  principle  is  that 
the  instrument  should  have  its  edge  placed  upon  the  lamina?  at  or  a  little  to 
the  outer  side  of  their  center,  and  be  made  to  cut  its  way  through  the  laminae 
strictly  at  a  right  angle  to  the  general  direction  of  their  surfaces  (Fig.  510,  A). 
Even  if  the  edge  of  the  bone-cutting  instrument  enter  in  about  the  same  site 
as  just  described,  and  the  section  be  made,  as  so  often  done  by  beginners, 
parallel  with  the  general  direction  of  the  spinous  processes,  the  chances  are 
that  the  section  wall  pass  on  into  the  solid  articular  processes  and  pedicles, 
and,  if  continued,  on  into  the  bodies  of  the  vertebrae  (Fig.  510,  B).  The 
writer  has  observed  the  marked  tendency  to  this  serious  error  upon  the  part 
of  students,  who  really  often  do  not  appreciate  their  difficulty  until  it  is  pointed 
out  to  them  upon  the  skeleton.  The  error,  once  made,  is  hard  to  correct; 
it. is  absolutely  impossible  to  go  ahead  upon  that  straight  line;  it  is  hard  to 
start  a  new  saw-cut,  and  often,  much  chagrined,  one  is  at  a  loss  to  know  what 
to  do  and  is  tempted  to  chisel  his  way  through.  It  is  better,  however,  to  perse- 
vere with  the  saw  until  the  groove  of  a  new  cut  is  made  in  the  right  direction. 

(9)  Instrument  for  Making  the  Bone-sections. — Doyen's  saw,  in  the  judg- 
ment of  the  writer,  is  the  instrument,  par  excellence,  for  all  bone-sections  which 
are  necessary  in  exposing  the  spinal  cord  and  canal.  It  is  useless  to  more  than 
mention  the  many  means  that  have  been  resorted,  to  to  divide  the  parts  of  the 
vertebrae,  such  as  excision  of  the  spines  with  bone-pliers,  followed  by  cutting 
away  the  laminae  with  bone-cutting  forceps,  or  sawing  them  off  with  Gigli  or 
chain  saw;  dividing  the  laminae  directly  by  bone-cutting  forceps,  one  blade 
of  which  has  been  thrust  through  an  interlaminous  ligament;  chiselling  through 
the  laminae  in  parallel  lines  (at  the  cost  of  much  jarring  and  irregular  division) ; 
the  use  of  small  trephine-openings,  the  intervening  laminae  being  cut  away, 
and  the  use  of  the  Hey  saw.  Doyen's  saw  is,  practically,  a  Hey's  saw  with 
an  adjustable  guard  (Fig.  419). 

(10)  Hartley's  Preliminary  Excision  of  the  Spinous  Process  immediately 
above  the  Flap  in  Osteoplastic  Resection  of  the  Spine. — While  this  procedure 
is  not  common  to  both  osteoplastic  resection  and  laminectomy,  and  conse- 
quently does  not  strictly  come  under  this  division  of  the  subject,  yet  it  is  a  fun- 
damental feature  of  the  osteoplastic  resection,  and  its  general  principles  will, 
therefore,  be  briefly  described  here.  It  is  difficult  to  see  how  an  osteoplastic 
resection  is  possible  without  first  removing  the  spine  immediately  above  the 
flap  to  be  turned  back.  Most  markedly  in  the  dorsal  region,  and  even  in  the 
cervical  and  lumbar  regions,  will  any  lower  spine  quickly  become  interlocked 
with  the  one  just  above  if  an  attempt  be  made  to  turn  it  backward  and  upward. 
So  that  without  the  preliminary  excision  of  the  spine  above,  the  flap  below 
can  only  be  turned  backward  and  upward  by  main  force,  and  often  a  con- 
siderable degree  of  force  is  necessary,  during  the  exercise  of  which  bony  por- 
tions of  contiguous  vertebrae  may  be  broken,  or  other  damage  done.  This 
preliminary  step  to  the  main  operation  may,  therefore,  be  regarded  not  only 
as  a  most  useful  feature,  but  almost  as  a  sine  qua  non  of  the  operation  as  a 
whole.  The  manner  of  its  execution  will  be  described  more  in  detail  under 
the  osteoplastic  resection. 

(11)  Control  of  Hemorrhage. — The  three  stages  at  which  hemorrhage  is 
apt  to  be  encountered  are:  After  making  the  skin  and  fascial  wound;  during 
the  incision  of  the  muscles  of  the  back;  and  after  opening  the  spinal  canal, 
in  removing  or  incising  the  vascular  fatty  areolar  tissue  from  around  the  mem- 
branes.    Hemorrhage  from  visible  vessels  encountered  prior  to  reaching  the 


648 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


spine  should  be  controlled  by  artery-clamp  forceps,  followed  by  ligature 
or  torsion.  General  oozing  and  hemorrhage  from  undetectable  sources 
(which  form  the  chief  bleeding)  should  be  arrested  by  gauze  packing,  or  by 
flushing  with  hot  normal  salt  solution,  and  by  alternately  working  upon  the 
two  sides  of  the  wound.  Intradural  bleeding  from  the  vascular  fatty  areolar 
tissue  surrounding  the  cord,  and  which  is  chiefly  venous,  should  be  stopped 
by  pressure  with  gauze  held  in  forceps. 


Fig.  511. — Lines  of  Skin  Incisions  in  Relation  to  Underlying  Bones  in  Osteo- 
plastic Resection*  and  in  Laminectomy  : — A,  Line  to  remove  seventh  dorsal  spine  in  Hartley's 
preliminary  operation  of  excising  the  spinous  process  of  the  vertebra  immediately  above  those 
forming  part  of  the  osteoplastic  flap;  B,  modified  U-shaped  incision  outlining  the  osteoplastic 
flap  for  turning  back  the  eighth  and  ninth  dorsal  spines  and  lamina;;  C,  line  of  incision  for 
laminectomy  of  third,  fourth,  and  fifth  dorsal  spines  and  lamina;.     (Drawn  from  the  skeleton.) 


OSTEOPLASTIC  RESECTION  OF  THE   SPINE. 

Description. — See  page  642,  above. 
Preparation. — See  page  644,  above. 
Position. — See  page  644,  above. 
Landmarks. — See  page  644,  above. 
Incision. — See  page  652,  below. 

Operation. — Two  distinct  operative  steps  are  here  undertaken, — the  pre- 
liminary excision  of  the  spinous  process  above  the  flap,  and  the  formation 


OSTEOPLASTIC    RESECTION    OF    THE    SPINE. 


649 


and  turning-back  of  the  osteoplastic  flap.     The  nature  of  the  operation  has 
been  briefly  described  under  General  Considerations. 

(A)  Preliminary  Excision  of  the  Spinous  Process  Immediately  Above  the 
Osteoplastic  Flap  (Hartley's  Operation). — This  preliminary  operation  may  be 
considered  under  the  following  headings:  Incision;  Exposure  of  Spinous 
Process;  Severing  of  Supra-  and  Inter-spinous  Ligaments;  Excision  of  Spine; 
Temporary  Packing  of  Preliminary  Wound;  Final  Suturing  of  Preliminary 
Wound. 


Fig.  512. — Osteoplastic  Resection  or  the  Spine;  Hartley's  Preliminary  Operation 
for  Excising  the  Spine  of  the  Vertebra  Immediately  above  the  Flap: — A,  A,  Retractors 
in  the  wound,  also  serving  as  protectors  of  soft  parts;  B,  H,  Gigli  saw  in  position  for  excising  the 
entire  spinous  process.  (Drawn  from  cadaveric  operation.)  Note: — The  subperiosteal  method 
is  not  shown  here. 


(1)  Incision. — A  vertical  incision  is  made  directly  in  the  median  line;  its 
center  over  the  spinous  process  to  be  excised,  and  extending  in  length  from 
the  tip,  or  near  the  tip,  of  the  spine  above  to  the  tip,  or  near  the  tip,  of  the 
spine  below  (Fig.  511,  A,  and  Fig.  514,  B). 

(2)  Exposure  of  the  Spinous  Process. — The  above  incision  is  carried  through 
skin  and  fascia  directly  onto  the  spinous  process  mentioned.  The  lips  of  the 
wound  are  then  well  retracted,  and  the  spine  in  question  is  exposed  fully  to 
its  base  by  prying  away  the  overlying  and  closely  attached  soft  parts  by  means 
of  a  chisel  used  against  the  spine  as  a  fulcrum,  in  the  special  manner  described 


650 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


under  General  Considerations.  This  freeing  having  been  accomplished, 
the  soft  parts  are  strongly  drawn  aside  by  means  of  retractors,  which  also 
serve  the  part  of  protectors  of  the  soft  parts  during  the  use  of  the  saw  (Fig. 
512,  A,  A).     A  subperiosteal  exposure  of  the  spine  should  be  attempted. 

(3)  Severing  of  Supra-  and  fiiler-spiiious  Ligaments. — These  ligaments 
are  now  to  be  divided,  both  in  order  to  sever  this  spine  from  the  one  below 
and  to  prepare  a  passage  for  the  Gigli  saw.  This  division  of  ligaments  may 
be  made  with  a  knife,  but  can  be  better  and  more  readily  accomplished  by 
means  of  curved  scissors  whose  concavity  is  held  upward.  Having  passed 
through  the  supraspinous  ligament,  the  inter-spinous  ligament  is  divided  down 
to  the  ligamenta  subflava.  The  spinal  canal  should  not  be  opened  in  this 
procedure. 

(4)  Excision  of  the  Spinous  Process. — A  passageway  having   been   thus 


Fig.  513. — Hartley's  Method  or  Preliminarily  Excising  the  Spinous  Process  Imme- 
diately ABOVE  THE  LAMIN/E  TO  BE  TEMPORARILY  TURNED  BACK  IN  OSTEOPLASTIC  RESECTION 

OF  the  Spinal  Column.     The  use  of  bone-cutting  pliers  is  here  shown. 


provided,  a  Gigli  saw  is  carried  deeply  down  to  the  very  base  of  this  spinous 
process  and  the  entire  process  removed  (Fig.  512,  B,  B).  Care  is  exercised 
to  avoid  making  but  a  partial  excision,  as  the  remaining  stump  may  interfere 
with  the  turning  back  of  the  flap  almost  as  much  as  though  the  entire  spine 
were  in  situ.  Some  operators  cut  the  spine  off  with  bone-cutting  forceps 
(Fig.  513);  but  the  use  of  bone-cutting  pliers  here,  as  in  many  other  instances, 
is  unsurgical,  removing,  as  they  do,  by  a  crude  process  of  crushing,  a  part  of 
bone  which  is  much  more  cleanly  and  less  traumatically  cut  away  by  a  Gigli 
or  other  form  of  saw. 

(5)  Temporary  Packing  of  the  Preliminary  Wound. — The  spine  of  bone 
having  been  removed,  the  preliminary  operation  is  for  the  time  being  ended. 
The  further  use  of  this  wound  will  be  described  in  connection  with  the  turning 
back  of  the  osteoplastic  flap.     Some  operators  here  permanently  suture  up 


OSTEOPLASTIC    RESECTION    OF    THE    SPINE. 


651 


the  wound  left  by  the  excision  of  the  spinous  process;  but  it  is  distinctly  best 
not  to  do  so,  as  will  be  evident  farther  on.  This  wound  should  be  tightly 
packed  with  gauze  and  temporarily  left  alone. 

(6)  Final  Suturing  of  the  Preliminary  Wound. — At  the  conclusion  of  the 
entire  operation  the  preliminary  wound  is  sutured  upon   the  same  general 


Fig.  514. — Region  of  the  Spinal  Column  and  Cord: — A,  Position  for  incision  in  lami- 
nectomy of  fourth,  fifth,  and  sixth  cervical  vertebras;  B,  Position  for  incision  in  Hartley's  pre- 
liminary excision  of  a  spinous  process  (of  sixth  dorsal  vertebra)  preceding  osteoplastic  resection; 

C,  Position  of  incision  in  an  osteoplastic  resection  of  seventh,  eighth,  and  ninth  dorsal  vertebras; 

D,  Lumbar  puncture  between  the  fourth  and  fifth  lumbar  laminas,  for  spinal  analgesia. 

principles  to  be  described  for  the  main  wound,  namely,  buried  chromic  gut 
sutures  to  bring  the  muscle  and  aponeurotic  structures  together  in  the  space 
formerly  occupied  by  the  now  excised  spinous  process,  and  silkworm-gut,  or 
silk,  for  the  skin  wound,  no  drainage  being  used  (Fig.  518,  A,  A). 

(B)    The  Formation  and  Turning  Back  of  the  Osteoplastic  Flap. — This,  the 


652  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

main  operation,  will  be  considered  under  the  following  divisions:  Incision; 
Division  of  Muscles  and  Aponeurosis;  Freeing  of  Laminae  Preparatory  to 
their  Division;  Division  of  Laminae  and  Ligamenta  Subflava;  Division  of 
Supraspinous,  Interspinous,  and  Interlaminous  Ligaments;  Separation  and 
Turning  Back  of  Osteoplastic  Flap;  Freeing  of  Spinal  Cord  from  Extradural 
Fatty  Areolar  Tissue  and  Control  of  Intraspinal  Hemorrhage;  Opening  of 
Membranes  of  Cord;  Manner  of  Dealing  with  Incised  Membranes;  Reposition 
of  Cutaneomusculo-osseous  Flap;  Deep  Buried  Suturing  of  Muscles  and 
Aponeurosis;  Skin  and  Fascial  Suturing;  Provision  for  Drainage  when  Indi- 
cated; After-treatment;  Comment. 

(i)  Incision. — A  modified  U-shaped  incision  is  used.  This  incision  out- 
lines the  two  sides  and  lower  limit  of  the  composite  flap  of  skin-muscle-aponeu- 
rosis-bone-and-ligament  to  be  temporarily  turned  back  (Fig.  514,  C).  Its 
two  strictly  vertical  limbs. begin  over  the  lamina'  of  the  vertebra  whose  spine 
is  to  be  excised,  commencing  to  the  outer  side  of  its  vertical  center,  near  the 
root  of  the  transverse  process  in  the  dorsal  and  lumbar  regions,  and  near  the 
base  of  the  articular  process  in  the  cervical  vertebras,  and  extend,  on  both  sides, 
downward  in  straight  lines,  parallel  with  the  tips  of  the  spinous  processes, 
until  opposite  the  tip  of  the  last  spine  to  be  included  in  the  resection;  here 
the  incisions  broadly  curve  toward  the  median  line,  meeting  midway  between 
the  tip  of  the  spinous  process  just  mentioned  and  the  tip  of  the  spinous  process 
next  below.  It  is  very  essential  that  this  broad  curve  should  be  given  to  the 
lower  end  of  the  incision  rather  than  that  a  narrow  contracted  curve  be  made, 
much  of  the  ease  of  subsequent  manipulations  depending  thereon.  For  the 
purpose,  solely,  of  providing  a  greater  influx  of  blood  into  the  base  of  the  semi- 
detached flap  of  skin-muscle-and-bone,  a  slightly  outward  curve  may  be 
given  to  the  upper  ends  of  the  vertical  portions  of  the  U-shaped  incision  (Fig. 
511,  B).  These  curves,  however,  are  awkward  if  the  limbs  of  the  incision 
have  to  be  extended  upward.  It  might  be  asked  how  the  bases  of  the  trans- 
verse processes  of  the  dorsal  and  lumbar  vertebra;  and  the  bases  of  the  cervical 
articular  processes  may  be  recognized  prior  to  the  skin-incision;  in  reply  to 
which  it  may  be  said  that  the  tips  of  these  processes  themselves  (transverse 
and  articular)  may  generally  be  felt  upon  firm  pressure  made  upon  backs  of 
medium  thickness,  and,  having  recognized  the  tips  of  these  processes,  their 
corresponding  bases  lie  approximately  midway  between  their  tips  and  the 
median  line  formed  by  the  apices  of  the  spinous  processes.  Where  the  tips 
of  the  transverse  processes  of  the  dorsal  and  lumbar  vertebrae  and  tips  of  the 
articular  processes  of  the  cervical  vertebrae  cannot  be  recognized  by  palpation 
at  all,  it  may  be  stated  that  the  tips  of  the  transverse  processes  of  the  dorsal 
vertebrae  lie,  in  the  average  skeleton,  about  3  to  3.5  centimeters  (one  and 
one-fourth  to  one  and  three-eighth  inches)  from  the  tips  of  the  dorsal  spines, 
the  tips  of  the  lumbar  transverse  processes  about  four  to  five  centimeters 
(one  and  five-eighth  to  two  inches)  from  the  tips  of  the  lumbar  spines,  and 
the  tips  of  the  cervical  articular  processes  about  three  centimeters  (one  and 
one-fourth  inches)  from  the  centers  of  the  cervical  bifid  spines. 

(2)  Division  of  the  Muscles  and  Aponeuroses. — The  direction  of  the  incision 
through  the  layers  of  muscles  and  aponeuroses  at  the  different  layers,  and  the 
reasons  therefor,  have  been  given  above  under  General  Considerations  (page 
644).  The  incision  through  skin  and  fascia  will,  upon  retraction,  have  exposed 
muscle  or  aponeurosis,  according  to  the  site  of  operation.  The  margins  of 
the  skin  and  fascial  wound  having  been  retracted  and  hemorrhage  controlled, 
the  muscular  and  aponeurotic  layers  in  view  are  incised  in  a  general  direction 
which  will  correspond  with  the  acuter  of  the  two  angles  which  their  component 


OSTEOPLASTIC    RESECTION    OF    THE    SPINE. 


653 


fibers  make  with  the  spine,  and  the  layers  below  similarly  incised.  Imme- 
diately prior  to  deepening  the  muscle  incision  down  to  the  bone,  it  is  advisable 
to  satisfy  one's  self,  by  means  of  a  finger  introduced  into  the  wound,  that  the 
vertical  limbs  of  the  U-shaped  incision  are  falling  well  within  the  bases  of  the 
transverse  processes  in  the  dorsal  and  lumbar  regions  and  within  the  tips  of  the 
articular  processes  in  the  cervical  region.  This  precaution  will  insure  the 
coming  of  the  incision  down  upon  the  spinal  column  over  the  laminae,  which 
will  make  the  clearing  of  the  laminae  correspondingly  easy. 


Fig.  515. — Osteoplastic  Resection  of  the  Spine: — A,  Position  of  dorsal  spines;  B, 
Wound  of  Hartley's  preliminary  excision  of  spinous  process  immediately  above  flap;  C,  C,  C,  C, 
Retractors  of  main  wound;  D,  Chisel,  against  transverse  processes  as  fulcra,  in  act  of  prying 
soft  parts  from  laminar,  E,  Lamina;  F,  Interlaminous  ligament  (ligamentum  subflavum);  G, 
Doyen's  saw  in  act  of  completing  section  through  lamina?  and  interlaminous  ligaments.  (Drawn 
from  cadaveric  operation.) 

(3)  JPreeing  the  Lamina  Preparatory  to  their  Division. — The  gauze  packing 
is  now  removed  from  that  side  of  the  U  which  was  first  incised  and  packed, 
by  which  time  the  hemorrhage,  which  is  usually  rather  free,  has  ceased.  While 
instrumental  retraction  should  be  practised  during  the  latter  stage  of  the 
freeing  of  the  laminae,  it  is  not  necessary,  and  is  certainly  better  omitted 
during  the  beginning  of  the  freeing,  owing  to  the  small  amount  of  room  in 
the  wound  for  finger  and  chisel.  At  the  stage  when  retractors  are  used,  they 
should  have  blunt  hooks,  to  avoid  wounding  the  fingers  of  operator  and  assist- 
ants, which  are  also  in  the  wound;  and  they  should  be  long  enough  to  reach 
to  the  bottom  of  the  incision.     Proceeding,  therefore,  at  first  without  retractors, 


654  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

the  left  index  is  introduced  into  the  wound  until  its  tip  is  in  contact  with  the 
laminae.  An  ordinary  chisel,  as  mentioned  in  the  Introduction,  is  now  inserted 
alongside  of  the  already  introduced  finger,  with  its  edge  parallel  with  the 
direction  of  the  spines  and  with  the  bevel  turned  away  from  the  parts  to  be 
pried  from  the  laminae,  in  the  manner  already  described.  A  path  for  the 
Doyen  saw  is  thus  made  over  those  laminae  which  are  to  be  temporarily  turned 
back, — the  chisel  being  used  as  a  lever, — braced  against  the  transverse  proc- 
esses in  the  dorsal  region,  against  the  articular  and  transverse  processes  in 
the  lumbar  region,  and  against  the  articular  processes  in  the  cervical  region, 
and,  with  these  as  fulcra,  is  made  to  pry  the  overlying  soft  parts  from  the  bony 
groove  formed  by  the  laminae  and  interlaminous  ligaments  (Fig.  515,  D). 
While  the  major  portion  of  this  clearing  of  the  saw-bed  can  be  accomplished 
by  manipulating  the  chisel  from  the  aspect  of  the  transverse  and  articular 
processes  toward  the  base  of  the  spines,  a  still  more  thorough  completion  of 
the  clearing  can  be  secured  by  withdrawing  the  chisel,  turning  it  around  (so 
that  the  bevel  is  toward  the  transverse  processes),  and  also  using  it  against 
the  spines,  covered  by  their  soft  parts,  as  fulcra,  while  prying  away  from  the 
laminae  those  soft  parts  lying  nearer  the  transverse  and  articular  processes. 
This  manipulation  is  shown  in  Fig.  519,  C,  where  the  principle  is  used  in 
the  laminectomy  operation.  Not  only  should  the  special  laminae  and  inter- 
laminous ligaments  involved  in  the  resection  be  completely  cleared  of  oyerlying 
soft  parts,  but  the  lower  half  of  the  laminae  above  and  the  upper  half  of  the 
laminae  below  these  should  also  be  freed,  as  it  will  be  necessary  for  them  to 
accommodate  the  end  of  the  saw  in  its  excursions.  This  additional  clearing 
is  shown  in  Fig.  515.  When  the  saw-bed  upon  one  side  has  been  thus  pre- 
pared, it  is  firmly  packed  with  gauze,  to  control  bleeding,  while  the  opposite 
side  is  being  similarly  prepared  and  packed. 

(4)  Division  of  Lamina:  and  Ligamenta  Subflava. — The  edges  of  each  of 
the  vertical  limbs  of  the  wound  should  be  retracted,  one  at  a  time,  by  four 
special  retractors  with  extra-long  blunt  teeth,  the  wound  presenting  a  rec- 
tangular shape  (Fig.  515,  C,  C,  C,  and  a  small  unlettered  retractor).  The 
guard  of  the  Doyen  saw  is  set  at  ten  millimeters  (about  seven-sixteenths  of 
an  inch),  which  will  give  a  sufficient  cutting-edge  to  pass  completely  through 
the  laminae  at  any  portion  of  the  spine,  provided  the  section  be  made  well 
within  the  laminae  proper,  and  at  a  right  angle  to  their  surface.  With  the 
guard  thus  set  it  is  simply  impossible  to  wound  the  cord  (the  cord  and  spine 
being  normal),  not  that  the  bone  is  here  ten  millimeters  thick,  but  because  the 
saw  will  bind  after  traversing  the  bone  part  of  the  way.  As  a  matter  of  fact,  the 
guard  may  be  entirely  dispensed  with ;  though  under  such  circumstances  care 
is  necessary,  and  the  saw  must  be  checked  immediately  upon  the  sense  of 
lost,  or  lessening,  resistance,  as  the  last  thickness  of  the  laminae  is  encountered. 
( )ne  has  frequently  thus  used  the  saw  upon  the  cadaver  without  other  than 
the  most  ordinary  precautions,  and  has  never  seen  injury  done  in  such  cases; 
nor  has  he  but  once  ever  seen  the  cord  injured  by  a  student  during  the  roughest 
manipulation,  independently  of  the  form  of  instrument  used  for  the  bone 
division,  so  securely  is  the  cord  ordinarily  protected  by  its  position.  The 
saw,  protected  by  the  guard  at  ten  millimeters,  should  be  used  until  it  has  cut 
its  way  completely  through  and  is  stopped  by  the  shoulder  of  the  guard.  The 
sweep  of  the  saw  at  each  stroke  should  be  as  full  as  the  length  of  the  wound 
will  allow;  and  the  general  cutting-edge  of  the  saw  should  be  held  as  level  as 
circumstances  will  permit,  that  the  bone-section  may  be  made  of  equal  depth 
throughout  as  great  a  length  of  the  wound  as  can  be  reached  in  one  position 
of  the  saw.     It  is  usually  impossible  to  complete  the  section  of  one  side  with 


OSTEOPLASTIC    RESECTION    OF    THE    SPINE. 


655 


the  saw  in  one  position,  owing  to  the  shape  and  position  of  the  handle  of  the 
saw,  as  the  end  of  the  saw  nearer  the  handle  will  not  travel  the  full  length  of 
the  wound  quite  as  satisfactorily  as  the  distal  end.  Fig.  515,  G,  illustrates 
this  principle.  The  surgeon,  therefore,  standing  at  the  patient's  back,  intro- 
duces the  saw  first  into  one  side  and  then  into  the  other,  using  the  instrument 
from  below  upward  and  sawing  through  the  lower  half  of  the  laminae  above 
those  to  be  turned  back,  as  well  as  through  as  many  of  the  laminae  to  be  resected 
as  the  teeth  of  the  saw  will  engage  themselves  in.     When  division  of  the  upper 


Fig.  516. — Osteoplastic  Resection  of  Spine: — A,  A,  A,  A,  Retractors  in  main  wound; 

B,  Surgeon's  left  index-finger  introduced  into  preliminary  wound  to  aid  in  bending  back  of  flap; 

C,  Curved  scissors  cutting  interspinous  and  interlaminous  ligaments;  D,  Chisel  introduced 
into  saw-cut  and  supported  against  transverse  processes  as  fulcra,  prying  out  osteoplastic  flap; 
E,  Opposite  saw-cut,  the  flap  being  levered  out.     (Drawn  from  cadaveric  operation.) 


parts  of  both  sides  has  been  made,  the  surgeon,  unless  ambidextrous,  must 
walk  around  the  table,  lean  over  the  thorax  of  the  patient  (in  his  semiprone 
position),  and,  sawing  now  from  above  downward,  complete  the  section  of 
those  laminae  to  be  temporarily  turned  back,  as  well  as  of  one-half  of  the  laminae 
next  below.  The  depth  of  the  bony  section  may  be  tested  from  time  to  time 
by  means  of  the  flat  end  of  a  specially  thin  probe.  This  division  of  one-half 
of  both  the  laminae  above  and  below  those  to  be  temporarily  displaced  is  only 


656  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

necessary  because  unavoidable,  as  the  saw-blade  cannot  be  carried  abruptly 
up  to  the  limit  of  one  lamina  and  completely  divide  it  without  also  at  least 
partly  dividing  a  portion  of  the  contiguous  lamina  (Fig.  515,  E).  But  no 
practical  harm  is  done  thereby,  as  only  a  very  small  proportion  of  these  two 
sets  of  laminae  is  divided  by  the  very  fine  blade  of  the  saw,  and  must  soon 
solidify.     The  ligamenta  subflava  are  also  divided  by  the  saw  (Fig.  515,  F). 

(5)  Division  of  the  Supraspinous,  Inter  spinous,  and  Interlaminous  Liga- 
ments.— The  lowest  one  of  the  spines  in  the  osteoplastic  flap,  with  its  corre- 
sponding laminae,  is  now  to  be  severed  from  the  corresponding  intact  structures 
next  below,  involving  the  division  of  the  above-mentioned  ligaments.  These 
ligaments  may  be  divided  with  a  knife  held  sidewise,  but  are  more  satisfactorily 
divided  by  a  pair  of  curved  scissors  held  with  their  concavity  backward  (Fig. 
516,  C).  The  process  of  division  is  aided  by  grasping  the  composite  flap  to 
be  displaced  and  lifting  the  lowest  spine  away  from  its  neighbor  next  below, 
thus  giving  the  scissors  more  room  for  dividing  the  V-shaped  ligamentous 
structure  formed  by  the  supraspinous  and  interspinous  ligaments  posteriorly 
and  the  ligamenta  subflava  to  either  side. 

(6)  Separation  and  Turning  Back  of  the  Osteoplastic  Flap. — The  detach- 
ment or  loosening  of  the  resected  portion  of  the  spinal  column  is  best  accom- 
plished by  means  of  the  same  chisel  used  in  clearing  the  soft  parts  from  the 
bones,  and  held  in  the  same  way,  that  is,  with  the  non-bevelled  edge  toward 
the  part  to  be  pried  out.  Preparatory  to  thus  using  the  chisel  as  a  lever,  the 
edges  of  one  of  the  vertical  limbs  of  the  wound  are  retracted  by  the  four  special 
retractors  mentioned  above  (Fig.  516,  A,  A,  A,  and  a  small  unlettered 
retractor),  the  parts  sponged  dry  with  gauze,  and  the  saw-cut  brought  well 
into  view.  The  surgeon's  left  index-finger  should  be  introduced  into  the  pre- 
liminary wound  through  which  the  spinous  process  has  been  removed  (Fig. 
516,  B),  carried  down  to  its  sawn-off  end  and  adjacent  interlaminous  ligaments, 
and  held  there  until  the  composite  flap  has  been  pried  out  of  its  site,  the  tip 
of  the  finger  greatly  aiding  in  this  manoeuvre  and  in  determining  the  progress 
of  the  elevation.  The  chisel  is  placed  in  position,  with  its  bevelled  side  against 
a  transverse  process  (in  the  dorsal  or  lumbar  region)  or  against  an  articular 
process  in  the  cervical  region,  and  its  edge,  with  non-bevelled  surface  toward 
the  spines,  engaged  in  the  saw-cut  (Fig.  516,  D).  The  composite  mass  is 
seized  between  the  surgeon's  left  thumb  and  index  and  steadied  and  gently 
drawn  away  during  the  prying-out  process.  Ordinarily,  a  single,  light,  down- 
ward pressure  of  the  handle  of  the  chisel  will  suffice  to  start  the  composite 
flap  from  its  normal  site,  after  which  the  entire  flap  can  be  readily  turned  back. 
This  is  always  so  if  the  section  of  bones  and  ligaments  haye  been  previously 
made  complete,  which  should  invariably  be  the  case,  and  verified  by  sounding 
along  the  entire  line  of  section  with  the  flat  end  of  a  thin  probe.  Should  the 
flap  not  readily,  and  without  force,  start  backward,  it  argues  that  the  section 
has  not  been  fully  made;  and  there  is  no  alternative  but  to  lay  down  the  chisel 
and  complete  the  division  of  bone  with  the  Doyen  saw,  or  of  the  ligaments 
holding  the  last  spine  and  laminae  with  scissors,  as  may  be  indicated,  before 
going  on  with  the  levering-out  process.  As  soon  as  the  section  is  felt  to  be 
started  from  its  bed  sufficiently  to  get  the  end  of  the  finger  under  the  tip  of  the 
lowest  one  of  the  spinous  processes,  all  instruments  may  be  laid  aside.  With 
the  left  index-finger  still  in  the  preliminary  wound  through  which  the  spine 
has  been  removed,  pressing  down  between  the  stump  of  the  excised  end  and 
the  upper  margin  of  the  laminae  below,  and  with  the  right  index  under  the  last 
spine  of  the  flap,  the  entire  mass  is  turned  backward  and  upward  onto  the 
patient's  back  (Fig.  517,  A).     The  backward  displacement  of   this   flap  is 


OSTEOPLASTIC    RESECTION    OF    THE    SPINE. 


657 


accomplished  in  the  following  way:  The  mass  hinges  over  the  stump  of  the 
excised  spinous  process,  the  interlaminous  ligaments  serving  as  the  hinge; 


Fig.  517. — Osteoplastic  Resection  of  the  Spine: — A,  Tenaculum-forceps  holding  back 
composite  flap;  B,  B,  Delicate  forceps  grasping  and  elevating  membranes  and  forming  a  trans- 
verse ridge;  C,  C,  Tenacula  holding  apart  edges  of  incised  membranes;  D,  Angular  scissors 
used  in  incising  membranes;  E,  Half-button  of  bone  bitten  out  of  lower  margin  of  last  lamina 
in  flap  by  rongeur  forceps;  F,  Similar  half-button  bitten  out  of  upper  margin  of  next  stationary 
lamina  below,  the  two  half-buttons  forming  a  circular  opening,  when  in  contact,  for  drainage; 
G,  Vascular  fatty  areolar  tissue  covering  membranes.  The  stump  of  the  excised  spine  is  shown, 
in  impression,  through  the  turned-back  flap.     (Drawn  from  cadaveric  operation.) 


at  the  maximum  of  tension  of  the  parts  the  upper  border  of  the  detached 
laminae  below  is  pried  downward  and  outward  from  under  the  lower  border 
of  the  intact  laminae  above,  and  then  slightly  rides  up  over  the  latter  in  the 


658  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

turning-back  process.  This  manoeuvre  does  not  so  fully  occur  in  the  lumbar 
region,  and  but  slightly,  if  at  all,  in  the  cervical  region,  owing  to  the  different 
deposition  of  these  lamime  and  their  wider  separation  from  each  other.  If 
the  line  of  bone-section  have  fallen  well  within  the  articular  processes,  the 
joints  of  the  articular  processes  will  not  be  opened.  This  manipulation,  though 
exercising  some  violence  upon  the  structures  entering  into  the  make-up  of  the 
interlaminous  relations  at  the  hinge,  does  no  permanent  harm,  as  the  parts 
readily  drop  back  into  their  normal  relationship  at  the  end  of  the  operation 
and  undoubtedly  soon  solidify.  The  composite  flap,  once  turned  back,  will 
generally  lie  in  situ  without  restraint,  or  may  be  held  so  with  a  light  retractor 
or  tenaculum-forceps  (Fig.  517,  A). 

(7)  Freeing  of  the  Spinal  Cord  from  the  Extra-dural  Fatty  Areolar  Tissue, 
and  Control  of  Intraspinal  Hemorrhage. — Having  turned  back  the  osteoplastic 
flap,  the  window  in  the  spinal  column  is  shown,  corresponding  in  length  with 
the  number  of  lamina?  resected,  and  in  width  with  the  distance  apart  of  the 
saw-cuts  (Fig.  517).  In  some  cases  the  membranes  of  the  cord  lie  readily 
within  view  and  touch  through  the  window  thus  formed,  surrounded  by  a 
minimum  of  connective  tissue.  In  other  cases  a  more  or  less  thick  layer  of 
vascular  fatty  areolar  tissue  may  intervene  between  the  bone  and  the  cord 
(Fig.  517,  G).  To  reach  the  membranes,  this  layer  must  be  removed,  which 
is  best  accomplished  by  grasping  it  with  delicate  forceps  and  cutting  it  with 
fine  angular  scissors.  The  hemorrhage  which  results  from  this  manoeuvre, 
and  which  may  be  somewhat  marked,  is  usually  readily  controlled  by  the 
pressure  of  gauze  held  in  small  forceps.  The  hemorrhage  will  be  less  if  this 
vascular  tissue,  chiefly  venous,  be  cut  accurately  in  the  median  line.  Upon 
the  removal  of  this  fatty  connective  tissue  the  white,  glistening  membranes  of 
the  cord  are  brought  into  the  field.  If  the  object  of  the  operation  have  been 
only  to  expose  the  membranes,  that  object  is  now  accomplished.  If  the  cord 
itself  is  to  be  exposed,  other  steps  are  necessary. 

(8)  Opening  of  the  Membranes  of  the  Cord. — The  most  satisfactory  manner 
of  incising  the  membranes  which  the  writer  has  found  is  the  following:  Two 
pairs  of  delicate,  toothed  forceps  are  taken,  one  held  in  the  surgeon's  left  hand 
and  one  in  an  assistant's  right  hand  (Fig.  517,  B,  B) ;  each  of  these,  on  the 
same  level,  takes  a  light  hold  upon  the  membranes  of  the  cord  about  three 
millimeters  (approximately  one-eighth  of  an  inch)  from  the  median  line  of 
the  membranes  (making  the  forceps  six  millimeters,  or  one-fourth  of  an  inch, 
apart),  care  being  taken  that  the  membranes  alone  are  grasped.  The  tips 
of  the  forceps  are  now  drawn  gently  outward  and  upward,  away  from  the  under- 
lying cord,  whereby  a  marked  transverse  ridging  of  the  membranes  is  produced 
at  a  right  angle  to  the  length  of  the  cord.  While  thus  held,  this  ridge  is  cut 
with  the  points  of  a  pair  of  small,  angular  scissors  held  in  the  right  hand  of 
the  operator  (Fig.  517,  D).  Having  made  an  opening  in  the  membranes, 
the  lower  blade  of  the  scissors  is  passed  along  between  the  cord  and  theca, 
and  the  incision  extended  to  the  desired  length,  the  holds  of  the  forceps  being 
shifted  as  the  incision  advances,  and  being  subsequently  maintained  to  retract 
the  incised  membranes,  or  the  edges  of  the  cut  theca  may  be  held  apart  with 
fine  tenacula  (Fig.  517,  C,  C).  Upon  the  wide  retraction  of  the  cut  mem- 
branes the  spinal  cord  and  the  exit  of  the  nerve-roots  from  the  cord  are  brought 
well  into  view.  The  special  object  of  the  operation,  if  it  involve  the  cord, 
is  now  carried  out.  The  present  chapter  deals  solely  with  the  manner  of  exposing 
the  cord  and  canal,  the  various  special  conditions  for  which  this  exposure 
may  have  been  made  not  being  taken  up. 

(9)  Manner   of  Dealing   with    the   Incised   Membranes. — This    will    pre- 


OSTEOPLASTIC    RESECTION    OF    THE    SPINE.  659 

eminently  depend  upon  the  nature  of  the  special  operation.  All  bearings  of 
the  operation  being  favorable,  it  is  best  to  close  the  membranes  after  the  carry- 
ing out  of  the  special  object  in  view.  This  is  done  with  fine,  plain  catgut 
threaded  upon  a  specially  adapted,  fully  curved  needle  held  in  an  appropriate 
needle-holder.  The  margin  of  each  lip  of  the  cut  theca  is  brought  into  proper 
relationship  for  suturing  by  being  held  by  the  delicate  toothed  forceps  used 
in  steadying  the  membranes  during  the  incision  of  its  structures.  A  continuous 
suture  completely  closing  the  incision  is  preferable. 

(10)  Reposition  of  the  Ciiianeoniusculo-osseous  Flap. — The  object  of  the 
operation,  as  a  whole,  having  been  fulfilled,  the  composite  flap  will  often  fall 
back  into  accurate  apposition  without  any  effort  to  make  it  do  so.  It  is,  how- 
ever, better  for  the  surgeon  to  reinsert  his  left  index  into  the  preliminary  wound 
through  which  the  spinous  process  has  been  excised,  and  carry  this  finger  down 
to  the  stump  of  the  excised  spine  (Fig.  516,  B),  while  with  his  right  hand  he 
replaces  the  flap,  thus  having  a  better  opportunity  to  verify  the  accurate  fitting 
of  the  parts.  This  fitting  of  the  structures  back  into  their  original  relationship 
should  be  absolute;  and,  fortunately,  it  is  easy  to  determine  whether  or  not 
it  is  so,  and  equally  easy  to  make  it  so  if  there  seems  to  be  difficulty.  This 
replacement  is  brought  about  by  manual  manipulation  alone,  the  left  index 
in  the  small  wound  guiding  the  parts  at  their  hinge-junction.  The  accuracy 
of  the  apposition  is  verified  by  exposing  the  saw-cuts,  and  seeing  that  the  parts 
of  the  laminae  on  either  side  of  the  section  line  are  on  an  exact  level;  and,  when 
this  is  the  case,  it  will  be  found  that  the  shelving  surfaces  of  the  contiguous 
laminae,  where  the  interspinous  and  interlaminous  ligaments  were  cut,  are  in 
accurate  apposition,  that  the  spines  are  in  line  and  on  a  level,  and  that  the 
skin  margins  come  easily  and  evenly  together. 

(11)  Buried  Suturing  of  Muscles  and  Aponeuroses. — Having  readjusted 
the  composite  flap,  the  soft  parts  intervening  between  skin  and  bone  should 
be  brought  together  by  deeply  buried  sutures  (Fig.  518,  C).  One  would 
give  the  preference  to  twenty-day  chromic  gut,  fairly  stout,  carried  upon  a 
fully  curved  needle.  The  cut  muscles  and  aponeuroses  are  brought  together 
in  their  proper  layers  and  relations  in  the  bite  of  heavy  forceps,  and  are  thus 
held  while  being  penetrated  by  needle  and  suture.  Two  continuous  sutures 
may  be  used,  each  passing  from  the  upper  end  of  one  of  the  limbs  of  the  U- 
shaped  incision  above  to  the  center  of  the  incision  below,  or  interrupted  sutures 
may  be  applied.  It  is  not  practicable  to  suture  together  the  cut  edges  of  the 
interspinous  and  interlaminous  ligaments,  nor  is  it  necessary,  so  closely  do 
the  parts  come  together,  but  the  cut  ends  of  the  supraspinous  ligament  may 
be  sutured. 

(12)  Skin  and  Fascial  Suturing. — The  skin  and  fascia  should  have  their 
edges  united  with  interrupted  sutures  of  silkworm-gut  or  silk.  A  continuous 
suture  of  a  wound  of  this  shape  and  extent  is  not  apt  to  bring  the  margins 
so  accurately  together  (Fig.  518,  D). 

(13)  Provision  for  Drainage,  When  Indicated. — Opinions  differ  upon  the 
subject  of  drainage, — some  advising  its  use  both  within  the  membranes  and 
in  the  extraspinal  wound,  and  some  its  non-use.  Unless  there  were  some 
special  contraindications,  the  preference  of  the  writer  would  be  to  completely 
and  accurately  suture  the  incised  membranes;  to  shut  off  infection  from  with- 
out, and  the  escape  of  cerebrospinal  fluid  from  within;  to  introduce,  for  from 
twenty-four  to  forty-eight  hours,  an  intraspinal  but  extradural  drain  of  a  few 
strands  of  horsehair  or  catgut,  bringing  these  out  between  a  couple  of  omitted 
>u]ierficial  sutures  (Fig.  518,  E),  incorporating  them  with  a  strip  of  gauze 
placed  in  the  deep  muscle  wound  and  leading  down  to  the  spine  (Fig.  518,  F), 


66o 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


both  emerging  together  from  the  skin  wound.  Where  intraspinal  drainage 
is  used,  whether  it  be  intra-  or  extra-dural,  special  provision  must  be  made  for 
it.  This  is  best  secured  by  biting  out,  with  rongeur  forceps,  a  half-button  of 
bone  from  the  lower  margin  of  the  lowermost  lamina  in  the  flap  (Fig.  517,  E), 
and  a  corresponding  half-button  of  bone  from  the  upper  margin  of  the  upper- 
most one  of  the  intact  lamina?  below  (Fig.  517,  F),  so  that  when  the  osteo- 
plastic flap  is  turned  back  into  place,  the  two  half-buttons  will  afford  a  circular 
bone-opening  for  drainage,  the  drains  being  conducted  thence  out  through 
muscles  and  skin,  as  just  mentioned. 


Fig.  518. — Osteoplastic  Resection  of  the  Spine: — A,  A,  Retractors  in  preliminary 
wound,  showing  buried  sutures  of  muscles  and  superficial  sutures  of  skin;  B,  B,  Large  retractors 
drawing  back  skin  of  main  wound;  C,  Line  of  continuous  buried  sutures  of  deeper  parts;  D, 
Line  of  interrupted  superficial  sutures;  E,  Intradural  horsehair  or  catgut  drains;  F,  Extraspinal 
gauze  drain.     (Drawn  from  cadaveric  operation.) 

(14)  After-treatment. — It  is  conceivable,  though  the  writer  knows  of  no 
such  recorded  case,  that,  through  the  excision  of  a  large  number  of  laminae  in 
the  operation  of  laminectomy,  a  patient  might  be  broken  into  two  by  subsequent 
rough  or  imprudent  handling,  so  that  it  might  be  well,  in  even  osteoplastic 
resection,  where  the  operation  has  been  extensive,  to  include  some  form  of 
spinal  splint  in  the  final  dressing  immediately  after  operation,  which  could  be 
worn  until  solidification  of  the  parts  had  taken  place  through  union,  as  after 
any  other  fracture,  the  patient  meanwhile  maintaining  a  strictly  horizontal 
posture.  In  ordinary  osteoplastic  resection  of  average  extent,  and  with  the 
spine  normal  as  to  strength,  the  use  of  a  splint  would  seem  superfluous.  The 
writer  has  never  used  any  form  of  spinal  support  following  laminectomy, 


LAMINECTOMY.  66l 

where  the  spine  is  left  even  weaker  than  after  an  osteoplastic  resection.  If  the 
need  of  it  were  felt,  following  the  convalescence  of  the  patient,  some  form  of 
leather,  or  leather  and  metal,  support  could  be  worn  as  long  as  indicated. 
Reference  has  been  made  to  the  occasional  need  of  such  a  support  under 
General  Considerations. 

(15)  Comment. — Both  during  and  immediately  following  all  operations 
in  which  the  membranes  of  the  cord  are  opened,  the  patient's  head  should  be 
kept  lower  than  the  body  and  the  spine  absolutely  horizontal,  in  order  to 
lessen  the  loss  of  cerebrospinal  fluid. 

Where  the  window  in  the  spine  has  been  made  too  narrow,  through  the 
placing  of  the  bone-sections  too  near  together,  if  more  space  for  manipulation 
be  absolutely  demanded,  there  is  no  alternative  but  to  bite  out  a  portion  of  the 
margin  of  the  opening  into  the  spine,  by  means  of  rongeur  forceps  or  bone- 
cutting  pliers.  If  this  be  done  to  a  limited  extent,  although  there  will  be  a 
corresponding  gap  when  the  osteoplastic  flap  is  turned  back  into  place,  the 
flap  will,  nevertheless,  be  held  in  position  and  kept  from  pressing  against  the 
spine  by  resting  upon  the  margins  of  the  bone-section  which  have  not  been 
thus  additionally  cut  away. 

While  the  normal  cord,  in  a  normal  canal,  is  not  apt  to  be  injured  by  any 
method  of  ordinarily  careful  approach,  in  pathological  cases  the  need  of 
additional  care  is  always  present. 

When  it  is  necessary  to  reach  the  anterior  aspect  of  the  spinal  canal,  the 
cord  must  be  displaced  temporarily  to  one  side  by  means  of  gentle  retraction. 
If  such  retraction  should  not  give  sufficient  room  for  manipulation,  one  or 
two  nerve-roots  have  been  severed  to  afford  the  required  additional  room,  and, 
at  the  end  of  the  operation,  sutured  with  fine  plain  catgut. 


LAMINECTOMY. 

Description. — See  page  642,  above. 

Preparation. — See  page  644,  above. 

Position. — See  page  644,  above. 

Landmarks. — See  page  644,  above. 

Incision. — See  page  661,  below. 

Operation. — The  nature  of  this  operation  has  been  briefly  described 
under  General  Considerations  (page  642).  So  many  of  the  features  of  the 
operation  of  laminectomy  are  in  principle  common  to  the  operation  of  osteo- 
plastic resection,  which  has  just  been  detailed  at  length,  that  only  the  salient 
and  distinguishing  points  of  laminectomy  will  be  here  mentioned. 

(1)  Incision. — A  median  incision  is  made  directly  over  the  centers  of  the 
apices,  which  are,  together  with  their  corresponding  laminae,  to  be  removed. 
In  order  to  give  greater  room  for  the  exposure  of  these  spines  and  lamina-, 
the  incision  should  begin  over  the  spine  next  above  and  end  over  the  spine 
next  below  those  to  be  removed  (Fig.  511,  C,  also  Fig.  514,  A).  It  is  a  bad 
practice  to  place  the  vertical  incision  immediately  to  one  side  of  the  spines,  in  a 
line  along  which  the  muscles  and  aponeuroses  are  to  be  subsequently  separated 
from  the  bone  in  the  subperiosteal  operation  (or  incised  in  the  open,  or  non- 
subperiosteal,  method) ;  for  if  this  be  done,  the  median  lip  of  this  wound  will 
have  to  be  retracted  to  and  beyond  the  line  of  the  apices  of  the  spines  when 
the  soft  parts  are  freed  from  the  side  of  the  spine  opposite  to  the  one  first 
attacked. 

(2)  Division  of  Muscles  and  Aponeuroses. — These  structures  are  divided 


662 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


in  the  same  general  way,  in  so  far  as  the  direction  of  incising  their  structures 
is  concerned,  as  described  under  Osteoplastic  Resection,  paragraph  2,  and  as 
indicated  in  Fig.  509,  A  and  B.  But  as  soon  as  the  spines  are  reached,  the 
knife  should  be  wielded  firmly  and  made  to  cut  its  way  through  the  periosteum 
to  the  bone,  in  a  straight  median  line  over  their  posterior  aspects,  from  the 
apex  of  each  up  to  a  point  where  the  apex  of  the  spine  above  prevents  further 
incision  of  the  periosteum.  The  subperiosteal  method  should  always  be 
undertaken  unless  specially  contraindicated;  but  if  it  be  elected  not  to  attempt 
the  subperiosteal  operation,  the  knife  should  hug  the  spines  so  closely,  in  deep- 
ening the  incision  through  the  soft  parts,  that  a  minimum  of  muscle  and  apo- 
neurotic tissue  be  left  adherent  to  the  bones. 


Fig.  519. — Dorsal  or  Lumbar  Laminectomy: — A,  A,  A,  Retractors  withdrawing  edges  of 
wound;  B,  Clamp-forceps  controlling  hemorrhage;  C,  Chisel,  against  spinous  processes  as  fulcra, 
levering  soft  part  away  from  laminae;  D,  Spine  of  vertebra;  E,  Lamina;  F,  Interlaminous  ligament; 
G,  Doyen  saw  completing  section  of  lamina  and  interlaminous  ligaments.  (Drawn  from  ca- 
daveric operation.)     Note: — The  feature  of  the  subperiosteal  operation  is  not  shown  here. 

(3)  Subperiosteal  Freeing  of  Spines  and  Lamince  Preparatory  to  their  Divi- 
sion.— Having  started  up  the  edge  of  the  incised  periosteum  from  the  apices  and 
posterior  aspects  of  the  spines  by  means  of  a  raspatory  or  periosteal  elevator, 
this  process  of  separation  may  be  continued;  or,  better,  a  chisel,  with  its  non- 
bevelled  edge  toward  the  parts  to  be  removed  and  its  blade  braced  against 
the  spinous  processes  (articular  processes  in  the  neck)  as  fulcra,  is  made  to 
clear  the  soft  parts  from  the  spines  and  laminae.  The  edge  of  the  chisel  is 
carefully  inserted  beneath  the  freed  margin  of  the  periosteum,  and  is  made 


LAMINECTOMY. 


663 


to  remove  the  periosteum  first  from  the  spines  and  then  from  the  laminae,  in 
the  form  of  as  intact  a  layer  as  possible,  and  as  adherent  as  possible  to  the  over- 
lying soft  parts.  As  it  is  impracticable,  in  advance  of  clearing  each  spine  and 
its  set  of  lamina?,  to  incise  through  the  periosteum  along  the  upper  and  lower 
borders  of  the  spine  and  lamina?,  the  layer  of  periosteum  on  each  side,  corre- 
sponding with  each  spine  and  the  lamina  of  that  side,  must  be  more  or  less 
shredded  and  imperfect,  especially  where  it  merges  into  ligamentous  tissue; 


Fig.  520. — Cervical  Laminectomy: — A,  A,  Saw-cuts  through  the  lamina?,  just  within 
their  junction  with  the  articular  processes;  B,  Doyen  saw  in  act  of  dividing  the  lamina;  at  a  right 
angle  to  their  surface,  its  guard  (determining  the  depth  of  section)  being  entirely  raised  at  the 
beginning  of  the  division;  C,  Knife  dividing  the  ligamenta  subflava;  D,  Osteotome  levering  away 
the  muscles  of  the  vertebral  grooves,  using  the  spinous  processes  as  fulcra. 

but  an  attempt,  nevertheless,  should  be  made  to  preserve,  even  if  in  strips, 
enough  periosteum  from  each  spine  and  lamina  to  make  the  deposition  of 
bone  therefrom  fairly  likely.  As  mentioned  under  General  Considerations, 
practically  the  only  practical  justification  for  performing  laminectomy,  ordi- 
narily recognized  by  the  writer,  is  the  doing  of  the  operation  subperiosteally. 
(If  the  subperiosteal  method  be  not  elected,  the  freeing  of  spines  and  lamina?  is 
done  in  the  same  general  way  as  in  osteoplastic  resection,  except,  in  the  present 
instance,  that  the  chisel,  with  bevel  toward  the  spines,  is  braced  against  the 


664 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


spinous  processes  as  fulcra,  and  the  soft  parts  are  pried  away  from  the  spines 
and  lamime  toward  the  transverse  processes  (or  articular  processes  in  the 
neck).  The  method  of  manipulating  the  chisel  is  shown  at  Fig.  519,  C, 
but  the  special  feature  of  removing  the  periosteum,  together  with  the  soft  parts, 
is  not  shown  in  this  illustration.  As  a  result  of  the  procedures  just  described, 
a  path  is  cleared  for  the  saw,  extending  onto  the  lamina  next  above  and  the 
one  just  below  those  to  be  removed. 


Fig.  521. — Laminectomy: — A,  A,  A,  A,  Retractors  separating  edges  of  wound;  B,  Curved 
scissors  dividing  interspinous  and  interlaminous  ligaments;  C,  Bone-holding  forceps  grasping 
spines  and  supraspinous  ligaments,  to  aid  in  lifting  out  the  excised  area  of  bone;  D,  Chisel,  against 
transverse  processes  as  fulcra,  with  edge  in  saw-cut,  prying  out  the  excised  part.  (Drawn  from 
cadaveric  operation.)  Note: — The  interlaminous  ligament  at  the  upper  part  of  the  wound  should 
also  be  represented  cut. 

(4)  Division  of  Lamina:  and  Ligamenta  Subflava. — Having  removed  the 
packing  from  the  wound  upon  one  side  of  the  spines,  its  lip  farther  from  the 
spinous  processes  is  firmly  retracted  by  two  special  retractors,  thus  exposing 
bared  lamina?  (Fig.  519,  A,  A).  The  saw,  held  with  its  edge  at  a  right  angle 
to  the  surface  of  the  laminae  and  somewhat  nearer  the  bases  of  the  transverse 
processes  (bases  of  the  cervical  articular  processes)  than  the  bases  of   the 


LAMINECTOMY. 


665 


spines,  is  made  to  cut  through  the  indicated  laminae,  as  well  as  through  one- 
half  of  the  lamina  next  above  and  next  below  those  to  be  removed  (Fig.  519, 
G,  also  Fig.  520,  B) .  The  course  of  the  saw  and  the  completion  of  the  section 
should  be  determined  as  in  the  osteoplastic  resection. 

(5)  Division  of  Supraspinous,  Interspinous,  and  Intcrlaininous  Ligaments. — 
The  above  ligaments  between  the  spines  and  laminae  at  the  lower  end  of  the 
section  are  divided  with  curved  scissors,  just  as  described  in  Osteoplastic 
Resection,  and  as  illustrated  in  Fig.  521,  B — or  less  safely  with  a  knife  (Fig. 
520,  C).     In  addition,  the  same  ligaments  are  divided  in  the  same  manner 


Fig.  522. — Laminectomy: — A,  A,  A,  A,  Retractors  holding  apart  margins  of  the  wound:  B, 
spinous  process  of  vertebra  above  segment  of  spinal  column  removed;  C,  Shelving  laminae  of 
intact  vertebra  below;  D,  Cut  surface  of  laminae;  E,  E,  Delicate  forceps  grasping  membranes 
so  as  to  form  a  transverse  ridge;  F,  Scissors  in  act  of  incising  transverse  ridge  and  continuation 
of  membranes.     (Drawn   from   cadaveric   operation.) 

at  the  upper  end  of  the  section.  The  segment  of  spines,  laminae,  and  ligaments 
is  thus  entirely  isolated  by  the  saw-cuts  on  either  side  and  the  division  of  the 
ligaments  above  and  below.  In  Fig.  520  the  saw  cuts  and  the  division  below 
are  alone  shown. 

(6)  Separation  and  Removal  of  Ligamento-osseous  Section. — Having  well 
retracted  the  margins  of  the  wound  (Fig.  521,  A,  A,  A,  A),  and  determined 
that  the  sections  through  bone  and  ligaments  are  complete,  the  segment  thus 
limited  is  ready  to  be  pried  from  its  bed.  While  the  spines  and  connecting 
ligaments  are  grasped  by  bone-holding  forceps  (Fig.  521,  C),  a  chisel,  with 


666  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

its  bevelled  edge  away  from  the  parts  to  be  removed,  and  its  blade  braced 
against  the  transverse  processes  (or  cervical  articular  processes)  as  fulcra,  is 
made  by  depressing  its  handle,  to  lever  out  the  mass  from  its  bed,  aided  by 
moderate  traction  upon  the  forceps  grasping  the  spines.  In  the  act  of  its 
removal  the  mass  is  given  a  downward  direction,  so  as  to  dislodge  the  upper- 
most laminae  of  the  section  from  the  laminae  and  spinous  process  of  the  last 
intact  vertebra  above  (Fig.  522,  B). 

(7)  Freeing  of  the  Cord  from  Extradural  Areolar  Tissue,  and  Control  of 
Intraspinal  Hemorrhage. — These  are  accomplished  exactly  as  in  the  Osteo- 
plastic Operation  described  above,  and  partially  illustrated  in  Fig.  517,  G. 

(8)  Opening  of  the  Membrane  of  the  Cord. — This  portion  of  the  present 
operation  is  also  accomplished  in  a  manner  similar  to  that  mentioned  under 
the  Osteoplastic  Resection,  and  is  pictured  in  Fig.  522,  E,  E,  and  F. 

(9)  Manner  of  Dealing  with  the  Incised  Membranes. — As  in  the  Osteoplastic 
Operation. 

(10)  Deep  Suturing  of  Muscles  and  Aponeuroses. — More  care  is  here  neces- 
sary than  even  in  the  osteoplastic  resection.  A  large  mass  of  tissue  has  been 
permanently  removed,  and  the  soft  parts  which  were  formerly  in  contact  with 
the  bones  and  ligaments  which  have  just  been  removed  are  now  to  be  brought 
into  contact  with  each  other  and  sutured  together  by  deeply  buried  stout 
twenty-day  chromic  gut.  In  the  apposition  of  these  soft  parts,  whatever 
periosteum  has  been  saved  should  be  so  manipulated  as  to  be  made  to  lie  in 
as  normal  a  relation  as  possible,  so  that  whatever  bony  deposit  occurs,  should 
take  place  as  nearly  as  may  be  in  the  site  of  the  missing  laminae  and  spines, 
and  thus  strengthen  the  spinal  column.  Interrupted  sutures  probably  accom- 
plish this  object  better  than  a  continuous  form  of  suturing. 

(11)  Skin  and  Fascial  Suturing. — A  median  continuous  or  interrupted 
suture  of  silkworm-gut  or  silk  should  be  placed  through  skin  and  fascia. 

(12)  Provision  for  Drainage,  When  Indicated. — What  applies  in  principle 
in  osteoplastic  resection  also  applies  here.  When  temporary  intraspinal 
drainage,  whether  intra-  or  extra-dural,  is  indicated,  drains  are  readily  con- 
ducted from  within  outward  to  the  skin  surface,  through  openings  left  in  the 
soft  parts  between  omitted  sutures. 

(13)  After-treatment. — Here,  much  more  than  in  Osteoplastic  Resection, 
may  it  be  indicated  not  only  to  include  some  form  of  splint  in  the  dressing 
immediately  following  the  operation,  but  also  the  wearing  of  some  form  of 
spinal  support  for  several  weeks  or  months  following  the  operation,  until  the 
spinal  column  has  solidified  through  the  deposit  of  bone  by  the  periosteum, 
or  otherwise. 

(14)  Comment. — The  observations  made  under  the  Osteoplastic  Operation 
also  apply  here  (page  661). 


SUBARACHNOID  PUNCTURE  FOR   SPINAL  ANALGESIA. 

Description. — The  injection  into  the  subarachnoid  space  of  the  spinal 
cord  of  an  anesthetic  solution  for  the  purpose  of  producing  regional  surgical 
anesthesia  or  analgesia. 

Spinal  analgesia,  recently  somewhat  extensively  and  enthusiastically  used, 
has  now  been  largely  abandoned,  as  being  more  unsafe  than  general  anesthesia, 
more  unpleasant  in  many  instances,  and  as  a  retainer  of  consciousness  during 
operation,  an  undesirable  thing  in  itself,  without  in  exchange  offering  greater 
safety  to  the  patient. 


SUBARACHNOID    PUNCTURE    FOR    SPINAL    ANALGESIA. 


667 


Injections  for  this  purpose  have  been  made  into  various  portions  of  the 
entire  cerebrospinal  tract — but  the  operation  as  practised  for  surgical  pur- 
poses is  practically  limited  to  the  lumbar  region  of  the  spine.  As  the  cord 
ends  at  the  lower  border  of  the  first  lumbar  vertebra,  any  intervertebral  space 
below  that  may  be  used,  namely,  between  the  second  and  third — between 
the  third  and  fourth — between  the  fourth  and  fifth — or  between  the  fifth 
lumbar  and  sacrum.  The  space  usually  chosen  is  that  between  the  fourth 
and  fifth  lumbar  vertebrae — next,  the  lumbosacral  space,  or  the  space  between 
the  third  and  fourth  lumbar. 


Fig.  523. — Subarachnoid  Lumbar  Puncture  (Between  Fourth  and  Fifth  Verte- 
br.e): — Showing  position  of  needle  among  nerves  of  Cauda  equina  in  vertical  section  of  the 
spinal  region.     (Modified  from  Stewart.) 


Various  anesthetic  solutions  have  been  used — chiefly  cocain  or  eucain  B, 
used  alone  or  combined  with  morphin.  The  cocain-morphin-saline  solution 
originally  used  by  Matas  (from  whose  writings  the  accompanying  description 
is  largely  taken)  consisted  of  cocain  hydrochlorate  gr.  j,  morphin  hydrochlorate 
gr.  7'n,  sodium  chlorid  gr.  i,  dissolved  in  20  minims  of  water,  the  water  first 
sterilized  and  the  mixture  subsequently  resterilized  by  the  fractional  method, 
and  injected  warm  by  means  of  a  special  syringe. 

More  recently  stovain  has  been  found  safer,  and  Matas  now  uses  §  of  a 
grain  dissolved  in  from  30  to  60  minims  of  the  spinal  fluid  withdrawn. 

Preparation. — Thorough  sterilization  of  the  field  of  operation. 

Position. — Where  possible,  the  patient  sits  upright  upon  the  edge  of  the 
table,  with  feet  upon  a  chair,  and  leaning  forward,  supporting  himself  by 
hands  upon  knees,  so  as  to  round  out  the  back  convexly  and  increase  the 


668  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

transverse  width  of  the  intervertebral  spaces  by  1.5  cm.  (§  inch) — and  also  to 
cause  the  cerebrospinal  fluid  to  gravitate.  Where  the  patient  cannot  sit  up, 
he  may  lie  upon  his  side  in  Sims's  position  with  back  similarly  arched. 

Landmarks. — The  spinous  processes  of  the  fourth  and  fifth  lumbar  ver- 
tebrae  should  be  identified,  which  is  not  always  easy  in  thickly  covered  backs. 
A  straight  line  drawn  transversely  between  the  highest  points  of  the  iliac  crests 
posteriorly,  while  the  patient  is  as  erect  as  possible,  will  cross  the  tip  of  the 
spinous  process  of  the  fourth  lumbar  vertebra.  The  point  of  injection  lies 
just  below  and  slightly  to  the  outer  side  of  the  junction  of  this  line  with  the 
tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra.  The  spinous  proc- 
esses may  be  also  identified  by  counting  downward  from  the  seventh  cervical 
spine  (the  vertebra  prominens) .     (See  Fig.  523,  D.) 

Operation. — (1)  The  skin  having  been  thoroughly  prepared — the  imme- 
diate area  infiltrated  with  a  few  drops  of  Schleich's  cocain  solution — the  back 


Fig.  524. — Subarachnoid  Lumbar  Puncture  (Between  Fourth  and  Fifth  Verte- 
brae):— Showing  position  of  needlt-point  among  nerves  of  cauda  equina,  in  the  subarachnoid 
space,  in  transverse  section  of  the  spinal  region. 

rounded  out  by  the  patient's  leaning  forward — the  tip  of  the  spinous  process 
of  the  fourth  lumbar  vertebra  is  marked  by  the  left  index-finger.  The  needle 
of  an  empty  syringe  (preferably  a  special  syringe  and  one  made  without  screw 
attachment  for  the  junction  with  the  needle)  is  entered  at  a  point  about  1  cm. 
(nearly  \  inch)  to  the  right  and  just  below  the  tip  of  this  spinous  process — 
and  is  made  to  penetrate  slowly  in  a  direction  forward,  inward  (toward  the 
median  line),  and  slightly  upward  into  the  interspinous  space  between  the 
fourth  and  fifth  lumbar  vertebrae  (Fig.  523),  recognizing,  if  possible,  the 
entrance  of  the  needle  into  the  subarachnoid  space  by  the  lessened  resistance 
as  the  needle  passes  through  a  tense  structure  into  a  freer  cavity.  The  distance 
thus  penetrated  is  generally  between  6.5  and  7.5  cm.  (about  2%  to  3  inches) 
(Fig.  524).  (2)  The  piston  of  the  syringe  is  now  drawn  and,  if  the  needle 
be  in  the  subarachnoid  space,  the  clear  cerebrospinal  fluid  will  appear  (if 
the  needle  be  of  fair  size  and  not  occluded).     As  soon  as  a  few  drops  have 


LUMBAR    PUNCTURE    FOR    DIAGNOSIS    AND    THERAPEUSIS.  669 

flowed,  the  cylinder  of  the  syringe  is  detached  from  the  needle  (which  is  left 
in  situ),  with  the  least  possible  loss  of  cerebrospinal  fluid — and  the  cylinder 
of  the  syringe,  now  charged  with  the  anesthetic  solution,  is  reattached  to  the 
needle  and  the  fluid  carefully  injected.  The  needle  is  allowed  to  remain  in 
situ  a  few  moments  and  is  then  withdrawn — and  the  needle  wound  sealed 
with  sterilized  cotton  and  flexible  collodion.  Anesthesia  should  follow  in 
from  ten  to  fifteen  minutes. 

Comment. — Where  the  space  originally  sought  cannot  be  found  or  satis- 
factorily entered,  resort  to  any  available  interlumbar  space  below  that  between 
the  first  and  second.  Sometimes  an  incision,  under  local  anesthesia,  has  been 
made  down  to  tiie  ligamenta  subflava.  A  laminectomy  has  sometimes  been 
first  performed.     But  these  steps  are  unnecessary  in  the  vast  majority  of  cases. 


LUMBAR  PUNCTURE  FOR  DIAGNOSIS   AND  FOR  THERAPEUSIS. 

This  comparatively  recent  aspect  of  lumbar  puncture  is  an  important 
application  of  the  operation — and  is  based  upon  the  examination  and  inter- 
pretation of  the  fluids,  and  especially  the  suspended  solids,  physiological  and 
pathological,  withdrawn  from  the  subarachnoidean  space  by  puncture  with 
needle  or  fine  trocar. 

These  examinations  embrace  several  fields  of  inquiry; — 

(1)  Physically; — For  characters  presented  in  such  conditions  as  meningitis, 
jaundice,  and  hemorrhage  (either  intra-cranial  or  intra-spinal) .  Cryoscopy 
of  the  cerebrospinal  fluid  has  been  practised,  especially  in  meningitis,  where 
the  freezing-point  has  been  reported  as  lowered. 

(2)  Chemically; — For  characters  presented  in  such  conditions  as  menin- 
gitis, general  paralysis  of  the  insane,  and  some  degenerative  lesions  of  the 
brain  and  cord. 

(3)  Bacteriologically; — Chiefly  for  the  purpose,  at  present,  of  determining 
the  variety  of  micro-organisms  in  a  special  case  of  meningitis. 

(4)  Microscopically ;— Not  only  is  the  centrifuged  fluid  examined  for 
bacteria,  but  also  an  especially  important  bearing  of  the  microscopic  exami- 
nation is  the  determination  of  the  type  of  leukocytes  (cytodiagnosis  proper), 
particularly  under  such  circumstances  as  in  the  differentiation  of  acute  and 
chronic  meningitis,  and  in  syphilitic  and  post-syphilitic  involvements  of  the 
central  nervous  system. 

A  particularly  valuable  bearing  of  the  diagnostic  possibility  of  lumbar 
puncture  for  the  surgeon  is  in  intra-cranial  and  intra-spinal  hemorrhage  from 
no  matter  what  source.  For  instance,  in  a  suspected  fracture  of  the  spine 
with  wounding  of  the  cord,  bloody  cerebrospinal  fluid  would  be  rather  corrobo- 
ratory. Again,  in  a  case  of  unconsciousness,  bloody  fluid  drawn  by  lumbar 
puncture  would  argue  more  strongly  for  intra-cranial  hemorrhage  than  for 
thrombosis — and  such  a  case  of  hemorrhage  is  recorded  as  diagnosed  by  this 
method,  operated,  and  saved. 

In  making  the  puncture  for  diagnosis,  it  should  be  made  as  low  as  possible, 
between  the  fifth  lumbar  and  first  sacral,  in  order  to  get  fluid  rich  in  sediment. 

The  chief  application  of  lumbar  puncture  as  a  means  of  therapeusis  is 
illustrated  in  injecting  antitetanic  serum  into  the  subarachnoidean  space. 

The  technic  of  puncturing  the  lumbar  subarachnoidean  space,  whether 
for  cytodiagnosis  or  therapeusis,  is  practically  the  same  as  described  under 
Lumbar  Puncture  for  Spinal  Analgesia. 


670  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD 


SPINAL  PUNCTURE  FOR  DRAINAGE  OF  THE  SUBARACHNOID 

SPACE. 

Description. — Excess  of  cerebrospinal  fluid  is  sometimes  removed  for 
the  relief  of  pressure  in  the  cerebrospinal  tract.  This  may  be  done  through 
any  of  the  interspinous  spaces — but  is  usually  done  in  the  lumbar  region,  in 
the  same  space  and  in  the  same  general  manner  as  Subarachnoid  Puncture 
for  Spinal  Analgesia.  For  the  same  purpose  the  occipital  bone  has  been 
trephined  and  the  basal  subarachnoid  space  beneath  the  cerebellum  entered 
and  drained — see  Incision  of  the  Cerebellar  Subarachnoid  Space  for  Drainage, 
page  595.  Drainage  of  the  cerebrospinal  fluid  is  chiefly  indicated  in  menin- 
gitis and  hydrocephalus,  cerebral  abscess,  intra-cranial  tumors,  uremic 
coma  and  convulsions,  syphilitic  headache,  and  in  some  auditory  troubles  of 
labyrinthian  origin. 

The  chief  applications  of  lumbar  puncture  therapeutically,  through  drain- 
age, are  either  as  a  cerebrospinal  "decompressive  agent"  alone,  as  where 
the  accumulated  fluid  is  harmful  only  because  of  the  pressure  exercised,  as 
in  hydrocephalus,  or  as  a  combined  decompressive  and  evacuant  agent,  as 
where  the  fluid  is  also  harmful  because  of  its  quality,  as  in  suppurative  menin- 
gitis. 

Preparation — Position— Landmarks. — As  in  Subarachnoid  Puncture 
for  Spinal  Analgesia. 

Operation. — The  steps  of  the  operation  are,  in  all  practical  respects,  the 
same  as  in  the  preceding  one.  The  cerebrospinal  fluid  may  be  withdrawn 
by  trocar  and  cannula — or,  better,  by  aspiratory  syringe — preceded  by  infil- 
tration anesthesia. 


OPERATIVE   TREATMENT  OF  FRACTURES   OF  THE   SPINE. 

All  cases  of  spinal  fracture  may  be  divided  into  three  categories,  in  so  far 
as  the  question  of  cord  involvement  is  concerned: — cases  in  which  it  is  reason- 
ably certain  the  cord  is  crushed; — cases  in  which  it  is  fair  to  assume  the  cord 
is  compressed  or  otherwise  involved; — and  cases  in  which  it  is  fair  to  assume 
the  cord  is  not  involved  by  the  fracture  or  its  consequences. 

It  is  often  impossible  to  tell  whether  the  cord  is  injured  until  the  cord  is 
exposed,  unless  one  waits  a  length  of  time  which  will  often  make  the  correction 
of  the  damage  impossible. 

Only  three  general  methods  of  treatment  are  open  to  the  surgeon: — the 
expectant;  reduction  by  bloodless  methods  and  fixation;  and  operation. 

The  non-operative  methods  are  usually  continuous  extension,  traction  in 
the  horizontal  position,  or  vertical  suspension. 

One  would  advise  waiting  a  reasonable  length  of  time,  to  exclude  shock  and 
a  certain  degree  of  anesthesia  often  caused  by  shock;  then,  if  not  otherwise 
contraindicated,  to  operate  on  the  second  day,  as  only  exposure  will  reveal 
the  exact  condition,  and  if  a  harmful  condition  be  allowed  to  exist  for  many 
hours,  irremediable  damage  may  be  done.  If,  on  the  other  hand,  there  be 
no  doubt,  and  the  general  condition  permit,  operation  should  be  done  imme- 
diately. 

One  should  also  exercise  judgment  in  being  deterred  by  the  general  con- 
dition, for  that  is  known  to  be  often  kept  up  until  the  local  condition  is  relieved. 

It  may  be  impossible  to  distinguish  compression,  concussion,  and  rupture 
of  the  cord,  and  while  it  would  be,  of  course,  desirable  to  recognize  compression 


OPERATIVE    TREATMENT    OF    FRACTURES    OF    THE    SPIXE. 


671 


before  operation,  valuable  time  may  be  lost  in  waiting  for  the  diagnosis  to  be 
made  clear. 

Compression,  or  even  destruction  of  the  cord  and  nerves,  may  occur  from 
hematoma,  extra-  or  intra-dural,  or  even  hematomyelia,  resulting  from  the 
fracture,  or  by  exudate,  and  not  directly  from  the  fracture  itself. 

In  cases  of  fracture  where  the  cord  is  not  injured  at  the  time  of  the  fracture, 
or  immediately  after,  it  may  be  subsequently  compressed  by  callus  thrown  out 
in  repair,  necessitating  operation. 

There  is  no  recognized  technic  in  operating  upon  fractured  spine.  The 
conditions  found  in  each  case  must  guide  the  operator,  the  underlying  principles 
being  to  remove  completely  detached  pieces  of  bone  which  are  exercising 


Fig. 


525. — Wire-ligaturing  in  Fractures  of  the  Spine: — A,  Interspinal  ligature  of  Hadra; 
B,  Intertransverse  ligature  of  Hadra;  C,  Interlaminar  ligature  of  Chipault. 


pressure,  and,  where  possible,  to  bring  into  alignment  and  retain  partially 
detached  bone.  The  latter  is  accomplished  by  simple  reposition  alone,  or 
reposition  followed  by  wiring  of  sound  bone  (Figs.  525  and  526).  In  either 
case  an  immobilizing  dressing  is  applied,  the  wound  being  closed  with  or 
without  drainage,  as  indicated. 

The  site  of  fracture  is  best  approached  along  the  lines  of  an  ordinary  lami- 
nectomy. This  gives  full  exposure  to  the  posterior  arches  of  the  vertebrae. 
The  transverse  processes  and  pedicles  may  be  exposed  by  continuing  the  freeing 
of  these  structures  of  their  soft  parts  through  the  laminectomy  incision  widely 
retracted.  In  the  case  of  fractures  of  the  bodies,  all  that  can  be  done  is  to 
pry  them  back  into  line  by  levering  them  into  place  by  using  the  neighboring 


672 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


bony  firm  parts  as  fulcra,  by  means  of  some  appropriate  metallic  instrument, 
or  by  means  of  manual  manipulation.  Whether  the  fracture  be  of  the  bodies 
or  the  arches,  the  method  of  using  wire  is  to  carry  it  from  some  sound  part  of 
the  arch  above  the  fracture  to  a  corresponding  sound  part  below  the  involve- 
ment. 


Fig.  526. — Wire-suturing  in  Fractures  of  the  Spine: — A,  Interspinous  suture  through 
drilled  spines  above  and  below  fracture;  B,  Intertransverse  suture  through  drilled  transverse 
processes  above  and  below  fractured  vertebra. 


OPERATIVE  TREATMENT  OF  DISLOCATIONS  OF  THE  SPINE. 

Dislocation  of  the  spinal  vertebrae  is  caused  by  the  articular  process  of  the 
higher  vertebra  gliding  downward  and  forward  over  the  lower.  If  the  gliding 
has  gone  far  enough  to  cause  the  posterior  margin  of  the  upper  articular  process 
to  pass  beyond  the  articular  margin  of  the  lower  articular  process,  where  it 
becomes  interlocked,  dislocation  is  said  to  have  occurred,  the  body  of  the 
upper  vertebra  having  glided  to  some  extent  over  the  body  of  the  vertebra 
below.  If  the  gliding  has  been  less  extensive,  so  that  these  margins  have  not 
passed  each  other,  and  interlocking,  therefore,  has  not  occurred,  subluxation  is 
said  to  have  taken  place. 

The  dislocation  may  be  unilateral  or  bilateral,  the  latter  always  causing 
cord  pressure. 


OPERATIVE  TREATMENT  OF  FRACTURE-DISLOCATIONS  OF  SPINE.    673 

Dislocation  in  the  dorsal  and  lumbar  regions  always  involves  fracture  of 
the  articular  processes,  and  generally  also  of  the  laminae,  owing  to  the  more 
nearly  vertical  position  of  the  articular  processes. 

Dislocation  is  most  common  in  the  cervical  region  (owing  to  the  play  of 
the  vertebra?),  usually  between  the  fifth  and  sixth  vertebra?;  next,  between 
atlas  and  axis.     It  is  rare  in  the  lumbar  region,  and  rarest  in  the  dorsal. 

Dislocations  should  be  reduced  by  non-operative  measures  if  possible.  If 
they  cannot  be  so  reduced,  there  are  those  wTho  make  no  further  effort  at 
rectifying  the  lesion,  provided  no  nervous  symptoms  be  present.  If,  however, 
nervous  symptoms  be  present  in  a  case  which  has  withstood  non-operative 
efforts  at  reduction,  operation  is  then  indicated.  What  has  been  here  said 
applies  to  recent  dislocations. 

If  the  case  be  an  old  one,  and  there  are  no  nervous  symptoms  and  no 
great  deformity,  it  may  be  let  alone.  If  there  be  nervous  symptoms,  or  great 
deformity  or  discomfort,  operation  should  be  undertaken — understanding 
the  increased  difficulties  in  the  way  of  reduction  and  the  likelihood  of  finding 
a  partially  degenerated  cord,  and  the  possibility  of  inflicting  additional  damage 
in  the  operation.  These,  however,  should  not  deter  one  from  a  radical  pro- 
cedure. 

The  non-operative  technic  consists  in  first  practising  firm  traction  upon 
the  column,  manual  or  instrumental,  and  then,  by  manipulation,  to  disengage 
the  interlocked  vertebra?  and  push  the  dislocated  one  back  into  place. 

In  operating,  especially  in  bilateral  dislocation,  it  is  to  be  remembered  that 
one  may  expect  to  find  the  intervertebral  articulation  torn,  the  supraspinous  and 
interspinous  ligaments,  ligamenta  subflava,  and  the  anterior  and  posterior 
common  ligaments  lacerated,  and  the  intervertebral  substance  damaged.  The 
soft  parts  should  be  well  retracted  from  the  bones,  so  as  to  expose  the  latter 
thoroughly.  By  manual  or  instrumental  manipulations,  while  the  spinal 
column  is  kept  under  traction,  an  effort  should  be  made  to  return  the  parts  to 
their  normal  positions.  Failing  in  this,  excision  of  part  of  one  or  both  articular 
processes  should  be  done — after  which  reduction  can  usually  be  accomplished. 
In  completing  the  operation,  the  ligaments  and  other  soft  parts  injured  by 
the  original  traumatism  and  by  the  operation  should  be  repaired  by  kangaroo- 
tendon  suture — the  spinous  processes  may  be  wired  with  silver  wire — and 
the  back  should  be  supported  by  a  metallic  or  plaster  brace. 


OPERATIVE    TREATMENT    OF    FRACTURE-DISLOCATIONS    OF    THE 

SPINE. 

Two  forms  of  fracture-dislocation  are  recognized: 

(A)  One  or  both  inter-articular  joints  are  dislocated,  and  there  is  pres- 

sure-fracture of  the  body  of  the  vertebra. 

(B)  Both  inter-articular  joints  are  dislocated,  and  the  body  of  the  ver- 

tebra is  both  dislocated  and  fractured. 

The  indications  for  operation  may  be  gleaned  from  what  has  been  said 
under  this  head  in  the  Sections  upon  Fractures  and  upon  Dislocations, — the 
methods  of  procedure  being  practically  the  same. 

The  injury  done  the  cord  in  these  cases  is,  naturally,  generally  greater  than 
in  either  fracture  or  dislocation  alone — and,  unless  the  case  be  absolutely  hope- 
less, the  indication  for  surgical  interference  is  also  usually  greater,  and  should 
be  prompt  and  radical. 

Chipault  advises,  following  the  rectification  of  the  injury,  to  drill  the  spi- 
nous processes,  and  even  the  transverse  processes  and  lamina?,  and  wire  them. 

43 


674  OPERATIONS    UPON    THE   SPINE    AND    SPINAL    CORD. 


OPERATIVE  TREATMENT  OF   INCISED  AND  PENETRATING  WOUNDS 

OF  THE  CORD. 

Classification  of  Wounds  as  to  Penetration — (penetration  meaning  either 
penetration  of  both  membranes  and  cord,  or  membranes  alone), 
(i)   Wounds  where  penetration  is  doubtful. 

(2)  Penetrating  wounds  without  injury  to  cord. 

(3)  Penetrating  wounds  involving  the  cord. 

It  is  evident  that  one  of  these  conditions  must  exist — but  it  is  evident  that 
it  may  often  be  impossible  to  tell  which.  Berger  and  Hartmann  summarize 
the   indications   for   operation   as  follows: — 

Indications  for  surgical  measures,  dependent  upon  the  period  of  the  wound, 
taken  in  conjunction  with  penetration  or  non-penetration: — 

(A)  /;/  the  Immediate  Period: — 

(i)   Where  penetration  is  doubtful — One  may  intervene   at  once — or 
await  the  development  of  the  case. 

(2)  Where  penetration  is  supposed  to  have  occurred,  but  no  nervous 
symptoms  have  developed; — Intervene. 

(3)  Where  penetration  is  supposed  to  have  occurred,  and  nervous  symp- 
toms have  developed; — two  possibilities  arise: — 

If  incomplete  section  of  the  cord  is  supposed — Operate. 

If  section  of  the  cord  is  supposed  to  be  complete — the  usual  advice 
is  not  to  operate.  The  writer  would  advise  operation  on  the 
ground,  first,  that  such  cannot  be  known  without  operation,  and, 
secondly,  that  it  is  better  to  attempt  to  repair  the  damage  than  not 
to  attempt  to  do  so. 

(B)  In  the  Secondary  Period: — 

If  continuous  suppuration  occurs  or  pressure  symptoms— Operate. 
If  foreign  body  be  present — 

If  it  be  a  determining  factor — Operate. 

If  an  unimportant  factor — Remove  if  accessible. 

Some  generalizations  may  be  made  in  connection  with  Incised  and  Penetrat- 
ing Wounds. 

An  escape  of  cerebrospinal  fluid  argues  a  penetrating  wound. 

A  suspicious  wound  accompanied  or  followed  by  cord-  or  nerve-phenomena 
is  more  apt  to  be  penetrating  than  otherwise. 

Lumbar  puncture  made  for  diagnosis,  in  which  bloody  fluid  is  withdrawn, 
is  sufficient  warranty  for  accepting  penetration,  provided  it  is  not  likely  the 
blood  comes  from  the  needle-wound.  Failure  to  withdraw  blood,  while  pre- 
sumptive, is  not  such  positive  proof  in  the  opposite  direction. 

If  one  be  in  doubt,  the  wound  can  be  enlarged,  stopping  short  of  exposing 
the  cord  if  there  be  reasonable  evidences  against  penetration. 

It  is  safer  to  drain  all  doubtful  wounds — reference  being  here  made  to 
wounds  of  the  overlying  soft  parts. 

If  the  membranes  have  been  opened  by  the  wound,  the  membranes  should 
not  be  sutured  where  infection  is  likely  to  have  occurred.  If  infection  be 
unlikely,  suturing  of  the  membranes  will  make  subsequent  outside  infection 
less  likely  to  occur,  and  will  prevent  the  escape  of  cerebrospinal  fluid. 

If  the  membranes  be  drained,  keep  the  head  low. 

Symptoms  may  be  caused  by  no  actual  wound  of  the  cord,  but  indirectly  by 
a  hematoma  resulting  from  the  wound  and  pressing  the  cord  intraspinally. 

Intraspinal  hemorrhage  may  be  extradural  or  intradural,  or  within  the 
cord — hematomyelia. 


OPERATIVE    TREATMENT    OF    GUNSHOT    WOUNDS    OF    THE    CORD.    675 

One  should  guard  against  considering  every  nervous  phenomenon  as  evi- 
dence  of   penetration. 

Undoubtedly  the  most  difficult  cases  in  which  to  reach  a  decision  will  be 
those  in  which  it  seems  certain  that  penetration  has  occurred,  and  yet  in  which 
there  are  no  nervous  symptoms.  Undoubtedly  the  safest  plan  in  such 
cases  would  be  to  operate,  yet  it  is  probable  that  many  surgeons  would  await 
evidences  of  infection  or  pressure.  The  method  of  dealing  with  a  cord  com- 
pletely divided  is  given  under  the  Operative  Treatment  of  Gunshot  Wounds 
of  the  Cord  (page  675). 

OPERATIVE   TREATMENT  OF  GUNSHCT  WOUNDS  OF  THE  CORD. 

Gunshot  wounds,  owing  to  the  nature  and  size  of  the  projectile,  form,  with 
fractures,  a  class  of  injuries  in  connection  with  which  complete  transverse 
destruction  of  the  cord  is  most  apt  to  occur. 

They  more  nearly  resemble  fractures  in  the  amount  of  damage  they  are  apt 
to  do  the  cord,  both  by  their  own  trauma  and  that  of  bone-splinters — while 
they  more  nearly  resemble  penetrating  wounds  in  other  respects. 

The  indications  for  surgical  interference  are,  practically,  the  same  as  those 
just  given  for  incised  and  penetrating  wounds,  with  even  more  emphasis  upon 
prompt  operative  treatment — and  the  generalizations  there  given  also  apply 
here. 

A  paper  upon  Gunshot  Wounds  of  the  Spinal  Cord,  read  before  the  Xew 
York  Academy  of  Medicine  by  Haynes,  gives  strong  argument  for  early  and 
more  general  operation — where  it  was  conclusively  shown  that  cases  so  treated 
stood  a  better  chance  of  recovery  than  the  non-operated  cases.  His  researches 
covered  the  ten  years  from  1896  to  1906.  During  this  time  he  could  find  only 
43  cases  recorded,  to  which  were  added  3  cases  (with  1  recovery  and  2  deaths) 
operated  by  the  writer  in  the  Charity  Hospital  of  Xew  Orleans.  Of  this  total 
of  46,  7,t,  were  operated,  19  recovering  and  14  dying — giving  a  mortality  of 
operated  cases  of  42^  per  cent.  Of  the  13  non-operated  cases,  4  recovered  and 
9  died — giving  a  mortality  of  69J  per  cent.  There  is  thus,  in  this  collection,  a 
percentage  of  26I  per  cent,  in  favor  of  operation. 

The  following  conditions  were  found  in  the  above  cases: — Bullet  in  spinal 
canal,  n  times; — cord  severed,  10  times; — cord  crushed,  4  times; — cord 
pierced  by  bullet  or  bone,  5  times; — cord  compressed,  n  times; — not  desig- 
nated, 5  cases; — total,  46. 

The  questions  of  greatest  practical  importance  in  gunshot  wounds  of  the 
spine  are  as  to  the  extent  of  injury  done  the  cord — and  the  best  method  of 
treating  the  condition.  It  is  exceedingly  interesting,  as  well  as  remarkable, 
to  know  that  among  the  above  46  cases  there  were  three  cases  reported  (by  the 
late  Dr.  Fowler,  of  Brooklyn;  by  Estes,  of  Bethlehem,  Pa.,  and  one  conjointly 
by  Stewart  and  Hart,  of  Philadelphia)  in  which  there  was  total  transverse 
destruction  of  the  cord,  with  loss  of  substance — in  which  the  ends  of  the  cord 
were  united  by  suture — and  in  which  not  only  was  life  saved,  but  also  some 
degree  of  functioning  regained. 

The  manner  of  dealing  with  the  cord  in  these  three  successful  cases  is  here 
given: — 

In  the  case  of  Stewart  and  Hart,  operated  three  hours  after  injury,  f  inch  of 
the  cord,  opposite  the  seventh  dorsal  vertebra,  was  destroyed  by  the  bullet. 
The  ends  of  the  cord  were  approximated  by  one  anteroposterior  and  two 
transverse  chromic-gut  sutures,  passing  through  the  entire  thickness  of  the 
cord. 


676 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


Estes,  operating  on  the  tenth  day,  writes:  "I  made  a  complete  section  of  a 
disintegrated  cord  at  the  first  lumbar  vertebra — removed  about  f  inch — squared 
off  the  ends,  and  brought  them  together  with  catgut  sutures,  and  sutured  the 
dura  over  the  united  cord." 

Fowler,  also  operating  on  the  tenth  day,  found  a  .38  caliber  bullet  lying 
between  the  ends  of  a  completely  divided  cord,  between  the  tenth  and  eleventh 
dorsal  vertebrae.  He  wrote:  "The  ends  of  the  cord  were  then  sutured  with  three 
fine  chromic  catgut  sutures.  No  special  difficulty  was  experienced  in  drawing 
together  the  ends  of  the  cord  and  closing  the  defect,  the  latter  representing  the 
width  of  the  diameter  of  a  .38  caliber  bullet.  The  dura  was  further  secured 
with  a  number  of  sutures  of  fine  catgut,  and  a  drain,  consisting  of  a  half-dozen 
narrow  strips  of  oiled-silk  protective,  introduced." 

In  all  three  cases  a  meningomyelorrhaphy  was  done  (Fig.  527) — and 
Estes  preceded  his  suturing  by  the  excision  of  the  ends  of  the  cord. 


Fig.  527. — Meningomyelorrhaphy: — Sutures  passing  through  both  cord  and  membranes. 


Instead  of  passing  the  sutures  through  both  membranes  and  cord,  Chipault 
advises  passing  them  through  membranes  alone  (meningeorrhaphy),  thus 
avoiding  further  damage  to  the  cord  proper.  In  the  writer's  case,  where  the 
cord  was  completely  severed  and  an  amount  corresponding  with  the  diameter 
of  the  ball  gone,  the  sutures  were  passed  through  the  membranes  and  cord — 
but  it  was  impossible  to  approximate  the  ends  of  the  cord.  In  the  future,  one 
would  temporarily  divide  two  or  three  sets  of  nerves,  if  necessary,  and  loosen  up 
the  dura  from  the  canal,  and  then  do  a  simple  circular  meningorrhaphy  (Fig. 
528),  by  interrupted  fine  chromic-gut  sutures  passed  through  the  membranes 
only — suturing  the  divided  nerves  at  the  end  of  the  operation — for  while  there  is 
no  full  consensus  of  opinion  upon  the  efficacy  of  cord-suturing,  and  while  the 
preponderance  of  experience  does  not  justify  the  belief  that  there  is  cord- 


OPERATIONS    FOR    REMOVAL    OF    TUMORS    OF    SPINAL    CORD.      677 

regeneration,  yet  in  those  cases  in  which,  at  operation,  the  cord  is  found  severed, 
it  is  better  to  make  an  attempt  to  suture  it  rather  than  to  make  none. 

Hart  and  Stewart  and  Haynes  have  made  satisfactory  union  of  the  cord  in 
experimental  work  upon  the  cadaver,  after  excising  up  to  one  inch — aided  by  the 
posture  of  the  subject  and  by  the  temporary  division  of  nerve-roots. 


Fig.   528. — Mexixgeorrhaphv: — Sutures    passing    through    membranes    alone. 


OPERATIONS  FOR   THE  REMOVAL  OF   TUMORS   OF  THE   SPINAL 

CORD. 

Indications  for  Removal  of  Tumors  Involving  the  Spinal  Cord  as 
Determined  by  their  Anatomical  Origin. — The  classification  of  William- 
son may  be  here  used: — 

(1)  Vertebral — originating  within  the  vertebrae  and  secondarily  compressing 
the  cord — the  most  favorable  for  removal. 

(2)  Extra-dural  Meningeal — originating  within  the  meninges  and  extending 
between  meninges  and  spinal  canal — favorable  for  removal. 

(3)  Intra-dural  Meningeal — originating  within  the  meninges  and  extending 
between  meninges  and  cord — generally  removable. 

(4)  Intra-medullary — originating  within  the  cord  substance — least  favor- 
able— inoperable  in  proportion  to  degree  of  involvement  and  infiltration  of  the 
cord. 

Tumors  within  the  spinal  canal  are  generally  best  removed  through  an 
osteoplastic  flap  exposure.  Those  involving  the  posterior  arches  of  the  spinal 
column  are  usually  removed  by  laminectomy. 


678 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


Preparation ;— Position ; — Landmarks.— As  in  Osteoplastic  Resection 
of  the  Spine  (page  648)  or  as  in  Laminectomy  (page  661). 

Operation. — The  general  principles  involved  in  the  removal  of  cerebral 
and  cerebellar  tumors  also  apply  to  tumors  of  the  cord  (pages  597  and  599). 

If  the  tumor  be  of  the  posterior  arches  of  the  spine,  it  is  exposed  by  incising 


Fig.  529. — Exposure  or  Intra-dural  Spinal  Tumor  by  Osteoplastic  Resection: — 
A,  Composite  flap  of  soft  parts,  lamina;,  spinous  processes,  and  ligamenta  subflava  turned  back- 
ward; B,  Spinal  canal  exposed  by  the  temporarily  severed  and  displaced  lamina;;  C,  Intra-dural 
meningeal  tumor,  displacing  and  pressing  upon  cord  and  nerves  of  left  side. 


and  retracting  the  overlying  soft  parts.     If  it  be  intra-spinal,  it  is  preferably 
exposed  by  an  osteoplastic  flap. 

Vertebral  and  extra-dural  meningeal  tumors  are  removed  without  opening 
the  membranes,  as  a  rule.  The  membranes  are  incised  in  exposing  intra-dural 
meningeal  and  intra-medullary  tumors. 


SPIXA    BIFIDA.  679 

After  exposure  the  tumor  may  be  found  non-removable,  and  nothing 
remains  but  to  close  the  wound.  This,  however,  is  the  exception,  unless  the 
tumor  be  intra-medullary. 

When  the  growth  is  exposed  it  is  sometimes  impossible  to  tell  whether  the 
tumor  originated  from  the  cord,  from  the  meninges,  or  from  the  vertebrae. 

The  tumor  is  best  removed  with  a  sharp  spoon  or  curette,  enucleating  it 
where  possible.  The  majority  of  strictly  intra-spinal  tumors  are  connected 
with  the  meninges,  and  their  removal,  mechanically,  is  usually  not  difficult. 

Intra-dural  meningeal  tumors  generally  involve  the  cord  only  by  pressure 
(Fig.  529).  Intra-medullary  tumors  which  only  involve  a  part  of  the  cord 
should  be  dissected  away  from  the  substance  of  the  cord  with  the  minimum 
damage — hoping  not  to  totally  impair  the  functions  of  the  cord  by  too  extensive 
transverse  destruction.  Should  the  tumor  prove  inoperable  the  pain,  which 
may  have  been  severe,  may  at  least  be  relieved  by  the  intra-spinal  section  of  the 
nerve-roots  involved  in  the  pressure,  and  it  is  necessary  to  cut  at  least  three 
roots,  owing  to  the  association  of  the  sensory  fibers. 

It  has  been  suggested,  in  operating  upon  tumors  of  the  anterior  aspect  of  the 
cord,  to  temporarily  divide  the  necessary  nerve-roots  intraspinally — displace 
the  cord  laterally  and  posteriorly— attack  the  growth — and  resuture  the  nerves 
at  the  end  of  the  operation. 

The  cerebrospinal  fluid  should  be  allowed  to  escape  slowly — if  too  freely  or 
rapidly,  surround  the  upper  end  of  the  cord  by  temporary  ligature  of  floss-silk 
(Schede) — or  lightly  pack  the  upper  end  of  the  canal  (Pearson  or  Woolsey). 

Suture  the  dura  lightly  with  fine  catgut — although  its  non-suture  is  advised 
by  some  surgeons.     Temporarily  drain  down  to  the  dura  in  any  case. 

In  spinal  tumors,  resection  of  the  vertebral  arches  may  be  indicated. 


INTRASPINAL  PARTIAL  NEURECTOMY   OF  THE  POSTERIOR  NERVE- 
ROOTS. 

Description. — In  cases  of  inveterate  neuralgia  sections  of  the  posterior 
nerve-roots,  representing  the  nerves  involved,  have  been  removed  after  opening 
the  spinal  membranes.  In  the  cases  operated  upon  the  results  have  not  been 
altogether  satisfactory.  If,  as  in  one  of  Abbe's  cases,  the  limb  has  been  ampu- 
tated and  spasms  still  continue  in  the  stump,  as  well  as  the  manifestation  of 
pain,  the  motor  roots  may  also  be  cut  (neurotomy),  besides  the  partial  excision 
(neurectomy)  of  the  posterior  roots.  In  addition  to  the  excision,  Keen  has 
suggested  the  breaking  up  of  the  ganglia  upon  the  posterior  nerve-roots,  for 
fear  of  reestablishment  of  connection.  The  technique  of  the  operation  is 
simply  that  of  a  laminectomy  or,  preferably,  an  osteoplastic  spinal  resection, 
as  far  as  the  exposure  of  the  membranes  and  cord  is  concerned.  Care  is 
exercised  in  choosing  the  site  of  the  exposure  that  the  roots  of  the  nerves 
involved  may  be  accurately  located.  After  the  canal  is  exposed  the  membranes 
are  opened  as  described  under  Laminectomy — the  particular  nerves  are  recog- 
nized— and  as  much  of  the  posterior  roots  as  can  be  resected  within  the  dura  is 
excised — and  the  membranes  and  the  wound  dealt  with  as  in  laminectomy 
or  osteoplastic  spinal  resection. 

SPINA  BIFIDA. 

Description. — This  condition  consists  of  an  abnormal  congenital  opening, 
due  to  error  in  development,  situated  in  some  part  of  the  spinal  column, 
generally  in  the  median  line  of  the  posterior  arches  of  one  or  more  vertebrae, 


680  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

rarely  in  the  bodies— through  which  cerebrospinal  fluid  and  a  part  or  all  of 
the  structures  of  the  cord  protrude,  or  with  which  they  are  in  contact. 

Varieties. — (i)  Spina  Bifida  Occulta— a  vertebral  cleft  existing  without 
the  protrusion  of  cord  or  membranes.  (2)  Meningocele — the  membranes 
alone  protruding  through  the  vertebral  cleft,  the  cord  proper  remaining  within 
the  spinal  canal— furnishing  about  8  per  cent,  of  all  cases.  (3)  Meningo- 
myelocele— both  cord  and  membranes  protrude  through  the  cleft,  the  wall  of 
the  sac  consisting  of  skin  and  dura  mater,  lined  by  arachnoid  membrane,  its 
cavity  being  continuous  with  the  subarachnoid  space.  The  cord  is  generally 
in  contact  with  the  posterior  wail  of  the  sac,  the  nerves  traversing  its  lateral 
walls  to  the  intervertebral  foramina  (though  sometimes  running  directly  through 
its  cavity).  In  the  lower  part  of  the  column  the  nerves  forming  the  cauda 
equina  are  usually  found  spread  over  and  adherent  to  the  wall  of  the  sac. 
This,  the  meningomyelocele,  is  the  commonest  form  of  spina  bifida,  forming 
about  62  per  cent,  of  the  cases.  (4)  Syringomyelocele — the  cavity  of  the  tumor 
is  here  formed  by  the  dilated  central  canal  of  the  cord,  its  membranes,  and  the 
integumentary  coverings — constituting  a  rare  form  of  the  disease.  (5)  In  the 
fifth  form  of  spina  bifida  the  central  canal  of  the  cord  communicates  with  the 
surface  of  the  body,  no  skin  covering  the  bony  defect  and  no  barrier  existing 
to  the  free  escape  of  cerebrospinal  fluid.  This  is  another  very  rare  form  of 
the  lesion. 

Rarely  is  the  bony  defect  in  the  body  of  the  vertebrae,  but  when  it  is,  the 
hernia  protrudes  anteriorly  into  the  pelvis,  abdomen,  thorax,  or  neck. 

The  order  of  frequency  in  which  spina?  bifida?  occur  is  lumbar,  lumbo- 
sacral, sacral,  cervical,  dorsal. 

Operation  for  spina  bifida  was  considered  impossible  a  few  years  ago. 
Indications  for  Operation. — In   the  ordinary  course  of  events,  death 
usually  occurs  in  about  six  months  after  birth  in  unoperated  cases. 

As  to  the  question  of  advisability  of  operation,  two  classes  of  cases  occur: 
In  the  first  category,  the  tumor,  following  birth,  grows  rapidly,  the  covering 
becomes  thin,  and  rupture  seems  imminent.  In  these  cases  the  general 
opinion  is  to  operate — and  prompt  operatio:  l  is,  undoubtedly,  the  better  course. 
Others,  Broca  among  them,  on  the  other  hand,  hold  that  it  is  in  just  such  cases 
that  operation  most  frequently  fails,  and  that  it  is  best  to  do  nothing.  While 
it  is  true  that  it  is  in  just  such  cases  that  the  chances  are  most  desperate,  and 
hydrocephalus  is  most  apt  to  follow,  if  parents  understand  and  accept  these 
conditions,  operations  should  be  done  in  the  great  majority  of  cases. 

In  the  second  category  of  cases  the  tumor  exists,  but  not  menacingly,  and 
parents  ask  for  its  removal  for  appearance's  sake  only.  In  such  cases,  other 
conditions  being  favorable,  one  should  operate. 

If  the  child  be  in  a  bad  general  condition,  the  longer  the  delay,  the  better 
the  chances  to  obtain  a  good  immediate  operative  result  and  a  satisfactory 
general  result.  The  condition,  rather  than  the  age,  should  determine  the  time 
of  operation — other  things  being  equal.  The  best  age  is  between  three  and 
four  years,  where,  as  mentioned  above,  death  is  not  threatened  earlier.  The 
outlook  is  not  so  good  when  other  deformities  or  involvements  coexist. 

To  summarize  the  indications  for  operation,  spina  bifida  is  preeminently 
a  condition  in  which  the  patient  has  nothing  to  lose  and  everything  to  gain  by 
operation — in  spite  of  the  fact  that  many  cases  of  successful  operation  for 
spina  bifida   die   subsequently  of  hydrocephalus. 

Preparation; — Position; — Landmarks. — Determined  by  the  position 
and  nature  of  the  tumor. 

Operation. — The  only  operation  to  be  seriously  considered  for  this  con- 


SPIXA    BIFIDA. 


68l 


dition  is  excision,  with  closure  of  the  cleft  by  means  of  flaps  of  the  soft  parts,  or 
by  one  of  the  osteoplastic  methods,  as  indicated — the  steps  and  modifications  of 
which  are  the  following: — An  elliptical  incision,  generally  in  the  long  axis  of  the 
spine,  is  so  planned  that,  beginning  and  ending  a  sufficient  distance  above  and 
below  the  base  of  the  tumor,  its  limbs  are  so  placed  upon  or  near  the  base  of 
the  tumor  laterally  as  to  enable  two  flaps  of  proper  size  and  shape  to  be  raised 
to  cover  the  bony  defect.  Or  a  single  median  skin  incision  may  be  made,  with 
elliptical  muscle  incisions  (Fig.  530).     These  two  flaps,  consisting  of  all  the 


Fig.  530. — Operation  for  Spina  Bifida  by  Mcsculo-aponeurotic  Flaps: — I. — 
A,  A,  Retractors  exposing  dorsal  structures;  B,  B,  Spines  of  vertebrae  above  and  below  bony 
defect;  C,  Remnant  of  sac  of  spina  bifida  after  excision  of  its  redundancy;  D,  D,  Lines  of  relaxing 
incisions  through  outlying  muscles  and  aponeuroses. 

soft  parts  down  to  the  membranes,  are  dissected  back,  on  each  side,  to  a  little 
beyond  the  margins  of  the  bony  cleft.  Having  exposed  the  sac  proper,  and 
having  placed  the  head  of  the  child  low,  so  as  to  avoid  loss  of  cerebrospinal 
fluid,  select  some  part  of  the  sac,  preferably  its  lateral  aspect,  where  it  is  not 
likely  to  encounter  cord  and  nerves  and  where  the  cicatrices  of  the  median 
skin  and  lateral  sac  incisions  will  not  coincide.  Incise  the  sac  carefully  and 
enlarge  the  opening  gradually,  both  to  better  safeguard  the  nerve  structures 
and  to  decrease  the  rapidity  of  outflow  of  cerebrospinal  fluid.     Having  opened 


682 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


the  sac,  one  of  three  conditions  may  be  found: — (A)  Where  the  sac  contains 
neither  cord  nor  nerves,  the  sac,  if  its  neck  be  small,  may  either  be  ligated  at  its 
emergence  from  the  spinal  cleft,  and  excised — or,  if  its  neck  be  large,  it  may  be 
excised  just  distal  to  the  cleft  and  its  cut  margins  sutured;  the  former  probably 
the  better  plan.  (B)  Where  the  sac  contains  unimportant  nerve  elements 
ending  in  its  walls,  one  may  ligate  or  suture  as  just  described,  as  such  nerves 
may  be  harmlessly  sacrificed:  (C)  Where  the  sac  contains  the  cord  and 
important  nerves,  or  even  important  nerves  alone,  running  through  the  sac, 


Fig.  531. — Operation  tor  Spina  Bifida  by  Musculo-aponeurotic  Flaps: — II. — 
A,  A,  B,  B,  As  in  above  figure;  C,  C,  Relaxing  incisions  showing  depth  and  extent  of  inward  retrac- 
tion of  musculo-aponeurotic  flaps;  D,  Line  of  suture  of  inner  margins  of  musculo-aponeurotic 
flaps  over  center  of  remnant  of  sutured  sac  of  spina  bifida. 

or  adherent  to  its  walls,  one  should  first  carefully  dissect  out  all  such  structures 
from  the  sac  and  return  them  to  the  spinal  canal,  after  which  the  sac  should  be 
excised  and  the  deep  edges  of  the  sac,  including  the  membranes,  should  be 
sutured  over  these  structures. 

The  bony  cleft  may  be  closed  by  the  already  overlying  or  adjacent  soft 
structures  (myoplasty)  or  by  adjacent  or  distant  bony  structures  (osteoplasty). 

I.  Myoplastic  Methods. — (A)  Where  the  case  is  simple,  the  bony  opening 
small,  and  the  overlying  skin,  connective  tissues,  and  adjacent  muscles  and 
aponeuroses  thick,  these  overlying  structures  may  simply  be  brought  together 


SPINA    BIFIDA. 


683 


in  the  median  line  and  sutured — with  or  without  lateral  liberating  incisions 

(Fig-  S31)-  ,      e 

(B)  In  larger  openings,  Bayer,  using  the  myoplastic  method,  after  under- 
cutting and  retracting  the  skin,  cuts  out  two  semilunar  flaps  of  dorsolumbar 
aponeuroses  and  muscles  from  the  spinal  furrows,  one  on  either  side  of  the  spine, 
which  he  then  displaces  inward  and  sutures  in  the  middle  line,  so  twisting  them 
that  their  deeper  surfaces  become   more  superficial. 

II.  Osteoplastic  Methods. — Where  large,  extensive  openings  exist,  some 
form  of  the  osteoplastic  method  secures  a  better  closure — and  of  these  there 
are  several: 

(1)  The  osseous  flap  may  be  borrowed  from  the  vertebral  column: — 
(a)  Dolinger,  retracting  the  muscles  covering  the  rudimentary  lamina? 
which  form  the  boundaries  of  the  osseous  defect,  cuts  through  their  bases,  in 
whole  or  in  part,  freeing  them  as  limitedly  as  possible  from  their  soft  parts, 
bends  them  toward  the  median  line  over  the  defect,  and  sutures  them  there 
(Figs.  532,  533). 


Figs.  532  and  533. — Dollinger's  Osteoplastic  Method  in  Operating  for  Spina 
Bifida: — In  A,  a  small  bony  opening  is  seen — which  is  shown  repaired  in  B,  by  partially  splitting 
the  rudimentary  laminas,  turning  them  backward,  and  suturing  them  together — thus  restoring 
the  spinal  canal  by  aid  of  the  laminae. 


(b)  Zenenko  and  Broca,  splitting  the  bounding  transverse  processes  of  the 
two  sides  parallel  with  their  faces,  so  as  to  form  anterior  and  posterior  halves, 
and  bending  their  posterior  halves  backward,  sutures  them  in  the  median  line 
over  the  cleft  (Figs.  534,  535). 

(2)  The  osseous  flap  may  be  borrowed  from  neighboring  or  distant  bones 
other  than  the  vertebral  column: — 

(a)  Chipault,  by  a  semi-circular  incision,  convexity  outward,  detached  a 
periosteal  or  osseo-periosteal  flap,  on  each  side,  which  he  turned  toward  the 
median  line  and  sutured. 

(b)  Bobroff  made  a  semi-circular  incision,  with  outward  convexity,  along 
one  iliac  crest  and  detached  a  small  osseo-periosteal  flap  from  the  postero- 
superior  crest  of  the  ilium.  The  flap  is  then  turned  backward  upon  the  defect, 
its  periosteal  face  inward,  and  sutured  to  the  revivified  borders  of  the  opening. 

(c)  Bobroff,  by  another  method,  raises  an  osseo-periosteal  flap  from  the 
ribs,  which  he  turns  backward  to  cover  the  cleft. 


684 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


(d)  A  bony  flap  may  be  raised  from  the  scapula  in  the  cervico-dorsal  spina 
bifida. 

Finally,  osseous  grafts  have  been  taken  from  the  scapula  of  dog  or  rabbit. 

Closure  of  the  Wound. — Having  provided  for  the  closure  of  the  bony 
cleft  in  one  of  the  manners  above  mentioned,  the  adjacent  soft  parts  are  care- 
fully sutured  in  the  median  line  without  drainage.  A  gauze  and  cotton  dress- 
ing is  applied  with  moderately  firm  pressure,  in  which  may  be  included  some 
form  of  mechanical  dressing  to  protect  the  parts  from  pressure  if  the  dorsal 
decubitus  is  to  be  employed — it  is  better,  however,  to  fix  the  child  face  down- 
ward in  a  special  or  plaster  appliance. 

Comments. — (i)  Escape  of  cerebrospinal  fluid  during  operation,  if  excess- 
ive, may  be  prevented  by  lightly  packing  the  upper  end  of  the  spinal  canal  with 
gauze.  (2)  In  Spina  Bifida  Occulta  no  operation  should  be  done,  as  no 
tumor  protrudes — but  if  symptoms  occur  from  mechanical  pressure  or  other- 
wise, an  attempt  may  be  made  to  close  the  cleft  by  a  myoplastic  or  an  osteo- 
plastic operation.     (3)   Experience  has  shown  that  even  large  bony  defects 


Figs.  534  and  535. — Zknenko's  Osteoplastic  Method  in  Operating  for  Spina'  Bifida: 
— In  A,  a  large  bony  opening  is  seen — which  is  shown  repaired  in  B,  by  partially  splitting  the 
transverse  processes,  turning  them  backward  and  suturing  them  together,  thus  restoring  the 
spinal  canal  by  aid  of  the  transverse  processes. 

have  been  effectively  closed  by  the  displacement  of  muscle-flaps  alone  to  cover 
them.  (4)  It  has  been  suggested  to  spring  a  celluloid  plate  into  the  gap. 
(5)  If  the  skin  covering  the  tumor  be  inappropriate  for  covering,  it  should  be 
gotten  from  the  neighboring  region  by  displacement.  (6)  Seek  primary 
union — to  prevent  leakage  of  the  cerebrospinal  fluid  and  infection.  Avoid 
drainage.  (7)  Bayer's  method  is  probably  the  most  generally  applicable 
and  most  frequently  used  of  any.  (8)  It  is  best  not  to  sacrifice  even  apparently 
unimportant  nerves,  as  their  relative  importance  often  cannot  be  determined  at 
the  operation.  (9)  In  syringomyelocele  (or,  synonymously,  myelocystocele), 
where  the  tumor  is  composed  of  the  dilated  cord  itself,  operation  is  more 
difficult  and  unsatisfactory,  especially  where  marked  paralysis  has  been  caused 
by  the  condition.  Some  surgeons  do  not  consider  operation  under  these  cir- 
cumstances justifiable.  The  dorsal  part  of  the  cord  makes  up  a  portion  of  the 
sac-wall  and  may  have  to  be  injured  or  partially  destroyed  during  operation. 


TREATMENT    OF    ANTERIOR    VERTEBRAL    TUBERCULAR    OSTEITIS.    685 

Often,  however,  in  such  cases  the  amount  of  paralysis  already  present  is  not 
at  all  increased  by  section  of  the  cord.  An  attempt,  nevertheless,  should  be 
made  to  dissect  the  skin  away  from  the  meninges,  then  empty  the  sac,  and 
finally  cover  the  defect  with  skin,  or  preferably  with  muscle  and  skin — or,  if 
feasible,  by  one  of  the  osteoplastic  methods. 


OPERATIVE  TREATMENT  OF  POSTERIOR  VERTEBRAL  TUBERCULAR 
OSTEITIS  OF  THE  SPINE. 

The  posterior  arches  and  transverse  processes  of  the  vertebra?  are  much  less 
frequently  the  site  of  tuberculosis  than  are  the  bodies  of  the  vertebrae. 

When  so  involved,  the  same  general  principle  as  employed  in  treating  the 
more  frequently  invaded  bodies  is  carried  out  here.  The  posterior  structures, 
being  much  more  superficially  situated,  the  problem  is  a  correspondingly 
simpler  one. 

The  disease  is  exposed  by  the  safest  and  most  direct  route,  differing  with  the 
part  diseased  or  the  presence  of  an  abscess — the  general  features  being  the 
opening  of  abscesses,  removal  of  sequestra,  and  the  scraping  away  of  diseased 
bone. 

The  spines  and  lamellae  are  exposed  as  in  a  laminectomy — the  transverse 
processes  are  less  accessible — but  may  be  reached  by  making  a  somewhat 
longer  vertical  incision,  so  as  to  allow  of  more  extensive  lateral  retraction  of  the 
overlying  soft  parts. 

It  may  be  necessary  to  remove  lamina?  in  order  to  expose  the  site  of  disease — 
or  in  order  to  remove  pus  which  may  be  compressing  the  cord. 

All  pus-tracts  should  be  enlarged  and  curetted. 

The  costo-transverse  articulations  and  even  the  heads  of  the  ribs  may  be 
involved,  requiring  a  considerable  exposure. 

The  methods  of  approaching  the  deeper  parts  are  more  fully  given  under 
Tubercular  Osteitis  of  the  Bodv. 


OPERATIVE  TREATMENT  OF  ANTERIOR   VERTEBRAL   TUBERCULAR 

OSTEITIS. 

pott's    disease. 

Description. — Pott's  disease,  originating  in  the  bodies,  may  extend  to 
adjacent  bony  processes  and  articulations — and  is  most  common  in  the  dorso- 
lumbar,  dorsal,  or  cervical  regions.  The  cord  may  be  pressed  upon  by  tuber- 
cular deposit  within  the  canal — pachymeningitis,  with  thickening  of  the 
membranes — pus-formation — bony  deposits,  narrowing  the  canal — and  by 
bony  angulation  of  the  canal.  The  most  usual  causes  of  pressure  of  the  cord 
are  tubercular  deposits  or  pachymeningitis,  rather  than  bony — often  the  greatest 
paralysis  occurring  with  the  least  bony  deformity. 

Indications  for  treatment  will  differ  with  the  stage  of  the  disease: — 

(I)  In  the  early  stages — General  constitutional  treatment  and  local  treat- 
ment, especially  immobilization. 

(H)  In  Pott's  disease  with  angular  curvature — of  which  there  are  two 
classes — ■ 

(1)  Old  cases  of  angularity — in  which  the  least  can  be  done. 

(2)  .Angularities  in  the  act  of  evolution; — of  which  there  are  three — 
(A)  Large  angularities,  or  angularities  which  may  be  classed  as  old,  accom- 
panied by  abscess,  or  occurring  in  cachectic  subjects  already  involved  in  other 


686  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

tubercular  lesions — immobilization.  (B)  Small,  recent  angularity,  existing 
without  abscess  and  occurring  in  otherwise  satisfactory  persons — extension 
and  immobilization.  Here  ligation  of  the  spines  has  also  been  done.  (C) 
Deviations  which  accompany  suboccipital  disease — continuous  extension. 

(III)  In  Pott's  disease  with  paraplegia; — compression  is  not  caused  by  the 
vertebrae  alone,  if  at  all,  but  by  the  tubercular  deposits,  thickened  membranes, 
chronic  abscesses,  sequestra,  and  the  like.  Myelitis  and  neuritis  are  often  so 
extensively  present  that  nothing  is  accomplished  by  the  operation.  The  para- 
plegia is  frequently  cured  when  the  disease  itself  is  cured.  Treatment  may  be 
as  in  more  recent  angularities — by  simple  immobilization.  If  angularity  co- 
exist, an  attempt  may  be  made  to  reduce  it.  As  a  last  resort,  more  active  inter- 
vention may  be  used,  such  as  an  attempt  to  liberate  the  cord  and  nerves  com- 
pressed by  the  tubercular  deposits,  chronic  abscess,  or  by  bony  deformity — the 
outcome  of  which  is  doubtful,  but  the  attempt  is  frequently  better  than  non- 
action. 

(IV)  In  Pott's  disease  with  chronic  abscess; — (i)  Immobilization  may  be 
used  alone  or  in  conjunction  with  other  methods.  (2)  If  the  abscess  accompany 
angular  deformity,  it  is  wiser  not  to  try  to  reduce  the  deformity  while  the  pus- 
sac  exists,  as  rupture  of  the  sac  is  apt  to  be  followed  by  mixed  infection,  exten- 
sive suppuration,  and  amyloid  degeneration.  (3)  If  the  abscess  be  deeply 
placed  and  show  no  tendency  to  increase  or  give  trouble — one  may  temporize 
without  operation,  as  the  abscess  is  often  cured  by  the  cure  of  the  disease.  (4) 
If  the  abscess  tend  to  be  large,  or  to  give  trouble  otherwise,  it  may  be  punctured, 
evacuated,  and  injected — or  operated  upon  as  described  elsewhere.  (5)  If  the 
abscess  be  about  to  rupture — it  should  be  incised  and  drained,  without  curet- 
tage, which  would  likely  lead  to  neighboring  infection.  (6)  If  the  abscess 
have  already  ruptured  and  fistula?  be  present,  with  or  without  mixed  infection, 
— the  openings  should  be  enlarged,  curetted,  and  the  pockets  connected — 
drainage  being  used.  (7)  If  an  open  abscess  exist  and  have  withstood  immo- 
bilization, curettement,  injection,  drainage,  and  general  treatment,  showing  no 
tendency  to  heal — the  site  of  lesion  should  be  operated  upon  as  described  below. 
(8)  Closed  abscesses  may  also  be  operated  upon  radically,  without  being  first 
subjected  to  less  radical  measures,  according  to  the  judgment  of  the  individual 
surgeon. 

The  more  chronic  manifestations  of  cord  pressure  may  be  due,  as  men- 
tioned by  Lloyd,  "to  a  pachymeningitis;  to  a  tubercular  deposit  in  the  canal;  to 
a  gradual  increase  in  the  kyphosis,  causing  bony  pressure;  to  an  inflammatory 
thickening  along  the  ligamentum  subflavum;  to  caseous  deposit  around  the 
tubercular  focus;  to  rupture  of  an  anterior  abscess  into  the  canal,  or  from  pres- 
sure of  such  an  abscess;  or  to  debris  from  a  tuberculosis  of  the  body  or  other 
portion  of  the  vertebras  being  forced  into  the  canal;  or  to  sequestra." 

The  length  of  time  of  paralysis  does  not  contraindicate  operations — it  is 
rather  the  kind  than  the  length  of  pressure  that  modifies  the  outlook. 

There  is  a  marked  tendency  for  paralysis,  even  after  long  duration,  to  recov- 
ery. 

The  condition  of  the  cord  is  rather  one  of  slowly  developed  pressure 
atrophy  than  a  myelitis. 

Schmaus  and  others  have  shown,  by  postmortem  work,  that  angularity  of 
the  column  is  the  cause  of  pressure  from  the  cord  in  only  about  two  per  cent, 
of  the  cases,  but  that  it  is  nearly  always  due  to  an  invasion  of  the  spinal  canal 
by  the  tubercular  process,  a  tubercular  peri-pachymeningitis,  or  tubercular 
abscess  in  the  canal  generally  being  the  immediate  cause. 

The  greatest  relief  from  operation  comes  when  the  paralysis  is  caused  by 


TREATMENT    OF    ANTERIOR    VERTEBRAL    TUBERCULAR    OSTEITIS     687 

an  intraspinal  abscess  or  tubercular  granulation  tissue — and  least  when  due  to 
an  extensive  peri-pachymeningitis. 

It  would  be  ideal  to  remove  the  focus  of  disease  before  time  for  pus-for- 
mation, although  the  technical  difficulty  and  the  danger  are  great. 

There  is  greater  mortality  in  operating  in  the  cervical  region  than  in  the 
dorsal.  Two  causes  of  death  are  peculiar  to  this  region — wounding  verte- 
bral arteries  and  phrenic  nerves. 

The  supposition  of  the  past,  of  recovery  following  forcible  straightening 
followed  by  prolonged  extension,  has  not  been  verified  of  late  years. 

Reinert  reports  a  mortality  of  60  per  cent,  from  the  Tubingen  Clinic,  of 
23  out  of  33  cases  treated  by  extension  alone — with  54  per  cent,  of  recoveries 
and  26  per  cent,  improved  of  the  10  treated  by  laminectomy. 

Operations — are  indicated — where  constitutional  and  mechanical  treat- 
ment have  failed — where  bony  pressure  from  dislocation,  sequestra,  or  angu- 
larity is  present — where  pressure  myelitis  is  threatened,  or  peri-pachymenin- 
gitis is  present. 

Operations  are  contraindicated — during  active  tuberculosis — where  other 
complicating  tubercular  lesions  exist — and  where  mechanical  treatment  has 
not  been  applied. 

The  site  of  disease  is  exposed  by  one  of  the  methods  already  described  for 
approaching  disease  of  the  posterior  arches,  or  by  one  of  those  about  to  be 
given  for  reaching  disease  of  the  more  anterior  aspect  of  the  spine. 

The  Puncture  of  Cold  Abscesses; — The  skin  should  be  punctured  obliquely 
so  that  the  superficial  and  deep  wounds  are  not  in  line.  After  evacuation  the 
injection  of  one  of  the  solutions  usually  used  may  be  carried  out  (iodoform 
and  ether;  iodoform  and  glycerin;  camphorated  naphthol;  5  per  cent,  carbolic 
acid  solution;  and  other  agents). 

The  Incision  of  Cold  Abscesses; — this  varies  with  the  region  and  promi- 
nence of  the  abscess. 

(A)  Lumbar  abscess,  tending  to  descend,  should  be  incised  in  the  inguinal 
region,  in  the  position  as  for  ligation  of  the  iliac  artery — or  extra-peritoneally 
in  the  iliac  fossa  or  pelvis,  as  indicated. 

(B)  Lumbo-dorsal; — these  should  be  incised  either  in  the  iliac  fossa — or 
along  the  spine,  in  the  lumbar  region,  as  in  Treves'  operation. 

(C)  Dorsal  Abscess; — is  best  reached  by  the  operation  of  costo-trans- 
versectomy,  as  described  below. 

(D)  Cervical  Abscess; — is  best  opened  by  an  incision  posterior  to  the  sterno- 
mastoid.  The  skin,  connective  tissue,  and  sterno-mastoid  are  drawn  forward — 
the  cervical  plexus  is  guarded — the  transverse  process  is  sought  and  followed 
down  posterior  to  the  sheath  of  the  vessel — until  the  bodies  are  met — where  the 
abscess  is  encountered. 

Methods  of  Approaching  the  Vertebras : — The  exposure  of  the  site  and  treat- 
ment of  the  lesion  are  here  given  for  the  different  regions. 

(I)   In  The  Lumbar  Region. 

The  technic  of  Treves  is  the  most  satisfactory — the  details  of  which 
are   given   below : 

Description. — The  abscess  is  opened  through  an  incision  in  the  loin — the 
pus-sac  irrigated — all  caseous  material  curetted  out — dead  bone  scraped  away, 
and  the  sac  and  the  wound  sutured  without  drainage. 

Preparation  and  Position. — As  for  osteoplastic  resection  of  the  spine 
(page  648). 

Landmarks. — Last  rib;  crest  of  ilium;  outer  border  of  erector  spinae 
muscle  (generally  from  2\  to  3  inches — 6  to  8  cm. — from  spinous  processes  of 
lumbar  vertebrae). 


688  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

Incision. — Vertical,  2-3  inches  long  (5  to  8  cm.),  with  its  center  midway 
between  last  rib  and  iliac  crest,  passing  parallel  with  outer  border  of  erector 
spina?  (Fig.  536,  B). 

Operation. — (1)  Having  incised  skin  and  superficial  fascia,  the  super- 
ficial layer  of  lumbar  fascia  (which  is  the  posterior  aponeurosis  of  the  erector 
spinae)  comes  into  view — the  lower  part  tendinous,  the  upper  part  giving 
origin  to  fibers  of  the  latissimus  dorsi.  (2)  Divide  this  superficial  layer  of 
lumbar  fascia  the  length  of  the  incision  and  expose  the  erector  spinse  muscle, 
with  its  fibers  running  vertically.  (3)  Recognize  the  outer  border  of  erector 
spinae  and  retract  toward  spine,  thus  exposing  the  middle  layer  of  the  fascia 
lumborum  (which  is  the  anterior  aponeurosis  of  the  erector  spinae  muscle) — 
its  glistening  fibers  tending  transversely.     The  erector  spinas  is,  at  this  site, 


Fig.  536. — Incisions  for  Exposing  the  Bodies  of  the  Vertebr.-e  in  Tubercular 
Osteitis: — A,  Angular  incision  for  exposing  the  dorsal  vertebrae  (costo-transversectomy); 
B,  Vertical  incision  for  exposing  the  lumbar  vertebrae  (Treves'  operation). 


now  adherent  to  its  aponeurosis  anteriorly  and  posteriorly.  (4)  Feel  for  the 
transverse  processes  of  the  lumbar  vertebra?  through  this  aponeurosis,  the 
third  usually  being  the  most  prominent.  Draw  the  erector  spinae  well  toward 
the  middle  line  and  divide  its  anterior  aponeurosis  vertically,  near  to  the  trans- 
verse processes,  thus  exposing  the  quadratus  lumborum  muscle,  with  its  fibers 
and  tendon  bundles  running  obliquely  outward  and  downward.  (6)  Carefully 
incise  the  quadratus  lumborum  near  the  transverse  processes  and  enlarge  to 
the  full  extent  of  the  wound,  guarding  abdominal  branches  of  lumbar  arteries. 
The  psoas  muscle  (with  its  fibers  running  outward  and  downward)  is  thus 
exposed,  overlapping  the  inner  edge  of  the  quadratus  lumborum  and  running 
about  parallel  with  its  posterior  fibers.  The  anterior  lamella  of  the  lumbar 
fascia  occupies  the  interval  between  these  two  muscles.  (7)  Having  divided 
some  of  the  fibers  of  the  psoas  close  to  a  transverse  process,  pass  a  finger  under- 


TREATMENT    OF    ANTERIOR    VERTEBRAL    TUBERCULAR    OSTEITIS.    689 

neath  the  muscle  and  cautiously  advance  along  the  transverse  processes  until 
in  contact  with  the  anterior  aspect  of  the  vertebral  bodies,  enlarging  the  incision 
in  the  psoas  as  far  as  necessary.  (8)  The  abscess  cavity  is  encountered  in  the 
passage  of  the  finger  around  the  body  of  the  vertebra  and  is  incised.  A  finger  is 
then  introduced  into  the  abscess  cavity  and  the  anterior  aspect  of  the  vertebral 
column  is  carefully  examined  where  disease  of  the  lumbar  or  dorso-lumbar 
regions  is  suspected — care  being  taken  to  make  provision  for  the  escape  of 
pus  directly  outward,  the  pus-sac  itself  and  the  lips  of  the  sac  after  incision 
being  drawn  well  into  the  wound.  P'ree  irrigation  with  normal  salt  or  anti- 
septic fluid  of  the  emptied  pus-sac  is  carried  out  by  means  of  a  tube  conducted 
to  its  bottom,  the  emptying  of  the  sac  being  made  more  thorough  by  an  assis- 
tant's compression  of  the  abdomen  from  in  front  and  by  change  in  the  position 
of  the  patient,  thus  alternately  filling  and  emptying  the  sac.  (9)  Following 
the  irrigation  of  the  abscess  cavity,  a  finger  is  introduced  into  the  sac  and  as 
much  of  its  lining  membrane  as  possible  is  removed.  Diverticula  are  opened 
up  and  caseous  masses  are  thus  removed  by  the  finger-nail,  or  by  a  semi- 
sharpened  spoon  used  with  care,  especially  upon  the  thinner  anterior  wall  of 
the  cavity — or  a  flushing  gouge  may  be  used.  The  sac  wall  should  finally  be 
scrubbed'  with  gauze  carried  in  upon  a  sponge-holder.  The  cavity  is  then 
once  more  flushed  out,  to  free  it  of  the  debris  of  these  last  manoeuvres,  and  once 
more  wiped  out  so  as  to  be  left  dry.  (10)  The  lips  of  the  incisions  are  now 
brought  together  by  buried  chromic-gut  suture — no  drainage  being  used.  The 
cut  edges  of  muscles  and  aponeuroses  are  also  sutured  with  buried  chromic  gut 
— and  the  skin  and  fascia  with  silkworm  gut. 

After-treatment. — As  these  abscesses  are  nearly  always  of  tubercular 
origin,  an  indefinite  recumbent  posture  should  be  observed  subsequently  to 
operation,  for  usually  a  period  of  about  six  months,  in  either  bed  or  spinal 
carriage.  The  abscess  may  refill  with  purely  tubercular  products  and  require 
to  be  again  treated  in  the  same  way  as  before.  On  the  other  hand,  the 
originally  tubercular  involvement  may  become  the  site  of  a  mixed  infection 
and  require  open  treatment,  an  unfortunate  sequence  to  be  especially  guarded 
against. 

Comment. — (1)  The  abscess  may  be  approached  almost  equally  well  from 
an  incision  on  either  side  of  the  spine,  though  somewhat  more  conveniently 
from  the  right  side — while  the  peritoneum  is  somewhat  less  exposed  on  the 
left.  (2)  The  difficulty  of  the  operation  is  much  increased  by  thickness  of 
the  patient's  back.  The  length  of  the  incision  may  need  to  be  much  increased, 
or  a  transverse  cut  added  to  it.  (3)  Great  care  is  necessary  to  avoid  wounding 
the  lumbar  arteries,  the  abdominal  branches  of  which  generally  run  behind 
the  quadratus  lumborum — except  that  from  the  first  (and  sometimes  those  of 
one  or  two  others)  which  runs  in  front.  Avoid  them,  and  the  trunks  from 
which  the)'  arise,  by  keeping  close  to  the  transverse  processes.  The  main 
vessels  pass  between  the  transverse  processes,  for  which  reason  the  spine  is 
more  safely  reached  following  along  a  transverse  process.  (4)  While  special 
care  should  be  taken  to  avoid  doing  so,  there  should  not  be  much  danger  of 
wounding  the  peritoneum — or  even  opening  up  the  subperitoneal  connective 
tissue,  both  risks  being  less  by  incising  close  to  the  transverse  processes.  (5)  If 
carious  and  necrosed  bone  be  encountered,  such  destroyed  bone  should  be 
curetted  away,  or  removed  as  sequestra  with  properly  shaped  instruments, 
and  the  debris  irrigated  out.  (6)  If  much  angular  deformity  of  the  spine 
exist,  the  last  rib  and  iliac  crest  may  be  so  near  each  other,  or  actually  overlap, 
as  to  make  the  operation  very  difficult  or  impossible,  though  in  such  extreme 
cases  operation  is  generally  contraindicated.     (7)   Iodoform  emulsion  thrown 


690 


OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 


into  the  sac,  and  the  excess  squeezed  out,  after  rubbing  its  walls,  is  sometimes 
used   before   suturing. 

(II)   In  the  Dorsal  Region. 

(A)  The  operation  of  costo-transversectomy  best  exposes  the  vertebra; 
in  this  region  and  is  performed  in  the  following  manner: — A  vertical  incision, 
3  to  4  inches  (8  to  10  cm.)  in  length,  is  made  about  one-half  inch  (1  cm.)  from 


Fig-  537-— Costo-transversectomy  for  Exposing  the  Bodies  of  the  Dorsal  Ver- 
tebra:— I. — Exposing  thr  Rib  and  Transverse  Process: — A,  A,  The  dorsal  muscles 
displaced  toward  the  median  line;  B,  C,  The  flaps  of  soft  parts  retracted  respectively  upward 
and  outward,  and  downward  and  outward;  D,  Subperiosteal  exposure  of  rib  and  transverse 
process;  E,  Excision  of  vertebral  end  of  rib  with  Gigli  saw;  F,  Line  of  similar  excision  of  trans- 
verse process  of  vertebra. 


the  median  line,  its  center  being  opposite  the  center  of  involvement.  A  second 
incision  is  made  from  the  first  (beginning  at  the  center  of  involvement)  and 
is  carried  over  the  rib  to  be  partially  excised  (Fig.  536,  A) .  The  incisions  are 
carried  through  skin,  fasciae,  and  muscles.  The  two  flaps  made  by  these  inci- 
sions are  turned  aside  (Fig.  537).  The  muscles  and  aponeuroses  are  levered 
from  the  spinal  groove  (made  by  the  transverse  processes  and  laminae — and 


TREATMENT    OF    ANTERIOR    VERTEBRAL    TUBERCULAR    OSTEITIS.    691 

corresponding  with  the  vertical  incision) ; — and  from  the  transverse  processes 
and  ribs  (corresponding  with  the  oblique  incision).  The  transverse  process 
is  excised  at  its  base  with  Gigli  saw  or  bone-pliers  and  torn  away.  The  rib 
is  exposed  subperiosteally,  most  carefully,  with  curved  periosteal  elevator — and 
is  then  resected  about  2 \  inches  (6  cm.)  from  its  extremity  and  removed — the 
head  remaining  attached  to  the  vertebrae  if  its  removal  be  unnecessary  or 
difficult — thus  giving  access  to  the  vertebrae  for  curettage  and  drainage  (Fig. 
538). 


Fig.     538. — COSTO-TRANSVERSECTOMY    FOR    EXPOSING   THE    BODIES   OF   THE    DORSAL   VER- 

TEBR.+;: — II. — Exposing  the  Body  of  the  Vertebra: — A,  A,  B,  C,  D,  As  in  above  figure; 
G,  right  side  of  body  of  vertebra;  H,  Vena  cava;  I,  Pleura;  the  sawn  ends  of  rib  and  transverse 
process  are  seen  in  section.  The  incised  periosteal  membrane  is  shown  drawn  apart  by  three 
small  retractors. 

(B)  Lambotti's  operation  is  an  osteoplastic  method  and  is  performed  as 
follows: — (1)  Elevation  of  Osseo-musculo-cutaneous  flap; — the  patient  lies 
upon  his  left  side — a  vertical  incision  is  made  on  the  right,  opposite  the  angles 
of  the  ribs,  and  two  horizontal  incisions  are  made  from  the  ends  of  this,  extend- 
ing toward  the  spine,  making  a  rectangular  flap.  The  flap  is  then  raised — 
the  spines  are  cut  at  their  bases — and  the  detachment  of  the  flap  is  continued 
as  far  as  the  left  transverse  processes.  A  flap  is  thus  raised,  consisting  of  skin, 
fascia,  aponeuroses,  muscle,  spines,  and  periosteum  of  the  laminae.    The  bottom 


692 


OPERATION'S    UPON    THE    SPINE    AND    SPINAL    CORD. 


of  thi  wound  is  formed  by  lamina'  and  the  right  ribs  and  transverse  processes. 
(2)  Laminectomy; — Resect  the  lamina?  with  a  Doyen  saw — and  thus  one 
reaches  the  transverse  process.     (3)   Resection  of  Extremities  of  Right  Ribs; — - 


Fig.  539. — Displacement  of  the  Cord  to  Expose  its  Anterior  Aspect  or  the  Spinal 
Canal;  also  showing  Intraspinal  Section  of  Nerves  and  Repair  of  Severed  Nerves: — 
A,  Tenaculum  forceps  holding  back  composite  flap;  B,  B,  Retraction  hooks  lifting  cord  from 
spinal  canal  and  displacing  it  laterally;  C,  C,  Sutures  placed  ready  to  repair  severed  nerve-roots; 
D,  Half-button  of  bone  bitten  from  lower  margin  of  last  lamina  in  flap  by  rongeur  forceps;  E, 
Similar  half-button  bitten  from  upper  margin  of  next  stationary  lamina  below,  the  two  half- 
buttons  forming  a  circular  opening,  when  in  contact,  for  drainage;  F,  Vascular  fatty  areolar 
tissue  covering  membranes. 


this  is  done  subperiosteally,  guarding  the  pleura  and  cutting  them  1^  inches 
(4  cm.)  from  the  spine  and  tearing  them  away  from  their  articulation  by  torsion. 
According  to  the  extent  of  the  caries,  one  resects  from  one  to  four  ribs.     The 


TREATMENT    OF    ANTERIOR    VERTEBRAL    TUBERCULAR    OSTEITIS.    693 

removal  of  two  ribs  gives  quite  a  large  space — in  which  the  pleura  is  pushed 
back  and  the  lateral  aspect  of  the  vertebras  reached.  (4)  Resection  of  the 
Vertebral  Bodies; — In  order  to  expose  the  intraspinal  aspect  of  the  Vertebral 
bodies,  two  or  three  nerves  on  the  right  are  temporarily  resected,  which  easily 
exposes  the  meningo-medullary  furrow  upon  the  retraction  of  the  cord.  The 
vertebral  bodies  are  thus  exposed — and  may  be  attacked  with  gouge  or  curette, 
without  danger  to  the  mediastinal  organs.  (5)  Closure  of  the  Wound; — the 
cord  is  replaced — the  cut  nerves  are  resutured  with  catgut — and  the  composite 
flap  is  replaced  and  sutured — temporary  drainage  being  used  or  not,  according 
to  indication. 

(Ill)   In  the  Cervical  Region. 

The  operation  is  here  performed  as  for  cold  abscess  of  that  region,  which 
has  been  just  described.     Incision  is  carried  along  the  posterior  border  of  the 


Fig.  540.— Spinal  Angularity  Resulting  from  Pott's  Disease:— A,  Disintegrated  and 
solidified  vertebrae,  causing  angularity;  B,  Compressed  and  atrophied  cord;  C,  Line  of  section  of 
bone  (which  is  made  by  chisel  or  gouge  after  exposure  and  retraction  of  cord)  so  planned  as  to 
make  spinal  canal  straighter  and  larger.     (Modified  from  Urban.) 

sterno-mastoid,  opening  its  sheath.  The  muscle  is  retracted  anteriorly. 
Opening  up  the  space  behind  the  sterno-mastoid,  one  works  toward  the  trans- 
verse processes  as  rallying  points,  and  then  works  further  inward  upon  the 
vertebral  bodies,  behind  the  prevertebral  muscles — and,  therefore,  behind  the 
sympathetic. 

The  general  method  of  treating  the  seat  of  disease  is  by  curettage,  removal 
of  sequestra,  and  the  ablation  of  fungosities — followed  or  not  by  drainage. 

The  drainage  is  either  prevertebral — trans-somatic  (that  is,  through  the 
bodies  of  the  vertebra?) — or  pre-medullary  (in  those  case-  in  which  the  bodies 
have  been  destroyed). 


694  OPERATIONS    UPON    THE    SPINE    AND    SPINAL    CORD. 

In  all  cases  in  which  the  spinal  column  may  have  been  weakened  by  the 
combined  disease  and  operation,  some  form  of  metallic  or  plaster  brace  should 
re-inforce  the  dressing. 

Generalizations  of  Treatment. — General  Comment. — (1)  Where  bony 
angularity  compresses  the  curd  in  front,  as  is  usually  the  case,  if  re- 
traction laterally  of  the  cord  does  not  expose  the  site  of  pressure,  tem- 
porarily resect  the  necessary  nerves  and  resuture  them  at  the  end  of 
the  operation  (Fig.  539).  (2)  The  angularity  of  bone  may  be  erased 
or  chiselled  after  retracting  the  cord  (Fig.  540).  (3)  Do  not  open  the 
dura  in  operating  for  Pott's  disease,  if  avoidable,  as  the  tubercular  infection 
may  be  spread  to  an  otherwise  uninvolved  structure.  (4)  If  the  cord  be 
pressed  upon  by  scar  or  granulation  tissue,  or  tubercular  or  carious  masses, 
these  are  to  be  scraped  or  cut  away  until  the  cord  is  made  comparatively  smooth 
and  pulsation  in  it  is  detected,  or  at  least  until  it  is  evident  that  the  constriction 
has  been  removed.  To  accomplish  this,  the  cord  is  displaced  to  first  one  side 
and  then  the  other  by  a  blunt  hook.  (5)  While  opening  the  dura  is  to  be 
avoided,  as  mentioned  above,  if  cause  of  constriction  cannot  be  otherwise 
located  and  appears  to  be  intra-thecal,  it  is  best  to  open  the  membranes  rather 
than  close  the  wound  in  doubt.  (6)  Especially  in  angulation  of  the  spine, 
or  adhesions  between  dura  and  bone,  the  close  proximity  of  the  cord  to  the 
laminae  is  to  be  expected  in  opening  the  canal.  (7)  The  extra-dural  plexus 
is  generally  obliterated  in  Pott's  disease — hence  hemorrhage  is  less  apt  to  occur 
from  this  source.  (8)  All  drainage  is  to  be  avoided  in  tubercular  diseases  if 
at  all  possible — as  mixed  infection  is  so  apt  to  occur  before  the  long  course  of 
the  tubercular  trouble  is  at  an  end — and  it  is  for  this  reason  that  the  dissection 
out  of  abscess  and  diseased  bones  and  the  closure  of  the  wound  (or  even  the 
closure  of  a  curetted  abscess  sac)  are  so  desirable.  (9)  In  operating  by  the 
costo-transversectomy  method  it  would  be  better,  unless  the  lesion  were  not 
accessible  from  this  side,  to  go  in  on  the  left,  as  it  would  probably  be  easier  to 
recognize  the  aorta  from  the  abscess  than  the  vena  cava  from  the  abscess. 
(10)  In  closing  off  the  neck  of  a  chronic  abscess  sac  the  sutures  should  be 
placed  deeply  just  within  the  neck.  (n)  The  osteoplastic  method  of  resec- 
tion is  pre-eminently  to  be  used  in  exposing  the  cord  in  Pott's  disease,  as  it 
does  not,  like  laminectomy,  remove  any  portion  of  the  already  weakened 
spinal  column.  (12)  The  spinous  processes  have  been  drilled  and  wired,  as 
well  as  the  laminae  and  transverse  processes.  (13)  One  may  often  learn  much 
of  the  nature  of  the  deformity  by  means  of  the  x-ray  plates — and  thus  be 
guided  in  the  steps  of  the  operation. 


NOTE. 

For  operations  upon  Bones,  Muscles,  Joints,  Ligaments,  Arteries,  Veins, 
and  Nerves  of  the  Spinal  Region,  see  General  Surgery. 


CHAPTER    III. 

OPERATIONS  UPON  THE  NECK. 
I.  THE  LARYNX. 

SURGICAL  ANATOMY  OF  THE  NECK. 

For  Surgical  Anatomy  of  the  antero-lateral  region  of  the  Neck,  see  under 
''Lymphatic  Glands  and  Vessels,"  page  149.  For  Surgical  Anatomy  of  the 
posterior  region  of  the  Neck,  see  under  "Spine  and  Spinal  Cord,"  page  630. 

SURGICAL  ANATOMY  OF  THE  LARYNX. 

Situation. — Lies  in  upper  forepart  of  median  aspect  of  neck — below 
tongue  and  hyoid  bone — in  front  of  pharynx — and  between  large  vessels  of 
neck. 

Relations. — Anteriorly,  skin  and  cervical  fascia; — Posteriorly,  sepa- 
rated from  fourth,  fifth,  and  sixth  cervical  vertebrae  and  prevertebral  muscles 
by  laryngeal  portion  of  pharynx; — Laterally,  sternohyoid;  sternothyroid; 
thyrohvoid;  superior  end  of  lateral  lobe  of  thyroid;  portion  of  inferior  con- 
strictor;— Superiorly,  opens  into  pharynx; — Inferiorly,  opens  into  trachea. 

Arteries. — Superior  laryngeal  branch  of  superior  thyroid;  inferior  laryn- 
geal branch  of  inferior  thyroid;  dorsalis  linguae  of  lingual. 

Veins. — Empty  into  superior,  middle,  and  inferior  thyroid  veins. 

Lymphatics. — Drain  into  carotid  glands  and  into  glands  in  front  of 
cricothyroid  membrane,  or  into  inferior  laryngeal  glands. 

Nerves. — From  superior  laryngeal  and  recurrent  laryngeal  branches  of 
the  pneumogastric,  and  from  the  sympathetic. 

SURFACE  LANDMARKS  AND  GENERAL  SURGICAL  CONSIDERATIONS. 

The  contour  of  the  thyroid  and  cricoid  cartilages,  with  the  intervening 
cricothvroid  membrane,  can  generally  be  outlined  in  the  average  neck — with 
the  thyrohyoid  membrane  extending  upward  from  the  upper  border  of  the 
thyroid  cartilages,  and  the  rings  of  the  trachea  extending  downward  from  the 
cricoid  cartilage.  The  height  of  the  cricothyroid  space  is  about  1  cm. 
(nearly  \  inch)  in  the  average  adult. 

The  internal  (sensory)  branch  of  the  superior  laryngeal  nerve  pierces  the 
thyrohyoid  membrane  above  the  superior  laryngeal  artery.  The  external 
branch  (principally  motor)  of  the  superior  laryngeal  is  distributed  to  the 
cricothyroid  muscle  and  to  the  mucous  membrane.  The  inferior  or  recurrent 
laryngeal  (motor)  runs  up  in  the  groove  between  the  trachea  and  esophagus, 
and  reaches  the  larynx  below  the  inferior  constrictor  and  just  behind  the 
cricothvroid  articulation,  where  it  divides  into  anterior  and  posterior  branches. 

The  cricothyroid  artery  (branch  of  superior  thyroid)  crosses  transversely 

695 


696 


OPERATIONS  I  PON   THE  NECK. 


over  the  upper  part  of  the  cricothyroid  membrane,  and  is  the  chief  artery 
complicating  laryngotomy. 

Small  venous  trunks  cross  the  laryngeal  region  irregularly,  chiefly  emptying 
into  the  superior  thyroid  vein. 


INSTRUMENTS. 

Scalpels;   scissors,    sharp   and   blunt,    curved    and    straight;   forceps;   dis- 
secting, toothed,  and    artery-clamp;   tenacula;    wound    hooks;   laryngotomy 


Fig.  541. — Positions  of  Incisions  for  Opening  the  Laryngotracheal  Tract:— 
A,  Hyoid  bone;  B,  Thyroid  cartilage;  C,  Cricoid  cartilage;  D,  Isthmus  of  thyroid  gland;  E, 
Anterior  belly  of  digastric;  F,  Mylohyoid  muscle;  G,  Sternohyoid  muscle;  H,  Sternothyroid 
muscle;  I,  Sternocleidomastoid  muscle;  J,  Omohyoid  muscle;  K,  Thyrohyoid  membrane; 
L,  Cricothyroid  artery  upon  cricothyroid  membrane;  M,  N,  Branches  of  superior  and  inferior 
thyroid  arteries  (the  lower  arteries  are  not  lettered);  O,  Inferior  thyroid  veins;  P,  Pneumogastric 
nerve;  Q,  Suprathyroid  laryngotomy  (subhyoid  pharyngotomy) ;  R,  Median  thyrotomy;  S, 
Laryngotomy;  T,   High   tracheotomy;   Y,  Low  tracheotomy. 

tubes;  tampon  cannula?;  artificial  larynx;  laryngeal  forceps;  artificial  feather 
for  cleansing  tube;  grooved  director;  mouth-gag;  tongue  forceps;  tongue 
depressor;  wound  retractors;  dilator  for  laryngeal  wound;  laryngeal  aspirator; 
spatulae;  needles,  curved  and  straight-  needle-holder;  sutures  and  ligatures, 


LARYNGOTOMY.  697 

silk  and  gut;  traction-ligatures;  O'Dwyer's  intubation  set;  shield  for  mouth 
and  eyes  of  operator;  tracheotomy  tubes. 

LARYNGOTOMY. 

Description. — Laryngotomy,  or  Infrathyroid  Laryngotomy,  consists  in 
the  opening  of  the  larynx  through  the  cricothyroid  membrane.  The  super- 
ficial incision  is  made  in  the  median  line  of  the  neck,  and  the  opening  into  the 
larynx  is  made  transversely  through  the  cricothyroid  membrane,  followed 
by  the  introduction  of  a  special  laryngotomy  tube  flattened  from  above  down- 
ward so  as  to  present  an  oval  opening. 

Preparation. — The  neck  is  shaved,  if  covered  by  hair. 


Fig.  542. — Laryxgotoity  : — A,  Tenaculum  steadying  thyroid  cartilage;  B,  Cricoid  cartilage; 
C,  Cricothyroid  muscle;  D,  Sternothyroid  muscle;  E,  Sternohyoid  muscle;  F,  Knife  in  act  of 
increasing  opening  in  cricothyroid  membrane  after  stab-incision;  G,  Forceps  grasping  margin 
of  incised  cricothyroid  membrane;  H,  H,  Retractors  retracting  sternohyoid  and  sternothyroid 
muscles. 

Position. — Patient  supine,  shoulders  supported  and  head  thrown  back, 
so  as  to  round  out  and  tense  the  laryngeal  region. 

Landmarks. — Thyroid  and  cricoid  cartilages  and  cricothyroid  space. 

Incision. — A  vertical  incision  is  made  exactly  in  the  median  line,  from 
3  to  4  cm.  (about  i^  to  1^  inches)  long — beginning  over  the  lower  part  of 
the  thvroid  cartilage,  passing  over  the  cricothyroid  membrane,  and  ending 
at  the  lower  border  or  just  below  the  cricoid  cartilage — while  the  larynx  is 
steadied  in  the  middle  line  between  the  left  thumb  and  forefinger.  (See 
Fig.  541,  C.) 

Operation. — (1)  Incise  the  skin,  superficial  fascia,  platysma,  and  cervical 
fascia — dividing  between  ligatures  any  veins  encountered.  (2)  Recognize  the 
interval  between  the  sternothyroid  and  cricothyroid  muscles  and  open  up 
this  interval  bv  blunt  dissection,  thus  exposing  the  cricothyroid  membrane 
(see  Fig.  542).     Retract  the  tissues  laterally.     Divide  the  cricothyroid  artery 


698  OPERATIONS  UPON  THE  NECK. 

between  two  ligatures.  (3)  Steady  the  larynx  by  means  of  left  thumb  and 
forefinger  and  incise  the  cricothyroid  membrane  laterally,  carefully  stabbing, 
with  a  narrow,  sharp  knife,  into  the  lumen  at  one  side  and  incising  trans- 
versely just  above  the  cricoid  cartilage  in  the  act  of  withdrawing  the  knife. 
(4)  Seize  and  evert  one  lip  of  the  laryngeal  wound  with  toothed  forceps,  and, 
parting  the  lips  of  the  wound  by  a  special  laryngeal  dilator,  insert  the  oval 
laryngeal  tube  into  the  larynx,  so  that  its  greatest  width  corresponds  with 
the  length  of  the  wound.  Attach  tube  to  the  neck  by  means  of  a  band.  (5) 
If  the  superficial  wound  be  long,  its  ends  may  be  sutured,  leaving  less  of  an 
area  for  granulation.  (6)  A  dressing  should  be  applied  between  the  flange 
of  the  tube  and  the  neck. 

Comment. — Stab  well  into  the  lumen  of  the  larynx  (while  guarding 
against  stabbing  too  far),  so  as  to  avoid  pushing  the  mucous  lining  of  the 
larynx  ahead  of  the  knife  and  really  not  entering  the  lumen  at  all.  Cut 
very  near  the  cricoid  cartilage,  especially  if  compelled  to  operate  hastily — 
as  the  cricothyroid  artery  runs  nearer  the  lower  border  of  the  thyroid  cartilage. 

Sometimes  the  cricothyroid  membrane  is  incised  vertically,  just  as  the 
superficial  wound — additional  room  being  gotten  by  dividing  the  cricoid 
cartilage  in  the  same  line.     The  above  is,  however,  preferable. 

Laryngotomy  and  Tracheotomy  compared; — Laryngotomy  is  rapidly  and 
easily  performed — it  is  the  operation  where  great  haste  is  necessary  and  few 
instruments  and  limited  assistance  are  at  hand.  It  is  inapplicable  under 
thirteen  years  (the  space  being  too  narrow).  It  is  more  difficult  to  insert  a 
proper  laryngotomy  tube  than  a  tracheotomy  tube.  The  vocal  cords  are 
nearer  and  are  more  apt  to  be  injured  by  wearing  a  laryngotomy  tube.  Laryn- 
gotomy is  not  applicable  where  a  tube  must  be  worn  for  some  time.  In 
Laryngotomy  the  cricothyroid  artery  must  be  avoided  or  tied. 

THYROTOMY. 

Description. — Division  of  the  thyroid  cartilage,  partially  or  completely, 
in  the  median  line,  in  order  to  expose  the  cavity  of  the  larynx.  Resorted  to 
for  the  removal  of  foreign  bodies  and  growths.  Vocalization  is  apt  to  be 
permanently  involved.     The  operation  is  very  similar  to  Laryngotomy. 

Preparation. — As  in  Laryngotomv.  In  addition,  a  preliminary  Trache- 
otomy is  done  (preferably  several  days  in  advance).  (A preliminary  laryngo- 
tomy may  be  done,  but  is  less  satisfactory.)  The  trachea  should  be  plugged, 
or  a  tampon  cannula  used  after  the  tracheotomy. 

Position. — As  in  Laryngotomy. 

Landmarks. — Hyoid  bone,  thyrohyoid  membrane,  thyroid  cartilage, 
cricothyroid  membrane  and  cricoid  cartilage. 

Incision. — A  vertical  incision  is  made  exactly  in  the  median  line,  begin- 
ning at  the  lower  border  of  the  hyoid  bone  and  ending  over  the  cricoid  cartilage 
— steadying  the  larynx  between  the  left  thumb  and  forefinger  (see  Fig.  541,  B). 

Operation. — (1)  Incise  skin,  superficial  fascia,  platysma,  and  cervical 
fascia — encountering  the  terminal  branches  of  the  superficial  cervical  and 
inframaxillary  nerves,  the  communicating  branches  between  the  anterior 
jugular  veins,  and  some  small  superficial  arterial  and  venous  branches.  (2) 
Open  up  the  connective-tissue  interval  between  the  sternothyroid  and  crico- 
thyroid muscles  by  blunt  dissection,  exposing  the  thyroid  cartilage  and  thyro- 
hyoid and  cricothyroid  membranes.  (3)  Divide  the  thyroid  cartilage  care- 
fully and  exactly  in  the  median  line,  by  cutting  from  above  downward  and 
from  without  inward,  with  a  sharp,  fairly  heavy,  rounded  knife.     If  the  upper 


COMPLETE  LARYNGECTOMY.  699 

margin  of  the  thyroid  cartilage  can  be  left  uncut,  better  subsequent  adjust- 
ment is  obtained — but  if  necessary,  not  only  the  entire  thyroid  may  be  divided 
but  as  much  of  the  thyrohyoid  and  cricothyroid  membranes  as  indicated. 
This  manner  of  division  is  safer  than  inserting  the  point  of  a  knife  below  the 
thyroid  and  cutting  upward  from  within.  In  calcined  cartilages  a  small  saw 
may  be  necessary.  (4)  The  two  aire  of  the  thyroid  cartilage  are  now  drawn 
aside  with  small,  blunt  hooks,  exposing  the  interior  of  the  larynx  and  enabling 
the  special  object  of  the  operation  to  be  carried  out.  If  the  alae  cannot  be 
separated  sufficiently  for  the  object  sought,  divide  the  thyrohyoid  or  crico- 
thyroid membranes,  or  both,  transversely  near  their  cartilages.  (5)  Having 
accomplished  the  object  of  the  operation,  the  severed  borders  of  the  thyroid 
are  united  by  chromic  catgut — (and  the  margins  of  membranes  if  cut).  The 
external  wound  is  left  open  in  the  center,  having  been  closed  at  the  ends. 
Temporary  drainage  is  used.  The  tracheotomy  tube  is  retained  for  several 
days. 

COMPLETE  LARYNGECTOMY. 

Description. — Excision  of  the  entire  larynx.  Its  removal  may  or  may 
not  be  followed  by  the  substitution  of  an  artificial  larynx.  Generally  resorted 
to  for  malignant  disease. 

Preparation. — As  for  Laryngotomy.  In  addition,  a  preliminary  low 
tracheotomy  should  be  done  ten  days  or  one  week  in  advance.  Some  form  of 
tampon  cannula  should  be  inserted  into  the  tracheotomy  wound  just  before 
the  major  operation. 

Position. — Patient  supine,  shoulders  elevated,  head  thrown  back,  neck 
prominent  over  a  cushion  or  sand-bag.  Surgeon  to  patient's  right.  Assistant 
opposite  surgeon. 

Landmarks. — Hyoid  bone,  thyrohyoid  space,  larynx,  cricoid  cartilage 
and  upper  tracheal  rings,  sternomastoid  muscles. 

Incision. — (1)  Vertical  incision,  exactly  in  the  median  line,  extending 
from  the  center  of  the  thyrohyoid  membrane  to  the  second  or  third  tracheal 
rings; — (2)  Transverse  incision,  carried  across  at  upper  limit  of  vertical 
incision,  passing  from  one  sternomastoid  muscle  to  the  opposite  one.  (See 
Fig.  548,  B.) 

Operation. — (1)  Having  carried  the  above  incisions  through  skin,  superfi- 
cial fascia,  platysma,  and  cervical  fascia;  ligated  the  superficial  vessels;  and 
encountered  branches  of  the  superficial  cervical  and  inframaxillary  nerves, 
the  two  rectangular  flaps  thus  outlined  are  turned  outward  and  downward, 
exposing  the  anterior  margins  of  the  sternomastoids,  thyroid  and  cricoid 
cartilages,  and  trachea.  (2)  Divide,  between  double  ligatures,  the  superior 
thyroid  arteries,  as  they  lie  at  the  posterior  border  of  the  thyrohyoid  muscles, 
near  the  superior  margin  of  the  thyroid  cartilage.  Similarly  ligate  and  divide 
the  inferior  thyroid  arteries  at  the  posterior  border  of  the  sternothvroids.  at 
the  lower  edge  of  the  larynx.  The  thyroid  veins  encountered  are  similarly 
dealt  with.  (3)  The  cricothyroid,  sternothyroid,  and  thyrohyoid  of  one  side, 
together  with  the  adjacent  soft  parts,  are  retracted  outward,  while  the  larynx 
is  retracted  to  the  opposite  side.  (4)  The  inferior  constrictor  muscle  of  that 
side  is  now  severed  from  the  thyroid  cartilage  bv  a  curved  blunt  dissector 
and  scissors — the  larynx  is  drawn  forward  and  the  tissues  between  the  cut 
inferior  constrictor  and  the  ends  of  the  superior  thyroid  arteries  are  divided 
• — the  superior  laryngeal  nerve  is  cut — and  the  thyroid  gland  is  retracted  out 
of  the  way.     (5)  The  larynx  is  now  drawn  to  the  opposite  (freed)  side  and 


700  OPERATIONS  UPON  THE  NECK. 

the  same  process  of  separation  is  repeated  upon  the  second  side.  (6)  Sever 
the  thyrohyoid  membrane  and  the  thyrohyoid  ligaments — divide  the  extra- 
laryngeal  attachments  of  the  epiglottis  while  putting  the  parts  on  the  stretch 
(thyro-epiglottic  ligament,  hyo-epiglottic  ligament,  glosso-epiglottic  folds,  and 
aryteno-epiglottic  folds).  (7)  Draw  the  larynx  forward  and  complete  the 
division  of  the  connections  of  the  larynx  to  the  pharynx  and  esophagus,  from 
side  to  side  and  from  above  downward,  guarding  the  esophagus  from  injury. 
(8)  If  the  trachea  be  bound  in  situ  by  the  preliminary  tracheotomy,  it  will 
retain  its  position  when  cut — if  not,  it  is  to  be  steadied  by  two  silk  sutures — 
and  then  divided  transversely  between  the  cricoid  cartilage  and  the  first  ring 
of  the  trachea,  from  behind  forward.  (9)  Secure  the  upper  end  of  the  trachea 
to  the  surrounding  integument  by  a  few  interrupted  silk  sutures.  A  deeper 
layer  of  silver  wire  or  silk  sutures  may  be  put  in  to  secure  the  deeper  part  of 
the  trachea  to  the  deeper  surrounding  parts — and  another  layer  uniting  the 
mucous  membrane  of  the  trachea  to  the  skin.  (io)  Suture  the  transverse 
part  of  the  wound,  packing  the  rest.  The  tampon  cannula  is  to  be  left  in 
situ  for  one  or  two  days,  then  replaced  by  the  ordinary  tracheotomy  tube. 
The  patient  is  fed  through  a  stomach-tube  at  first.  An  artificial  larynx  is  to 
be  inserted  in  from  four  to  six  weeks,  if  one  be  used. 

Comment. — (a)  Some  surgeons  do  the  tracheotomv  only  at  the  time  of 
the  main  operation,  (b)  All  bleeding  vessels  are  ligated  or  clamped  as  en- 
countered, (c)  It  may  be  necessary  to  divide  the  isthmus  of  the  thyroid 
gland  between  ligatures,  (d)  All  enlarged  glands  encountered  are  to  be 
removed,  (e)  Hug  the  cartilages  throughout  the  entire  operation,  (f)  The 
larynx  may  be  detached  from  below  upward,  dividing  transversely  below  the 
cricoid  cartilage,  (g)  If  in  doubt  as  to  the  needs  of  removing  the  entire 
larynx,  split  the  larynx  and  thoroughly  examine,  (h)  The  epiglottis  is  best 
removed — some  leave  it — it  may  interfere  with  the  artificial  larynx — or 
become  the  seat  of  returning  disease,  (i)  The  cricoid  cartilage  is  best  away. 
Some  prefer  to  leave  it  as  a  support  to  an  artificial  larynx.  Others  think  its 
retention  interferes  with  swallowing. 


PARTIAL  LARYNGECTOMY. 

Description. — Excision  of  one-half  (in  the  middle  line)  of  the  larynx. 
Indicated  in  the  partial  involvement  of  the  organ. 

Preparation. — Same  as  for  Complete  Laryngectomy,  including  the  pre- 
liminarv  tracheotomv. 

Position — Landmarks. — Same  as  in  the  complete  operation. 

Incision. — Same  as  for  total  Laryngectomy,  except  that  the  transverse 
portion  of  the  incision  is  made  only  upon  one  side.     (See  Fig.  548,  B.) 

Operation. — Same,  practically,  as  for  the  total  excision,  except  that  the 
thyroid  cartilage  is  divided  dowm  its  center  and  the  involved  half  removed 
after  being  separated  from  its  soft  parts  by  carefully  hugging  the  cartilage 
during  the  freeing.  The  superior  cornu  of  the  thyroid  cartilage  is  divided 
at  its  base  by  forceps.  The  epiglottis  is  left,  the  aryteno-epiglottic  fold  of 
the  involved  side  being  severed  near  WrrSberg's  cartilage — though  one-half 
of  the  epiglottis  may  be  left  and  one-half  removed.  The  cricoid  cartilage 
may  be  left.  The  after-treatment  is  practically  the  same  as  for  the  total 
removal,  except  briefer. 


INTUBATION  OF  THE  LARYNX.  701 


INTUBATION  OF  THE  LARYNX. 

O'DWYER'S  OPERATION. 

Description. — The  introduction,  by  a  special  instrument  (introductor),  into 
the  larynx  of  a  special  metallic  tube — which,  upon  the  accomplishment  of  the 
object,  after  a  shorter  or  longer  time,  is  removed  by  another  form  of  special 
instrument  (extractor).  Intubation  is  used  in  cases  of  impeded  breathing 
arising  in  the  larynx  or  upper  trachea  from  causes  other  than  foreign  body. 

Operation. — (1)  Supposing  the  case  to  be  a  child — the  nurse  sits  upright 
in  a  straight-back  chair — the  child,  enveloped  in  a  sheet  or  large  bath-towel, 
thus  pinioning  its  arms,  is  held  upright  in  the  nurse's  right  lap,  her  right 
arm  passing  forward  around  the  child's  shoulders  and  chest,  her  left  forward 
around  its  hands  and  abdomen — its  legs  are  placed  between  her  knees — its 
head  is  thrown  slightly  backward  over  the  nurse's  right  shoulder,  and  is 
steadied  by  an  assistant  standing  behind  the  nurse — the  child's  mouth  is 
gagged  on  the  left  side  and  the  gag  held  by  the  assistant's  left  hand.  (2) 
The  surgeon,  standing  in  front  of  the  child  (his  mouth,  eyes,  and  nose  pro- 
tected from  the  cough,  etc.,  of  the  patient,  in  contagious  cases) — inserts  his 
left  index  into  the  throat  until  in  contact  with  the  epiglottis,  which  he  elevates 
by  hooking  forward  and  presses  against  the  root  of  the  tongue  with  the  tip 
of  this  finger,  at  the  same  time  also  drawing  the  base  of  the  tongue  slightly 
forward.  The  tube,  with  its  contained  obturator  attached  to  the  introductor, 
is  passed  into  the  mouth  parallel  with  the  left  index  as  a  guide  (the  handle 
of  the  instrument,  at  this  stage,  being  about  parallel  with  the  chest-wall)  and 
is  directed  in  the  necessary  curve  by  elevating  the  handle  of  the  introductor 
— and  is  guided  through  the  rima  glottidis  by  the  tip  of  the  finger  which  has 
drawn  the  epiglottis  forward.  As  soon  as  the  instrument  is  felt  to  be  engaged 
within  the  larynx,  the  left  index-finger  is  shifted  to  the  shoulder  of  the  tube 
and  aids  in  gently  pushing  it  down  into  place  between  the  cords.  The  obtu- 
rator is  then  detached  from  the  tube  by  a  special  mechanical  movement, 
controlled  within  the  handle  of  the  instrument,  and  is  withdrawn  together 
with  the  introductor.  If  the  safety-thread  (which  has  been  previouslv  intro- 
duced through  the  eye  of  the  laryngeal  tube)  be  removed,  the  left  index 
remains  in  contact  with  the  tube  until  the  thread  is  withdrawn.  The  thread 
is  often  retained  as  a  means  of  hasty  and  easy  withdrawal  in  case  of  need, 
and  is  tied  about  a  tooth  or  the  ear.  (3)  To  withdraw  the  tube,  let  the  same 
position  of  patient,  surgeon,  assistant,  and  nurse  be  assumed  as  before — 
similarly  draw  the  epiglottis  forward  with  the  left  index — and,  having  similarly 
guided  the  beak  of  the  extractor  into  the  lumen  of  the  laryngeal  tube,  expand 
the  blades  of  the  beak  and  withdraw  the  tube.  If  the  thread  have  been  left 
in  situ,  the  tube  may  be  withdrawn  by  it. 

Comment. — Always  be  ready,  in  advance,  to  do  an  immediate  trache- 
otomy— in  the  event  that  intubation  cannot  be  performed,  or  that  tube  get 
into  trachea,  or  that  membrane  be  protruded  ahead  of  the  tube  and  impede 
trachea  and  tube. 

To  feed  the  child  while  the  tube  is  in  the  larynx — place  it  upon  its  back 
in  the  nurse's  lap — let  its  head  bend  over  her  knee,  lower  than  its  shoulders — 
feed  it  fluid  food  from  a  bottle  on  to  the  roof  of  its  mouth  (which  is  now  lower 
than  the  floor) — the  liquid  will  then  flow  over  the  soft  palate  on  to  the  posterior 
pharyngeal  wall,  and  thus  nothing  pass  over  the  laryngeal  tube.  Some 
children,  however,  feed  naturally  without  trouble. 

The  shoulders  of  the  laryngeal  tube  are  grasped  by  the  superior  or  false 
vocal  cords. 


7°2  OPERATK  >NS  UPON  THE  NECK. 


OTHER  OPERATIONS  UPON  THE  LARYNX. 

Suprathyroid  Laryngotomy. — 

Same  as  Subhyoid  Pharyngotomy  (page  709).  Sometimes  employed  to 
expose  the  upper  part  of  the  larynx  and  the  region  of  the  epiglottis. 

Laryngo-tracheotomy. — 

Larynx  and  trachea  are  both  opened  in  one  continuous  median  line — 
where  more  room  is  required  than  furnished  by  either  laryngotomy  or  trache- 
otomy alone. 

Tamponing  of  Larynx. — 

The  placing  of  gauze  or  sponge  packing  over  the  entrance  of  the  larynx 
in  order  to  prevent  the  entrance  of  fluids  or  blood  into  the  air-passages  during 
operations  about  the  oral,  pharyngeal,  and  nasal  cavities — a  preliminary 
tracheotomy  having  been  done. 

Introduction  of  Artificial  Larynx. — 

After  the  parts  have  healed,  following  a  total  laryngectomy,  an  artificial 
larynx  is  sometimes  inserted  through  the  wound  in  the  neck — a  mechanical 
contrivance  having  a  longer  tracheal  tube  which  fits  into  the  trachea,  a  shorter 
pharyngeal  tube  passing  up  toward  the  site  formerly  occupied  by  the  larynx, 
and  an  external  protected  opening  occupying  the  cervical  wound,  and  a  vibrat- 
ing apparatus  for  speech. 

Operation  for  the  Removal  of  Foreign  Bodies. — 

Foreign  bodies  are  removed  either  by  means  of  instruments  introduced 
into  the  larynx  through  the  rima  glottidis  by  way  of  the  mouth — or  by  opening 
the  cavity  of  the  larynx  from  without  by  means  of  one  of  the  operations  above 
described. 

Laryngoscopy. — 

Examination  of  the  larynx  by  means  of  a  laryngoscopic  mirror  introduced 
through  the  mouth. 

II.  THE   TRACHEA. 
SURGICAL  ANATOMY. 

Situation. — The  trachea  extends  from  lower  border  of  fifth  cervical 
vertebra  above,  where  it  is  continuous  with  the  larynx,  to  fourth  or  fifth 
dorsal  vertebra  below,  where  it  bifurcates  into  right  and  left  bronchi.  Its 
length  is  from  10  to  13  cm.  (4  to  5  inches) — its  width  from  about  2  to  2.5  cm. 
(f  to  1  inch).     It  lies  in  a  bed  of  lax  connective  tissue. 

Relations. — (a)  Cervical  portion, — anteriorly ;  skin;  superficial  cervical 
fascia;  anterior  jugular  veins;  communicating  branch  between  anterior 
jugular  veins;  inferior  thyroid  veins;  thyroidea  ima  artery  (when  present); 
sternohyoid  and  sternothyroid  muscles,  separated  by  deep  cervical  fascia, 
and  partly  overlapping  sides  of  trachea;  isthmus  of  thyroid  gland;  thymus 
gland  (or  its  remains).  Posteriorly;  esophagus.  Laterally;  lateral  lobes 
of  thyroid  gland  (especially  on  left);  inferior  thyroid  arteries;  recurrent 
laryngeal  nerves;  sheath  of  common  carotid,  internal  jugular  and  pneumo- 
gastric.  (b)  Thoracic  portion, — anteriorly;  sternum;  remains  of  thymus; 
origins  of  sternohyoid  and  sternothyroid  muscles;  left  innominate  vein; 
transverse  arch  of  aorta;  innominate  artery;  left  common  carotid  artery; 
deep  cardiac  plexus;  left  recurrent  laryngeal  nerve.  Posteriorly;  esophagus. 
Laterally;  lies  between  the  pleural  sacs;  pneumogastrics. 

Arteries. — From  inferior  thyroid  branch  of  thyroid  axis. 

Veins. — End  in  thyroid  plexus. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  TRACHEA.        703 

Nerves. — From  trunk  of  pneumogastric;  recurrent  laryngeal  branch  of 
pneumogastric;  sympathetic. 


SURFACE  FORM  AND  LANDMARKS. 

The  isthmus  of  the  thyroid  gland  crosses  the  second  and  third  tracheal 
rings  in  the  adult.     It  is  generally  higher  in  the  child. 

In  an  average  adult,  about  2  cm.  (f  inch)  of  additional  trachea  is  drawn 
up  into  the  neck  in  full  extension  of  the  cervical  region. 

In  infants  under  two  years,  the  thymus  gland  extends  upward  nearlv  or 
quite  to  the  lower  border  of  the  thyroid  gland. 

Small  venous  trunks  cross  the  tracheal  region  irregularly,  chiefly  emptying 
into  the  superior  thyroid  veins. 

A  communicating  vein  between  the  superior  thyroid  veins  crosses  the 
trachea  above  the  isthmus  of  the  thyroid  gland. 

Arteria  thyroidea  ima,  when  present,  passes  up  from  the  innominate 
along  the  anterior  surface  of  the  trachea. 

The  upper  portion  of  the  trachea  is  comparatively  superficial.  The 
lower  portion  is  comparatively  deep  and  the  vascular  relations  more  com- 
plicated. 

GENERAL  SURGICAL  CONSIDERATIONS. 

Tracheotomy  may  be  done  in  three  sites — (1)  Above  the  isthmus  of  the 
thyroid  gland,  or  High  Tracheotomy  (the  operation  of  election,  because  the 
trachea  is  here  more  accessible), — (2)  Below  the  isthmus,  or  Low  Trache- 
otomy,— and  (3)  Behind  the  isthmus  (by  its  ligature  and  removal  of  the 
isthmus — hardly  a  separate  operation,  but  generally  added  to  one  of  the 
others  where  more  room  is  required). 

Structures  of  the  anterior  aspect  of  the  neck  more  or  less  involved  in 
tracheotomy  above  the  isthmus  of  the  thyroid, — skin;  superficial  cervical 
fascia;  superficial  cervical  nerves;  inframaxillary  nerves;  cutaneous  arteries; 
anterior  jugulars  and  communicating  vein;  deep  cervical  fascia;  superior 
thyroid  arteries  and  veins;  tracheal  layer  of  deep  cervical  fascia. 

Structures  of  the  anterior  aspect  of  the  neck  more  or  less  involved  in 
tracheotomy  below  the  thyroid  isthmus, — the  superficial  structures  men- 
tioned above;  communicating  branch  between  the  anterior  jugular  veins 
larger;  sternothyroids  closer;  inferior  thyroid  veins  larger;  arteria  thyroidea 
ima  possibly  present;  innominate  artery  may  cross  seventh  tracheal  ring; 
trachea  deeper  and  more  movable;  thymus  gland  present  up  to  second  year. 
The  innominate  and  common  carotid  arteries  may  be  in  the  way  of  a  low 
tracheotomy. 

The  thymus  gland  or  the  isthmus  of  the  thyroid  gland  is  to  be  incised, 
between  ligatures,  if  in  the  way. 

If  the  tracheal  fascia  be  not  well  incised,  there  is  a  liability  of  working 
between  the  fascia  and  trachea  rather  than  in  the  latter. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  TRACHEA. 

Scalpels:  scissors,  sharp  and  blunt,  curved  and  straight;  forceps,  dis- 
secting, toothed,  and  artery-clamp;  tenacula;  wound  hooks;  tracheotomy 
tubes;  tampon  cannula?;  tracheal  forceps;  artificial  feather  for  cleansing 
tube;  grooved  director;  wound  retractors;  dilator  for  tracheal  wound;  tracheal 


7°4 


OPERATIONS  UPON  THE  NECK. 


aspirator;  needles,  curved  and  straight;  needle-holder;  sutures  and  ligatures; 
silk  and  gut;  traction  ligatures;  Langenbeck's  double  tracheotomy  hook, 
shield  for  mouth,  nose,  and  eyes  of  operator. 

HIGH  TRACHEOTOMY. 

Description. — The  opening  of  the  trachea  above  the  isthmus  of  the 
thyroid  gland.  This  is  the  operation  (if  choice,  because  of  the  greater  acces- 
sibility of  the  trachea  here,  and  because  of  the  fewer  important  relations. 

Preparation. — The  neck  is  to  be  shaved,  if  necessary. 

Position.— Patient  supine,  at  edge  of  table,  shoulders  elevated,  head 
thrown  back,  neck  made  prominent  by  being  bent  well  backward  over  a 


Fig.  543. — High  Tracheotomy: — A,  Tenaculum  steadying  cricoid  cartilage;  B,  Retractor 
drawing  down  thyroid  isthmus  from  tracheal  rings;  C,  Sternohyoid  muscle;  D,  Sternothyroid 
muscle;  E,  E,  Sternohyoid  and  sternothyroid  muscles  retracted  from  median  line;  F,  Forceps 
drawing  outward  one  lip  of  incised  trachea;  G,  Knife  in  act  of  increasing  tracheal  opening  after 
stab-incision. 


cushion  or  sand-bag,  chin  kept  rigidly  in  median  line.  Surgeon  to  the  right 
of  patient.     Assistant  opposite  surgeon. 

Landmarks. — Median  line  of  neck;  cricoid  cartilage;  upper  rings  of 
trachea. 

Incision. — Vertical  incision  made  exactly  in  the  median  line  of  the  neck, 
extending  from  the  upper  border  of  the  cricoid  cartilage  downward  for  2.5 
to  4  cm.  (about  1  to  ij  inches) — the  skin  and  trachea  being  steadied  between 
the  left  forefinger  and  thumb  on  either  side.     (See  Fig.  541,  D.) 

Operation. — (1)  Divide  skin,  subcutaneous  fatty  areolar  tissue,  possibly 
the  platysma,  and  the  anterior  layer  of  the  cervical  fascia,  cutting  between 
double  ligatures  any  communicating  branches  between  the  anterior  jugular 
veins.     (2)  Recognize  and  open  up  the  cellular  interval  between  the  sterno- 


HIGH  TRACHEOTOMY.  705 

hyoid  and  sternothyroid  muscles  by  clean,  full-length  cuts — the  inner  border 
of  these  muscles  being  separated  by  blunt  dissection.  All  separated  tissues 
are  retracted  laterally.  (See  Fig.  543.)  (3)  Divide  the  deeper  cervical  fascia 
overlying  the  trachea,  cutting  between  double  ligatures  any  veins  crossing 
the  line  of  incision — a  small  venous  plexus  lies  over  the  isthmus,  and  a  trans- 
verse branch  between  the  superior  thyroids,  crossing  above  the  isthmus, 
sometimes  occurs — also  abnormal  branches  of  the  superior  thyroid  arteries 
may  cross  the  upper  part  of  the  trachea.  The  isthmus  of  the  thyroid  gland 
is  exposed,  and,  if  in  the  way,  drawn  down  by  a  hook.  The  tracheal  rings 
are  felt  for  by  the  finger-tip  and  exposed  to  view.  The  parts  are  still  steadied 
laterally  by  the  left  thumb  and  forefinger,  until  the  tracheal  rings  are  well  in 
the  field.  (4)  All  bleeding  having  been  controlled  and  the  white  rings  of  the 
trachea  being  clearly  defined,  the  trachea  is  to  be  steadied  preparatorv  to 
opening.  For  this  purpose,  a  tenaculum,  or,  preferably,  Langenbeck's 
double  tenaculum  hook,  is  fastened  by  its  point  into  the  anteroinferior  aspect 
of  the  cricoid  cartilage  and  given  to  an  assistant,  who  draws  the  cricoid 
cartilage  upward  and  forward  directly  in  the  median  line,  gently  following 
the  play  of  the  larynx,  thus  steadying  the  trachea  by  making  it  tense.  The 
tip  of  the  surgeon's  left  forefinger  feels  for  the  upper  border  of  the  isthmus 
of  the  thyroid  gland — and,  with  a  sharp,  slender  knife,  held  with  its  cutting- 
edge  upward,  a  quick,  limited  stab  is  made  into  the  median  line  of  the  trachea, 
just  above  the  thyroid  isthmus,  and  the  trachea  divided  upward  toward 
the  chin,  to  but  not  into  the  cricoid  cartilage,  in  the  act  of  withdrawing  the 
knife.  (5)  Gently  seize  the  right  lip  of  the  tracheal  wound  with  toothed 
forceps  held  in  the  left  hand,  and  evert  it  just  sufficiently  to  cause  a  slight 
gap  between  the  cut  margins — into  which  gap  gently,  quickly,  but  steadily 
insert  the  tracheotomy  tube — still  steadying  the  cricoid  with  the  tenaculum 
until  the  tube  is  in  place.  (6)  Having  seen  that  all  hemorrhage  is  controlled, 
the  tube  is  tied  in  place  by  bands  passing  around  the  neck,  a  dressing  being 
applied  between  skin  and  instrument.  The  upper  and  lower  ends  of  a  long 
wound  may  be  united  by  suture,  to  lessen  the  area  to  be  closed  bv  granulation. 

Comment. —Observe  the  following, — Incise  only  in  the  median  line;  See 
and  feel  bare  tracheal  rings  before  opening  trachea;  Be  sure  the  opening  is 
made  into  the  trachea,  and  not  into  the  surrounding  areolar  tissue.  If 
possible,  control  all  bleeding  before  incising  the  trachea — although  often 
venous  hemorrhage,  otherwise  difficult  to  stop,  will  cease  as  soon  as  air  enters 
the  lungs  freely  through  ihe  tracheal  wound. 

Where  the  thyroid  isthmus  encroaches  upon  the  field,  draw  it  down  with 
a  hook  or  special  retractor. 

Where  the  tissues  of  the  neck  are  very  thick,  outward  retraction  bv  thread 
or  instrument  retractors  aids  in  exposing  the  trachea  and  keeping  the  bottom 
of  the  wound  freer  from  blood. 

It  is  easier  to  insert  the  tube  if  the  neck  be  straightened  just  before  everting 
the  lip  of  the  tracheal  wound,  to  relax  the  tension  of  the  structures.  The  lips 
of  the  tracheal  wound  may  be  held  apart  by  a  tracheal  dilator  while  the  tube 
is  being  inserted,  or  by  two  tenacula. 

Modification. — Where  it  is  found  that  the  isthmus  of  the  thyroid  gland 
encroaches  too  much  upon  the  site  of  operation  to  avoid  it — or  in  those  cases 
in  which  it  is  elected  to  perform  tracheotomy  beneath  the  isthmus — having 
incised  and  separated  the  tissues  down  to  the  isthmus  in  the  usual  way,  cut 
vertically  directly  through  the  center  of  the  isthmus — immediately  seize  each 
cut  half  with  clamp-forceps  and  allow  the  clamped  ends  to  drop  away  from 
the  trachea  without  any  special  effort  to  further  dissect  or  retract  them  from 

45 


706  OPERATIONS  UPON  THE  NECK. 

the  trachea  unless  the  opening  be  encroached  upon.  These  cut  portions 
are  subsequently  gut  ligatured.  If  time  allow,  the  isthmus  may  be  doubly 
ligated  in  situ  and  divided  between  these  ligatures. 

Modification. — Hose's  Bloodless  Method  of  Tracheotomy. — Make  a 
median  vertical  incision  from  the  middle  of  the  thyroid  cartilage  downward 
for  4  to  5  cm.  (about  ij  to  2  inches) — the  soft  parts  are  retracted  laterally — 
incision  is  made  through  the  deep  layer  of  the  cervical  fascia  along  the  upper 
border  of  the  cricoid  cartilage,  covering  the  trachea  and  binding  down  the 
thyroid  isthmus — this  fascia  is  detached  by  blunt  dissection  and  retracted 
downward  bv  a  special  hook,  carrying  the  isthmus  and  vascular  supply 
covering  the  front  of  the  trachea.  The  trachea  being  thus  bared,  the  opera- 
tion is  completed  as  above. 


LOW  TRACHEOTOMY. 

Description. — Inferior  or  Low  Tracheotomy  consists  in  the  opening  of 
the  trachea  below  the  thyroid  isthmus.  The  trachea  is  much  deeper  here 
and  its  relations  much  more  important — and  subsequent  wound  complications 
more  serious. 

Preparation — Position. — As  in  High  Tracheotomy. 

Landmarks. — Median  line  of  neck;  cricoid  cartilage;  rings  of  the  trachea, 
recognizing  the  upper  ones,  if  possible,  so  as  to  determine  the  site  of  the 
thyroid  isthmus  over  the  second  and  third  tracheal  rings. 

Incision. — Vertical  incision  is  made  exactly  in  the  middle  line  of  the 
neck,  extending  from  the  lower  border  of  the  cricoid  cartilage  downward  to 
within  2  cm.  (about  \  inch)  of  the  sternal  notch — while  the  trachea  is  steadied 
by  the  left  forefinger  and  thumb  on  either  side.     (See  Fig.  541,  V.) 

Operation. — (1)  Divide  skin,  subcutaneous  fatty  areolar  tissue,  anterior 
layer  of  the  cervical  fascia,  cutting  between  double  ligatures  communicating 
veins  crossing  between  the  anterior  jugulars.  (2)  Having  incised  the  connec- 
tive tissue,  thicker  here  than  in  the  high  operation,  expose  and  separate  the 
inner  borders  of  the  sternothyroids  and  sternohyoids.  (3)  Incise  the  deeper 
cervical  fascia,  also  thicker  here  than  in  the  high  operation,  and  divide  between 
double  ligatures  the  communicating  veins  between  the  inferior  thyroids,  and 
whatever  other  vessels  may  be  encountered,  including  the  thyroidea  ima 
artery,  if  present — retracting  all  tissues  laterally.  (4)  The  trachea  is  brought 
within  sight  and  touch — hemorrhage  is  controlled  by  pressure  forceps — the 
trachea  is  caught  by  Langenbeck's  double  tenaculum  hook,  or  an  ordinary 
tenaculum,  and  lifted  upward  and  forward — the  thyroid  isthmus  being  re- 
tracted upward  if  necessary — and  a  sharp,  slender  knife  is  thrust  with  a  con- 
trolled stab-movement  into  the  trachea  and  made  to  cut  through  three  or  four 
rings  in  an  upward  direction  as  it  is  withdrawn.  (5)  The  tracheotomy  tube 
(which  must  have  a  deeper  curve  than  for  the  high  operation)  is  inserted  as 
in  the  higher  operation.  (6)  The  treatment  of  the  tube  and  wound  are  the 
same  as  in  the  high  operation. 


OTHER  OPERATIONS  UPON  THE  TRACHEA. 

Tracheo-laryngotomy. — 

An  opening,  by  median  incision,  involving  both  the  upper  rings  of  the 
trachea  and  the  cricothyroid  membrane  of  the  larynx — performed  where 
more  room  is  required  than  furnished  by  either  operation  alone. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE    PHARYNX.     707 

Tamponing  of  Trachea. — 

The  use  of  some  form  of  packing,  or  some  form  of  inflation,  applied  around 
the  stem  of  an  ordinary  tracheotomy  tube,  or  a  special  form  of  tampon  cannula, 
whereby  fluids  and  blood  are  prevented  from  entering  the  lungs  during 
operations  upon  the  oral,  nasal,  and  pharyngeal  cavities. 

Operation  for  the  Removal  of  Foreign  Bodies. — 

Foreign  bodies  may  be  removed  by  means  of  special  forceps  introduced 
through  one  of  the  tracheotomy  wounds  above  described. 

Tracheoscopy. — 

Examination  of  the  upper  part  of  the  trachea  by  means  of  the  laryngo- 
scopy mirror. 

Thoracic  Tracheotomy. — 

Opening  of  the  trachea  in  the  posterior  mediastinum  (see  page  752). 


III.  THE  PHARYNX. 
SURGICAL  ANATOMY  OF  THE  PHARYNX. 

Situation,  Extent,  and  Structure. — A  conical,  musculo-membranous 
sac  (consisting  of  nasal  and  buccal  portions)  placed  base  upward,  apex  down- 
ward, behind  the  nose,  mouth,  and  larynx.  It  extends  downward  from  base 
of  skull  to  lower  border  of  cricoid  cartilage  in  front,  and  fifth  (or  between 
fifth  and  sixth)  cervical  vertebra  behind.  It  is  composed  of  three  coats — 
Inner  Coat,  of  mucous  membrane: — Middle  Coat,  of  pharyngeal  aponeurosis 
(thickest  above,  where  muscles  are  thinnest;  and  thinnest  below,  where 
muscles  are  thickest): — Outer  Coat,  of  muscles  (inferior,  middle,  and  superior 
constrictors,  reinforced  by  stylopharyngeus,  palatopharyngeus  and  salpingo- 
pharyngeus). 

Relations  and  Boundaries. — Superiorly,  body  of  sphenoid;  basilar 
process  of  occipital: — Inferiorly,  continuous  with  esophagus  opposite  fifth 
(or  between  fifth  and  sixth)  cervical  vertebra: — Anteriorly  (incomplete), 
attached,  from  above  downward,  to  internal  pterygoid  plate,  pterygomaxillary 
ligament,  inferior  maxilla,  tongue,  hyoid  bone,  thyroid  cartilage,  cricoid 
cartilage: — Posteriorly,  attached,  by  lax  connective  tissue,  to  prevertebral 
fascia,  longi  colli,  and  recti  capitis  antici  majores  muscles,  and  to  cervical 
vertebral  column: — Laterally,  attached  to  styloid  process  and  its  muscles 
(styloglossus,  stylohyoid,  and  stylopharyngeus) ;  and  in  relation  with  common 
carotid,  internal  carotid,  and  ascending  pharyngeal  arteries,  internal  jugular 
vein,  glossopharyngeal,  pneumogastric,  hypoglossal,  and  sympathetic  nerves, 
internal  pterygoid  muscle  (above)  and  lateral  lobes  of  thyroid  gland. 

Openings  Into. — Two  posterior  nares;  two  eustachian  tubes;  mouth; 
larynx;  esophagus. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  PHARYNX. 

Scalpels;  scissors;  forceps,  dissecting,  toothed  and  artery-clamp;  re- 
tractors; probe;  grooved  director;  tenacula;  wound  hooks;  mouth-gag;  tongue 
forceps;  tongue  depressor;  needles;  needle-holder;  ligatures  and  sutures; 
aneurism-needle. 


708  OPERATIONS  UPON  THE  NECK. 


MEDIAN  PHARYNGOTOMY 

BY  MEDIAN*  VERTICAL  INCISION  THROUGH  THE  MOUTH. 

Description. — Incision  of  the  posterior  pharyngeal  wall  in  the  median 
line,  through  the  mouth.  Applicable  to  cases  of  retropharyngeal  abscess  of 
small  size  and  due  to  temporary  cause  (e.  g.,  an  acute  abscess). 

Preparation. — Mouth  cleansed  by  frequent  antiseptic  washings. 

Position. — Patient  on  side,  head  elevated  and  turned  to  one  side,  with 
mouth  dependent.     Surgeon  in  front  of  patient. 

Landmarks. — Median  line  of  the  prevertebral  region;  contour  of  involved 
region. 

Operation. — The  mouth  is  gagged  and  so  directed  that  pus  or  other 
fluid  will  flow  out.  A  straight,  sharp  bistoury,  protected  by  wrapping  except 
for  about  i  cm.  (about  \  inch)  at  its  point,  is  directed  in  toward  the  center 
of  the  posterior  pharyngeal  wall,  or  toward  the  most  fluctuating  point,  guided 
by  the  left  forefinger,  which  marks  the  site — an  incision  about  i  cm.  (about 
\  inch)  long  is  then  made  vertically  in  the  median  line,  either  upward  or 
downward.  The  incised  wound  is  not  closed  by  suture,  but  allowed  to 
drain. 


LATERAL  PHARYNGOTOMY 

BY    CURVED    LATERAL    INCISION    THROUGH    THE    NECK  — KOCHER'S   OPERATION. 

Description. — Incision  of  the  pharynx  through  the  lateral  wall  of  the 
neck — for  the  exposure  of  the  lateral  wall  of  the  pharynx,  together  with  the 
tonsil,  base  of  tongue,  and  retropharyngeal  space.  Applicable  to  cases 
requiring  the  fullest  exposure  of  the  pharynx. 

Preparation. — Shaving  of  the  neck,  if  necessary.  Cleansing  of  the  throat 
with  antiseptic  washes. 

Position. — Patient  supine,  shoulders  elevated,  neck  prominent,  head  to 
opposite  side.  Surgeon  either  in  front  of,  or  behind,  the  neck.  Assistant 
opposite  surgeon. 

Landmarks. — Apex  of  mastoid  process;  anterior  border  of  sternomastoid 
muscle;  hyoid  bone. 

Incision. — Begins  at  the  anterior  border  of  the  apex  of  the  mastoid 
process — runs  in  a  slight  downward  curve,  with  posterior  convexity,  crossing 
the  anterior  border  of  the  sternomastoid  about  2  cm.  (about  J  inch)  behind 
the  angle  of  the  jaw — ending  at  the  middle  of  the  hyoid  bone.  (See  Fig. 
544,  A.) 

Operation. — (1)  Divide  the  skin,  superficial  fascia,  and  platysma  along 
the  above  line — cutting  between  double  ligatures  the  external  jugular,  facial, 
and  temporofacial  veins.  (2)  Expose  the  submaxillary  region — dissect  out 
the  submaxillary  gland  and  either  throw  it  upward  over  the  border  of  the 
inferior  maxilla,  or  extirpate  it — dividing  the  facial  artery  between  two  liga- 
tures— and  preserving,  if  possible,  the  auricularis  magnus  and  cervicofacial 
nerves.  (3)  The  lingual,  ascending  pharyngeal,  and  ascending  palatine 
arteries  are  tied,  if  necessary,  close  to  their  origin — or  the  external  carotid 
itself.  (4)  Retract  backward  the  great  cervical  vessels,  with  the  pneumo- 
gastric  and  spinal  accessory  nerves — draw  the  hypoglossal  nerve  upward — 
the  superior  laryngeal  nerve  and  superior  thyroid  artery  remaining  under  the 
lower  margin  of  the  wound.  (5)  Work  up  along  the  internal  surface  of  the 
inferior  maxilla  and  of  the  internal  pterygoid  in  the  direction  of  the  mucous 
membrane  of  the  pharynx,  in  order  to  preserve  the  muscles  lying  anteriorly 


SUBHYOID  PHARVXGOTOMV 


709 


and  connected  with  the  act  of  swallowing.  If  the  muscles  must  be  sacrificed, 
so  cut  them  that  their  innervated  ends  will  be  as  long  as  possible — dividing 
the  posterior  belly  of  the  digastric  and  stylohyoid  near  the  hyoid  (their  supply 
from  the  facial  entering  posteriorly) — the  styloglossus  near  the  tongue,  avoiding 
the  lingual  and  glossopharyngeal  nerves  (unless  involved,  when  they  must 
be  divided)  lying  upon  it — the  stylopharyngeus  near  the  pharyngeal  insertion 
— and  the  hyoglossus  and  mylohyoid,  to  the  extent  indicated,  near  their 
insertion  into  the  hyoid.  (6)  The  wall  of  the  pharynx  will  now  be  exposed, 
the  superior  constrictor  lying  above  and  the  inferior  constrictor  below.  Having 
well  retracted  the  sur- 
rounding parts  and 
having  incised  the  con- 
strictors, forming  the 
lateral  boundary  of  the 
pharynx,  its  interior  is 
exposed.  (7)  Having 
accomplished  the  object 
of  the  operation,  in  clos- 
ing the  wound  suture 
up  the  pharyngeal  wall 
as  completely  as  pos- 
sible, in  so  far  as  the 
mucous  membrane  is 
concerned — leaving  the 
center  of  the  outer 
wound  unsutured  and 
packed  down  to  the  mu- 
cous membrane  with 
gauze,  to  provide  for 
drainage  both  from  pos- 
sible leakage  from  the 
mouth  and  from  the 
fluids  of  the  wound — 
the  ends  only  of  the 
outer  wound  being 
closed  by  suture. 

Comment. — If  a  part  of  the  wall  of  the  pharynx  be  removed,  the  operation 
becomes  a  partial  pharyngectomy. 

Compare  this  operation  with  that  for  exposure  of  the  tonsils  through  the 
neck,  page  719. 


Fig.  544.— Incisions  Exposing  Pharyngo-esophageal  Re- 
gion:— A,  Curved  lateral  incision  for  lateral  pharyngotomy,  and 
for  exposure  of  tonsil,  base  of  tongue,  and  retropharyngeal  space 
(Kocher's  operation);  B,  Lateral  cervical  incision  for  exposing  the 
retropharyngeal  space  (Chiene's  operation);  C  Incision  for  cer- 
vical esophagotomy. 


SUBHYOID  PHARYNGOTOMY 

BV  TRANSVERSE  CURVED  INCISION  THROUGH  THE  NECK. 

Description. — Subhyoid  Pharyngotomy,  or  Suprathyroid  Laryngotomy, 
consists  in  opening  the  pharynx  through  the  thyrohyoid  membrane,  just 
below  the  hyoid  bone.  Chiefly  done  to  expose  the  entrance  of  the  larynx 
for  the  purpose  of  removing  foreign  bodies  or  growths  from  the  upper  air- 
passages,  or  for  abscesses  at  base  of  epiglottis. 

Preparation. — As  for  Lateral  Pharyngotomy. 

Position. — Patient  supine,  shoulders  elevated,  head  thrown  back,  neck 
prominent,  resting  upon  a  cushion  or  sand-bag.  Surgeon  on  patient's  right 
or  left.     Assistant  opposite. 


710  OPERATIONS  UPON  THE  NECK. 

Landmarks. — Hyoid  bone,  upper  border  of  thyroid  cartilage. 

Incision. — Transverse  curved  incision  along  the  lower  border  of  the 
body  and  greater  cornua  of  the  hyoid  bone.  In  very  thick  necks  a  vertical 
incision  may  have  to  be  added  to  this. 

Operation. — (i)  Having  incised  the  skin,  superficial  cervical  fascia,  and 
platysma,  divide  between  double  ligatures  the  anterior  jugular  veins  and 
their  branches.  Some  branches  of  the  superficial  cervical  and  cervicofacial 
nerves  are  encountered.  The  hyoid  arteries  and  veins  along  the  hyoid  bone 
are  generally  not  injured — and  the  superior  thyroid  artery  is  generally  avoided, 
running  parallel  with  the  incision.  (2)  Divide  most  of  the  muscles  attached 
to  the  lower  border  of  the  hyoid  bone  (sternohyoids,  omohyoids,  and  most 
but  not  all  of  the  thyrohyoids).  (3)  The  thyrohyoid  membrane  (its  middle 
and  lateral  portions)  is  now  exposed — and,  together  with  the  subjacent 
mucous  membrane  lying  between  the  base  of  the  tongue  and  the  superior 
border  of  the  epiglottis,  is  incised  along  the  inferior  border  of  the  hyoid  bone, 
while  a  finger  in  the  mouth  guides  the  knife — keeping  rather  near  the  hyoid 
bone  to  avoid  the  superior  laryngeal  nerves  piercing  the  lateral  parts  of  the 
thyrohyoid  membrane  (because  of  the  importance  of  preserving  the  sensi- 
tiveness, and  thereby  the  expulsive  power,  of  the  larynx).  (4)  Seize  the 
epiglottis,  which  projects  into  the  wound,  with  toothed  forceps  and  draw  it 
forward,  when  the  interior  of  the  larynx  and  the  lowest  part  of  the  pharynx 
will  be  exposed  to  view.  (5)  Having  accomplished  the  object  of  the  operation, 
suture  the  mucous  membrane  throughout — suture  the  ends  of  the  external 
wound — and  pack  with  gauze  the  central  portion  of  the  wound  down  to  the 
sutured  mucous  membrane. 


EXPOSURE  OF  THE  RETROPHARYNGEAL  SPACE 

BV  LATERAL  CERVICAL  INCISION  ALONG  POSTERIOR  BORDER  OK  STERNO- 
MASTOID  MUSCLE  — CHIENE'S  OPERATION. 

Description. — The  retropharyngeal,  or  retro-esophageal,  prevertebral 
areolar  tissue  is  opened  up — without  incising  the  pharyngeal  or  esophageal 
wall.  Indicated  in  cases  of  retropharyngeal  abscesses  due  to  protracted 
cause  (e.  g.,  chronic  abscess,  generally  from  tubercular  disease  of  the  cervical 
vertebra?)  where  drainage  is  apt  to  be  prolonged; — also  in  large,  acute  retro- 
pharyngeal abscesses,  especially  where  jaws  can  no  longer  be  widely  opened. 

Preparation. — Shave  neck,  if  necessary. 

Position. — Patient  supine,  or  turned  slightly  to  one  side,  shoulders 
elevated,  neck  prominent,  resting  upon  cushion  or  sand-bag  and  turned  to 
one  side.     Surgeon  on  side  of  operation.     Assistant  opposite. 

Landmarks. — Posterior  border  of  the  sternomastoid. 

Incision. — Along  the  posterior  border  of  the  sternomastoid,  beginning 
at  the  mastoid  process  and  descending  as  far  downward  as  necessary,  de- 
pendent upon  the  thickness  of  the  structures  of  the  neck.     (See  Fig.  544,  B.) 

Operation. — (1)  Incise  skin  and  fascia  in  the  above  line — ligate  super- 
ficial vessels  encountered — avoid  the  transverse  and  the  descending  superficial 
cervical  nerves.  (2)  Recognize  the  posterior  border  of  the  sternomastoid 
(which  overlaps  the  scalenus  anticus  somewhat)  and  draw  it  forward — the 
intermuscular  groove  between  the  sternomastoid  and  the  scalenus  anticus, 
in  the  deep  cervical  fascia,  is  thus  made  evident.  (3)  Follow  with  a  blunt 
dissector,  closely  along  the  anterior  surface  of  the  scalenus  anticus  and  in  the 
connective-tissue  plane  between  the  scalenus  behind  and  the  common  sheath 


SURGICAL  ANATOMY  OF  THE  ESOPHAGUS.  711 

of  the  great  vessels  in  front,  guarding  the  spinal  accessory  nerve  beneath  the 
sternomastoid  as  the  dissection  passes  behind  its  posterior  border.  (4) 
Recognize  the  outer  border  of  the  longus  colli  muscle  as  soon  as  reached, 
and  keep  behind  this,  as  well  as  behind  the  great  vessels — and  having  passed 
beneath  the  longus  colli  the  prevertebral  areolar  tissue  of  the  retropharyngeal 
space  is  reached — and  the  pus  thus  evacuated  through  a  route  behind  and 
comparatively  free  of  important  structures.  (5)  Free  drainage  is  established 
from  the  bottom  of  the  wound — only  the  ends  of  the  original  incision  being 
sutured. 

Comment. — The  retropharyngeal  space  may  be  also  approached  by  in- 
cising along  the  anterior  border  of  the  sternomastoid,  on  the  level  of  the 
larynx  (Buckhardt's  operation) — passing  in  front  of  the  common  sheath  of 
the  great  vessels — retracting  these  and  the  sternomastoid  backward,  and  the 
thyroid,  larynx,  trachea,  and  anterior  cervical  muscles  forward — opening  the 
fascia  covering  the  longus  colli  and  passing,  anteriorly  to  it,  transversely 
across  to  its  inner  side  into  the  retropharyngeal  or  retro-esophageal  pre- 
vertebral areolar  tissue. 


IV.  THE  ESOPHAGUS. 
SURGICAL  ANATOMY  OF  THE  ESOPHAGUS. 

Situation  and  Extent. — A  muco-areolar  muscular  canal,  from  23  to  26 
cm.  (about  9  to  10  inches)  long — beginning  at  lower  boundary  of  pharynx,  at 
upper  border  of  cricoid  cartilage,  opposite  fifth  cervical  vertebra  (or  between 
fifth  and  sixth),  passes  down  through  superior  and  posterior  mediastina  along 
front  of  spine,  lying  at  first  behind  left  part  of  the  aortic  arch,  then  descending 
along  right  side  of  aorta  until  it  curves  forward  anterior  to  and  somewhat 
to  left  of  aorta — to  descend  through  esophageal  opening  in  diaphragm  into 
abdomen,  ending  in  cardiac  orifice  of  stomach,  opposite  tenth  dorsal  vertebra 
(or  between  tenth  and  eleventh). 

Curves  of  the  Esophagus. — The  antero-posterior  curves  of  the  esophagus 
follow  those  of  the  vertebral  column.  Laterally,  it  curves  to  the  left  at  the 
root  of  neck,  and  at  esophageal  opening  of  diaphragm — and  is  in  the  middle 
line  at  fifth  cervical  and  fifth  dorsal  vertebra\ 

Relations. — (a)  In  the  neck  :  anteriorly,  trachea,  posterior  part  of  left 
lateral  lobe  of  thyroid,  left  recurrent  laryngeal  nerve.  Posteriorly,  spinal 
column,  left  longus  colli  muscle,  prevertebral  fascia.  Right,  right  common 
carotid,  right  recurrent  laryngeal  nerve.  Left,  left  carotid,  left  inferior 
thyroid  artery  and  vein,  left  subclavian  artery,  thoracic  duct.  (The  relation- 
ships are  more  marked  on  the  left.)  (b)  In  the  thorax  :  anteriorly,  lower 
part  of  trachea,  beginning  of  left  bronchus,  transverse  arch  of  aorta, 
left  common  carotid,  left  subclavian,  posterior  surface  of  pericardium. 
Posteriorly,  spinal  column,  longi  colli  muscles,  thoracic  duct,  right  inter- 
costal arteries  and  veins,  left  inferior  azygos  vein,  inferior  part  of  thoracic 
aorta.  Laterally,  pleurae,  pneumogastrics  (forming  plexus  gulae  below  root 
of  lungs,  thence  left  pneumogastric  passes  to  anterior  surface  and  right  pneu- 
mogastric  to  posterior  surface  of  esophagus).  Vena  azygos  major  lies  on  the 
right,  and  descending  aorta  on  left. 

Arteries. — From  inferior  thyroid  branch  of  thyroid  axis;  descending 
thoracic  aorta;  gastric  branch  of  cceliac  axis;  left  inferior  phrenic. 

Veins. — Empty  into  inferior  thyroid,  azygos,  and  gastric  veins. 

Lymphatics. — Empty  into  inferior  cervical  and  posterior  mediastinal 
trlands. 


712  OPERATIONS  UPON  THE  NECK. 

Nerves.-  From  recurrent  laryngeals,  pneumogastrics,  and  sympathetic. 
(The  recurrent  laryngeal  branches  of  the  pneumogastric  run  upward  on  both 
sides  to  the  interval  between  trachea  and  esophagus — the  left  nerve  lying 
somewhat  anterior  to  the  esophagus — the  right  nerve  at  some  distance  from  it.) 


GENERAL  SURGICAL  CONSIDERATIONS. 

The  narrowest  parts  of  the  esophagus  are — at  its  beginning  (narrowest) 
■ — opposite  the  fourth  dorsal  vertebra — at  the  diaphragm. 

Distances  (in  the  average  adult) — from  upper  incisor  teeth  to  diaphrag- 
matic opening,  about  37  cm.  (about  14^  inches) — from  same  point  to  aorta, 
about  23  cm.  (about  9  inches) — from  same  point  to  upper  end  of  esophagus, 
about  14  cm.  (about  5^  inches). 

The  deviation  from  the  median  line  toward  the  left,  in  the  cervical  portion 
of  the  esophagus,  amounts  to  about  1  cm.  (about  h  inch). 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  ESOPHAGUS. 

Scalpels;  scissors,  blunt,  sharp,  straight,  curved;  forceps,  dissecting, 
toothed,  artery-clamp;  retractors;  probe;  grooved  director;  tenacula;  ligature- 
retractors;  needles,  straight  and  curved;  needle-holder;  ligatures  and  sutures, 
silk  and  gut;  mouth-gag;  tongue-forceps;  esophageal  forceps,  various;  com- 
bined mouth-gag  and  tongue  depressor;  esophageal  bougies;  blunt  bistoury; 
drainage  tubing  and  material;  blunt  dissector;  wound-hooks;  elevators; 
bristle  probang;  special  foreign-body  forceps  and  devices;  stomach-tube; 
dilating  bougies;  esophagotomes;  bougie  with  string  attachment;  tubage  set. 


EXTERNAL  CERVICAL  ESOPHAGOTOMY. 

Description. — Incision  of  the  esophagus  in  the  neck — the  opening 
ordinarilv  being  made  on  the  left  side,  opposite  the  natural  curve  of  the 
esophagus,  except  when  the  object  is  more  prominent  and  more  easily  reached 
on  the  right.  Generally  indicated  for  the  removal  of  foreign  body,  and 
sometimes  for  tumor  and  for  dilatation  of  the  esophagus. 

Preparation. — The  neck  is  shaved  if  necessary.  Where  the  operation 
is  for  foreign  body,  the  position  of  the  body  is  sought  by  instruments  before 
incision,  and  the  position  of  the  incision  regulated,  as  far  as  possible,  by  its 
situation. 

Position. — Patient  supine,  shoulders  elevated,  neck  prominent,  upon 
cushion  or  sand-bag,  head  thrown  back  and  turned  to  opposite  side  (generally 
to  the  right).     Surgeon  on  side  of  operation — Assistant  opposite. 

Landmarks. — Thyroid  and  cricoid  cartilages;  trachea;  anterior  border 
of  sternomastoid  muscle 

Incision. — Straight  incision,  generally  made  on  the  left  side,  8  to  10  cm. 
(about  3  to  4  inches)  in  length,  beginning  opposite  the  upper  border  of  the 
thyroid  cartilage  and  continuing  downward  along  the  anterior  border  of  the 
sternomastoid,  toward  the  clavicle,  as  far  as  necessary.     (See  Fig.  544,  C.) 

Operation. — (1)  Incise  skin,  superficial  fascia,  and  platysma.  Ligate, 
between  double  ligatures,  the  communicating  veins  between  the  anterior  and 
external  jugular  veins,  and  between  the  anterior  jugular  and  facial,  and 
possibly  also  the  anterior  jugular  vein.     Some  branches  of  the  superficial 


EXTERNAL  CERVICAL  ESOPHAGOTOMY. 


713 


cervical  nerve  will  also  be  cut.  (2)  Expose  the  anterior  border  of  the  sterno- 
mastoid  and  draw  it  outward — also  the  sternohyoid  and  sternothyroid  and 
draw  them  inward — divide  the  omohyoid  (unless  it  can  be  displaced  down- 
ward). (See  Fig.  545.)  (3)  Divide  the  thyroid  fascia — which  is  deep  cervical 
fascia  forming  the  capsule  of  the  thyroid  gland — which  is  blended  externally 
with  the  sheath  of  the  large  vessels — and  which  must  be  divided  before  the 
esophagus  can  be  reached.  After  dividing  this  fascia,  draw  the  thyroid 
gland,  larynx,  and  trachea  inward  and  forward — and  the  common  sheath  of 
the  large  vessels  and  pneumogastric,  together  with  the  descendens  noni 
nerve,  outward.  (4)  Ligate  and  divide  between  two  ligatures  the  inferior 
thyroid  artery  as  it  crosses  the  longus  colli  transversely,  lying  behind  the 
common  carotid — also  the  middle  and  superior  thyroid  veins  if  necessary. 
Carefully  avoid  the  recurrent  laryngeal  nerve,  ascending  in  the  groove  between 


Fig.  545.— Cervical  Esophagotomy  : — A,  Sternomastoid  muscle;  P.,  Sternohyoid  muscle;  C, 
Sternothyroid  muscle;  D,  Omohyoid  muscle;  E,  Trachea;  F,  Esophagus,  showing  incision,  with 
lips  of  esophageal  wall  retracted;  G,  Recurrent  laryngeal  nerve;  H,  Common  carotid;  I,  Inferior 
thyroid  artery,  ligated ;  J.  Communicating  vein  between  anterior  and  external  jugular;  k",  Thyroid 
gland, showing  superior  and  inferior  thyroid  arteries,  and  superior,  middle,  and  inferior  thyroid  veins. 


the  trachea  and  esophagus,  drawing  it  downward  and  inward  if  necessary. 
(5)  The  esophagus,  in  the  form  of  a  red  tube,  will  now  appear  in  the  bottom 
of  the  wound.  Pass  a  sound  or  esophageal  bougie  into  the  esophagus  through 
the  mouth,  so  as  to  protrude  the  esophageal  wall  prominently  into  the  wound. 
A  vertical  incision  is  now  made  through  the  lateral  or  postero-lateral  aspect 
of  the  wall  of  the  esophagus,  while  steadied  with  toothed  forceps,  carefully 
avoiding  the  recurrent  laryngeal  nerve.  (6)  The  lips  of  the  wound  in  the 
tube  are  grasped  in  turn  with  toothed  forceps  and  a  thread-retractor  carried 
through  each  lip  upon  a  fully  curved  needle — thus  enabling  the  wound  to 
be  held  widely  open  and  the  interior  brought  to  view  for  the  purpose  of  in- 
spection, removal  of  foreign  body,  or  operation.  (7)  At  the  conclusion  of 
the  operation,  unless  contraindicated  by  nature  of  operation  (generally  after 
the  simple  removal  of  foreign  bodies),  the  lips  of  the  esophageal  wound  should 


714  OPERATIONS  UPON  THE  NECK. 

be  sutured  with  gut.  The  outside  wound  is  sutured  at  its  ends,  leaving  the 
portion  opposite  the  wound  in  the  tube  open  and  lightly  packed  with  gauze, 
until  the  tube  has  healed  and  no  longer  danger  of  leakage  exists  from  the 
esophagus.  Where  indicated,  the  wounds  in  the  esophagus  and  in  the  neck 
are  both  left  open  until  the  esophageal  wall  has  healed,  when  the  outer  wound 
is  aided  to  granulate  as  rapidly  as  possible,  or  granulating  surfaces  may  be 
brought  together  by  suture  and  the  process  of  union  hastened.  (8)  The 
patient  is  temporarily  fed  by  bowel  at  first — then  by  stomach-tube  carefully 
introduced. 

Comment. — The  wound  in  the  esophageal  wall  is  best  closed  by  two 
rows  of  fine  catgut  sutures — one  whipping  together  the  edges  of  the  mucous 
coat — the  other  passed  a  short  distance  from  the  margins  of  the  wound, 
after  the  manner  of  a  Lembert  suture,  approximating  the  connective-tissue 
coats. 

CERVICAL  ESOPHAGOSTOMY. 

Description. — The  making  of  an  artificial  opening  in  the  esophagus 
through  the  neck.  Generally  resorted  to  below  the  site  of  an  inoperable 
stricture,  or  during  the  treatment  of  an  operable  one,  for  the  purpose,  in  the 
former  case,  of  introducing  food  into  the  stomach,  and,  in  the  latter,  of  prac- 
tising mechanical  dilatation. 

Preparation  —  Position  —  Landmarks  —  Incision. — As  for  Esophago- 
tomy. 

Operation. — All  the  steps  in  the  operation  are  the  same  as  for  Cervical 
Esophagotomy,  up  to  the  opening  of  the  esophagus.  This  having  been 
accomplished,  the  edges  of  the  esophageal  wound  (the  walls  of  the  esophagus) 
are  sutured  to  or  as  near  to  the  skin  of  the  external  wound  as  possible — the 
external  incision  being  then  closed  up  to  the  margin  of  the  funnel-shaped 
wound  leading  into  the  esophagus.  After  healing,  the  patient  is  fed  by  an 
esophageal  tube  introduced  through  the  cervical  wound — or  his  stricture 
is  svstematically  dilated  through  the  same  channel.     (See  Figs.  544  and  545.) 

Comment. — YYheie  it  is  found  that  a  single  seance  of  dilatation,  in  the 
case  of  esophageal  stricture,  accomplishes  the  object,  the  esophageal  wound 
is  closed  at  once — and  the  operation-wound  becomes  in  name,  and  in  all  other 
respects,  an  Esophagotomy. 


PARTIAL  CERVICAL  ESOPHAGECTOMY. 

Description. — The  excision  of  a  portion  of  the  cervical  esophagus  through- 
out its  entire  circumference — with  the  restoration  of  the  severed  ends  by 
suturing,  if  possible — or  as  a  preliminary  to  a  Cervical  Esophagostomy. 
Generally  done  for  malignant  growth  of  the  esophagus. 

Preparation  Position  —  Landmarks  —  Incision.  —  As  for  Cervical 
Esophagotomy. 

Operation. — (1)  Having  exposed  the  esophagus  as  in  the  above  opera- 
tions, this  tube  is  isolated,  being  separated  by  blunt  dissection  upward  and 
downward — from  the  trachea  in  front — from  the  prevertebral  areolar  tissue 
behind— from  the  connective  tissue,  lateral  lobes  of  the  thyroid,  recurrent 
laryngeal  nerves,  and  the  great  vessels  laterally.  (2)  The  involved  portion 
of  the  esophagus  is  then  excised  by  transverse  division  with  scissors  above 
and  below.  (3)  If  the  gap  be  not  too  great,  and  it  be  otherwise  possible, 
the  proximal  and  distal  ends  are  now  sutured  by  two  tiers  of  chromic  gut — 


OTHER  OPERATIONS  UPON  THE  ESOPHAGUS.  715 

the  first  whipping  the  edges  of  all  the  coats  of  the  esophagus  together — the 
second  being  interrupted  Lembert  sutures  passing  through  the  outer  walls 
of  the  esophagus  a  short  distance  from  the  lips  of  the  wound  in  the  tube — 
the  suturing  being  done  over  an  esophageal  bougie  passed  through  the  mouth 
and  distending  the  esophagus  opposite  the  site  of  suturing.  (4)  If  the  ends 
of  the  esophagus  cannot  be  made  to  meet,  the  proximal  end  is  closed,  first  by 
whipping,  then  by  suturing  the  outer  coats  in  the  Lembert  fashion — and  the 
distal  end  is  sutured  into  the  wound  in  the  neck  permanently,  as  for  esopha- 
gectomy, the  entire  circumference  of  the  distal  portion  being  sutured  into  the 
cervical  wound  (differing  in  this  respect  from  the  Cervical  Esophagostomy 
above  described,  where  only  the  lips  of  the  lateral  wound  in  the  esophagus 
care  stitched  into  the  cervical  wound).  (5)  The  external  wound  is  left  open 
in  either  case — temporarily  in  the  first  instance — permanently  in  the  second. 
Figs.  544,  C  and  545  illustrate  some  common  features.) 


INTRODUCTION  OF  ESOPHAGEAL  BOUGIE. 

Description. — (1)  Seat  the  patient  upright,  preferably  in  a  chair — head 
thrown  back  and  slightly  to  side  away  from  surgeon,  and  steadied  in  this 
position  by  the  individual  or  by  an  assistant.  Gag  the  mouth,  the  handle 
of  the  gag  being  upon  the  patient's  left.  Place  a  small,  thin  napkin  upon  the 
tongue,  extending  well  back.  Insert  the  left  index-finger  to  the  base  of  the 
tongue,  both  depressing  it  and  simultaneously  drawing  it  forward,  the  napkin 
giving  a  firmer  hold.  (2)  Upon  this  left  finger  as  a  guide,  introduce  the 
lubricated  bougie,  held  between  the  right  index  and  thumb,  straight  into  the 
mouth,  until  its  tip  reaches  the  posterior  pharyngeal  wall — then  direct  it 
downward  and  backward  along  the  esophagus — causing  the  patient  to  swallow 
it  as  he  gags — being  guided  as  to  the  depth  of  introduction  by  the  circum- 
stances of  the  case  and  the  known  distances  of  the  structures  from  the  upper 
incisor  teeth.     (See  General  Surgical  Considerations.) 


OTHER  OPERATIONS  UPON  THE  ESOPHAGUS. 

Esophagoscopy. — 

The  introduction  into  the  esophagus  of  a  special  instrument,  elec- 
trically illuminated,  and  with  or  without  mirrors  (an  esophagoscope) — wherebv 
the  lumen  of  the  canal  may  be  examined  as  it  is  withdrawn  from  the  stomach 
to  the  mouth  (after  the  manner  of  an  urethroscope). 

Internal   Esophagotomy. — 

The  division  of  the  strictured  esophagus  upon  the  principle  of  the 
stnetured  urethra — by  means  of  a  cutting  instrument  passed  through  the 
narrowed  portion  upon  a  guide — or  by  some  special  form  of  esophagotome. 

Operation  for  Foreign  Bodies  in  the  Esophagus. — 

Foreign  bodies  high  up  in  the  esophagus  can  often  be  seen  or  felt,  and 
removed  with  special  pharyngeal  forceps.  Those  lower  down,  out  of  sight 
and  reach,  may  still  often  be  removed  by  special  instruments  for  that  purpose, 
introduced  through  the  mouth.  Impacted  bodies  not  removable  by  instru- 
ments alone,  are  removed  by  instruments  introduced,  in  the  majority  of  cases, 
through  an  esophageal  wound — generally  a  cervical  esophagotomy.  Foreign 
bodies  very  low  down  may  be  reached  by  forceps  or  the  fingers  through  the 
cardiac  orifice  of  the  stomach,  introduced  through  a  gastrotomy  wound. 


716  OPERATIONS  UPON  THE  NECK. 

Direct   Dilatation   of   the   Esophagus   for  Stricture. — 

The  dilating  bougies  or  instruments  of  increasing  sizes,  are  passed  directly 
from  the  mouth  through  the  narrowed  esophagus,  in  the  same  manner  as  de- 
scribed under  the  Introduction  of  the  Esophageal  Bougie,  the  stricture  being 
gradually  distended. 

Direct  Divulsion  of  Esophageal  Stricture. — 

The  passage,  from  the  mouth,  in  quick  succession,  of  increasing  sizes 
of  dilators — thus  rupturing,  in  a  minor  degree,  the  surrounding  contracted 
tissues. 

Retrograde  Dilatation  of  the  Esophagus  for  Stricture.— 

Here  the  dilating  instrument  is  passed  from  below — through  a  gastrotomy 
wound,  in  cases  where  but  one  sitting  of  the  retrograde  method  is  necessary, 
followed  by  the  immediate  closure  of  the  stomach  wound, — or  through  a  gas- 
trostomy wound,  where  frequent  resorts  to  the  method  are  necessary.  Dila- 
tation may  be  begun  by  passage  of  the  instrument  from  the  stomach  through 
the  strictured  esophagus  (as  the  title  indicates) — but  is  often  commenced  by 
causing  the  patient  to  swallow,  prior  to  anesthesia,  a  thread  with  a  split 
shot  attached — this  is  found  in  the  stomach,  and  upon  it  the  dilating  rubber 
tubes,  or  other  instruments,  are  drawn  from  the  mouth,  through  the  esophagus, 
out  of  the  stomach  wound — or  vice  versa. 

Retrograde  Divulsion  of  Esophageal  Stricture. — 

The  same  as  Direct  Divulsion — except  performed  in  the  reverse  direction, 
through  a  gastrotomy  or  gastrostomy  wound. 

Division  of  Esophageal  Stricture  by  String  Friction  (Abbe's  Opera- 
tion).— 

A  preliminary  gastrostomy  is  done — after  recovery  from  which  a  small 
bougie,  with  attached  silk  thread,  is  passed  from  the  mouth  into  the  stom- 
ach— the  ends  of  the  thread  are  grasped  by  fingers  at  the  mouth  and 
stomach — the  small  bougie  is  then  withdrawn — another  large  enough  to 
gently  engage  the  stricture  is  introduced — the  thread  is  then  drawn  back 
and  forth,  and  the  frictioning  process,  as  it  passes  between  the  engaged  bougie 
and  the  esophageal  wall,  soon  causes  the  engaged  bougie  to  become  loose — 
and  it  is  then  similarly  replaced  by  a  larger  size,  until  the  desired  caliber  is 
reached.  Sometimes  the  thread  is  passed  through  a  cervical  esophagostomy 
wound,  instead  of  through  the  mouth,  and  then  out  of  the  stomach.  When 
sufficient  dilatation  has  been  secured,  the  gastrostomy  wound  is  closed  (and 
also  the  esophagostomy  wound,  if  one  have  been  made). 

Division  of  Esophageal  Stricture  by  String  Friction  (Bryant's 
Operation). — 

A  special  form  of  bougie,  carrying  a  thread  passed  through  an  opening 
near  its  tip  and  running  over  a  concealed  pulley,  is  passed  through  the  mouth 
and  down  the  esophagus,  until  well  engaged  in  the  stricture — when  by  the 
sawing  motion  of  the  thread  the  stricture  is  worn  down  as  in  the  above 
operation.     By  this  method,  gastrostomy  may  often  be  dispensed  with. 

Treatment  of  Esophageal  Stricture  by  Permanent  Tubage. — 

Consists  in  the  passage  through  the  stricture  of  a  funnel-shaped  rubber 
tube,  by  means  of  a  guide,  until  the  funnel  portion  of  the  tube  rests  above  the 
stricture — a  piece  of  silk  attached  to  a  hole  in  the  tube  being  also  tied  to 
the  ear  of  the  patient.  The  tube  remains  in  situ  for  ten  days  at  a  time,  and 
is  then  cleansed  and  replaced — fluid  food  being  taken  through  it.  Applic- 
able to  some  otherwise  inoperable  cases  of  malignant  disease. 


TONSILLOTOMY.  717 

V.  THE  TONSILS. 
SURGICAL  ANATOMY  OF  THE  TONSILS. 

Situation. — In  the  recesses  between  the  anterior  pillars  of  the  fauces 
(the  palatoglossi  muscles)  and  the  posterior  pillars  of  the  fauces  (the  palato- 
pharvngei  muscles) — corresponding,  externally,  to  the  angle  of  the  inferior 
maxilla. 

Relations. — Externally,  inner  surface  of  superior  constrictor — which, 
together  with  the  pharyngeal  aponeurosis,  separates  the  tonsil  from  the 
internal  carotid  and  ascending  pharyngeal  arteries.  Internally,  free. 
Anteriorly,  palatoglossi  muscles.     Posteriorly,  palatopharyngei  muscles. 

Arteries. — Dorsalis  linguae  of  lingual;  ascending  palatine  of  facial; 
ascending  pharyngeal  from  external  carotid;  tonsillar  of  facial;  descending 
palatine  of  internal  maxillary;  branch  from  small  meningeal  of  internal 
maxillary  (or  from  middle  meningeal). 

Veins. — End  in  the  tonsillar  plexus,  outside  of  the  tonsil. 

Nerves. — From  Meckel's  ganglion,  and  from  the  glossopharyngeal. 


GENERAL  SURGICAL  CONSIDERATIONS. 

The  internal  carotid  artery  lies  about  2  cm.  (about  f  inch)  to  the  postero- 
external aspect  of  the  tonsil — and  nearer  when  tortuous — separated  from  it 
by  the  superior  constrictor,  styloglossus,  and  stylopharyngeus.  The  facial 
artery,  when  tortuous,  may  approach  the  anterior  border  of  the  tonsil.  The 
ascending  pharyngeal  artery  and  the  glossopharyngeal  nerve  lie  to  its  outer 
side. 

INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  TONSILS. 

(1)  For  Operations  through  the  Mouth: — bistouries,  straight  and  curved, 
sharp-pointed;  Whitehead's  combined  tongue-depressor  and  mouth-gag; 
head-mirror;  tonsillotomes;  scissors,  long-handled,  sharp  and  blunt,  straight 
and  curved;  forceps,  long-handled;  artery-clamp  forceps,  long-handled; 
tenacula,  long-handled;  aneurism-needles,  long-handled,  straight  and  laterally 
curved;  sponge-holders;  needle-holder,  long-handled;  curved  needles;  liga- 
tures; sutures.  (2)  For  Operations  through  the  Neck: — Same  as  those  used 
for  approaching  the  esophagus,  omitting  those  for  use  within  the  esophagus. 


TONSILLOTOMY. 

Description. — Incision  of  the  tonsil  by  means  of  a  knife  introduced 
through  the  mouth.     Indicated  in  abscess. 

Preparation. — Mouth  is  washed  frequently  with  antiseptic  solutions. 

Position. — Patient  sits  upright  in  a  chair,  in  a  good  light — mouth  gagged 
on  the  opposite  side — head  thrown  back  and  steadied.  Surgeon  sits  in  front 
— assistant  stands  behind  patient's  head,  steadying  it  and  gag,  and  pressing 
tonsil  into  the  field  by  fingers  in  the  neck. 

Operation. — A  straight  or  slightly  curved  sharp-pointed  bistoury,  wrapped 
with  plaster  or  silk  to  within  a  little  more  than  1  cm.  (about  h  inch)  of  its 
point,  is  made  to  enter  the  mouth  flatwise  (its  surfaces  looking  upward  and 
downward),  with  the  back  of  the  blade  toward  the  cheek — it  passes  backward 
horizontally  and  is  made  to  enter  the  protruding  anterior  border  of  the  tonsil 


718  OPERATIONS  UPON  THE   NECK. 

(which  border  generally  extends  out  beyond  the  anterior  pillar  of  the  fauces) 
in  this  position — passes  into  the  gland  parallel  with  its  free  inner  surface — 
and  cuts  its  way  from  within  outward  on  to  its  free  aspect,  in  the  act  of  with- 
drawal. 


PARTIAL  TONSILLECTOMY  THROUGH  THE  MOUTH. 

Description. — Excision  of  the  free  portion  of  the  tonsil  (generally  hyper- 
trophied) — by  means  of  a  special  instrument  (tonsillotome) — or  by  means 
of  scissors  or  knife,  aided  by  forceps. 

Preparation — Position. — As  for  Tonsillotomy. 

Operation. — (a)  With  the  Tonsillotome;  Having  applied  a  combined 
mouth-gag  and  tongue-depressor,  introduce  the  tonsillotome  flatwise,  with 
blade  drawn  back,  until  the  pharynx  is  reached — then  rotate  it  through  a 
quarter  circle,  holding  its  handle  parallel  with  the  median  line — engage  the 
tonsil  in  the  ring  of  the  instrument,  encircling  it  everywhere  to  an  equal  depth, 
drawing  the  tonsil  out  with  a  tenaculum  if  necessary — push  the  blade  home 
firmly  and  steadily — and  withdraw  the  instrument  with  the  attached  portion 
of  the  tonsil,  (b)  With  long,  curved,  blunt  scissors;  Having  similarly  applied 
a  combined  mouth-gag  and  tongue-depressor,  and  supposing  the  tonsil  to 
be  the  left  one,  this  tonsil  is  grasped  with  long  forceps  held  in  the  operator's 
left  hand — the  scissors,  held  in  the  right  hand,  are  introduced  closed — and  are 
then  opened  and  made  to  seize  the  portion  of  the  tonsil  protruding  beyond 
the  pillars  of  the  fauces,  between  the  grasp  of  the  forceps  and  the  pillars, 
and  to  sever  the  tonsil  with  one  stroke — which  is  withdrawn  in  the  hold  of 
the  forceps.  In  operating  on  the  right  side,  hold  the-  instruments  in  the 
opposite  hands,  (c)  With  long  straight,  blunt  bistoury;  The  operation  is  done 
as  with  scissors. 


COMPLETE  TONSILLECTOMY  THROUGH  THE  MOUTH. 

Description. — The  entire  tonsil  is  excised  through  the  mouth — preceded, 
where  difficulty  i-  anticipated,  by  a  preliminary  tracheotomy,  a  temporary 
ligation  of  the  common  carotid,  and,  if  necessary,  by  a  temporary  splitting 
of  the  cheek.  Indicated  in  those  cases  where  the  growth  is  limited  to  the 
tonsil,  or  but  slightly  involves  the  adjacent  portion  of  the  base  of  the  tongue 
or  pillars  of  the  fauces,  but  in  which  the  tissues  of  the  neck  are  not  infiltrated. 

Preparation. — As  for  Tonsillotomy. 

Position. — Patient  supine,  shoulders  and  head  raised,  and  head  turned 
so  as  best  to  expose  and  illuminate  field — Surgeon  n  side  opposite  operation 
= — Assistant  opposite  surgeon.  Positions  for  the  preliminary  operations  will 
be  determined  by  those  operations. 

Landmarks. — Anatomical  boundaries  (see  Surgical  Anatomy,  page  717). 

Preliminary  Operations.— (a)  Preliminary  tracheotomy,  with  plugging 
of  the  larynx,  or  the  use  of  a  tampon-cannula — performed  several  days  in 
advance  of  the  operation,  preferably  (or  may  be  done  at  the  time  of  the  opera- 
tion), (b)  Preliminary  temporary  ligation  of  the  common  carotid — performed 
at  the  time  of  the  operation,  (c)  Preliminary  splitting  of  the  cheek,  if  con- 
sidered necessary — from  the  angle  of  the  mouth  backward  to  the  masseter, 
with  twisting  or  gut-ligaturing  of  both  ends  of  the  facial  artery — performed 
at  the  time  of  the  main  operation. 

Operation. — (1)  Having  completed  the  preliminary  tracheotomy  and  the 
temporary  ligation  of  the  common  carotid,  expose  the  region  of  the  tonsil 


COMPLETE  TONSILLECTOMY  THROUGH  THE  NECK.  719 

bv  means  of  a  gag  on  the  opposite  side,  and  by  splitting  of  the  cheek  on  the 
same  side,  and  by  drawing  the  tongue  well  out  of  the  mouth.  The  tumor 
is  now  dealt  with  as  indicated.  (2)  Where  a  movable,  encapsulated  tumor  is 
encountered,  the  overlying  mucous  membrane  is  incised  and  the  tumor 
shelled  out  by  means  of  blunt  dissection  and  the  fingers.  These  simple  cases 
hardly  call  for  such  extensive  preliminary  operations.  (3)  Where  the  tumor 
is  immovable,  and  involves  to  some  extent  the  fauces  and  the  base  of  the 
tongue, — the  soft  palate  is  divided  in  the  middle  line  and  thence  outward, 
with  scissors — the  growth  is  seized  with  forceps  or  tenaculum  and  drawn 
toward  the  median  line — while  its  boundaries  are  attacked  with  long,  blunt, 
curved  scissors,  removing  the  pillars  and  tonsillar  tumor  en  masse — together 
with  the  entire  gland  and  growth,  and  as  much  of  the  fauces  and  tongue  as 
necessary,  all  being  deliberately  dissected  out  of  their  bed — controlling 
hemorrhage  by  pressure-forceps,  or  by  twisting  or  traction  upon  the  tem- 
porary ligature  around  the  common  carotid  until  the  vessels  can  be  controlled. 

(4)  No  suturing  of  the  parts  about  the  bed  of  the  tonsil  is  done.  If  necessary, 
the  region  is  packed  with  gauze,  and  pressure  kept  up  without  and  within. 

(5)  The  wound  of  the  cheek  is  neatly  repaired  by  interrupted  external  and 
internal  sutures,  the  latter  being  applied  first.  The  wound  of  the  common 
carotid  is  closed.  The  tracheotomy  tube  is  retained  in  situ  for  a  few  days. 
The  mouth  is  frequently  rinsed  with  antiseptic  washes. 


COMPLETE  TONSILLECTOMY  THROUGH  THE  NECK. 

CHEEVER'S  OPERATION. 

Description. — The  lateral  pharyngeal  wall  is  exposed  by  means  of  a 
careful  dissection  through  the  neck,  and  removed  to  the  indicated  extent, 
together  with  the  tumor,  tonsil,  and  all  lymphatic  glands  and  involved  tissues 
adjacent.  The  operation  is  at  first  a  cervical  pharyngotomy,  and  becomes 
a  partial  pharyngectomy,  in  proportion  to  the  amount  of  pharyngeal  wall 
removed.  Indicated  in  large,  adherent  diffused  tumors  of  the  tonsillar 
region,  with  lymphatic  involvement  of  the  neck. 

Preparation. — Mouth  frequently  cleansed  with  antiseptic  washes.  Xeck 
and  side  of  face  shaved,  if  necessary. 

Position. — Patient  supine,  shoulders  elevated,  head  thrown  back  and  to 
opposite  side,  over  a  cushion  or  sand-bag,  rendering  neck  prominent — 
Surgeon  on  side  of  operation  (or  on  opposite  side  leaning  over) — Assistant 
opposite  surgeon. 

Landmarks. — Lobule  of  ear;  anterior  border  of  sternomastoid ;  hyoid 
bone;  lower  border  of  inferior  maxilla  and  its  angle;  known  anatomical 
relations  of  the  tonsil. 

Incision.  — (1)  Oblique  incision  begins  opposite  lobule  of  ear — passes 
down  anterior  border  of  sternomastoid  as  far  as  the  level  of  the  hyoid  bone, 
or  to  below  the  level  of  the  lower  border  of  the  tumor.  (2)  A  second  nearly 
horizontal  incision  begins  from  the  oblique  one.  opposite  the  angle  of  the 
jaw,  and  is  continued  transversely  forward  along  the  lower  border  of  the 
inferior  maxilla.     (See  Fig.  546,   A.) 

Operation. — (1)  These  incisions  are  carried  through  skin,  platysma, 
and  superficial  fascia — the  external  jugular  and  temporofacial  veins  are 
divided  between  two  ligatures — branches  of  the  cervicofacial  nerve  encoun- 
tered are  guarded  as  far  as  possible.  (2)  The  flaps  thus  marked  out  are 
drawn,  the  one  upward  and  forward,  the  other  downward  and  forward,  and 


720  OPERATIONS  UPON  THE  NECK. 

the  dissection  carried  on  deeply  in  the  submaxillary  and  superior  carotid 
triangles  (see  Surgical  Anatomy  of  the  neck,  page  149) — dividing  the  stylo- 
hyoid, styloglossus,  stylopharyngeus,  and  probably  the  digastric — dividing 
the  facial  artery  and  vein  between  double  ligatures — and  guarding  the  hypo- 
glossal and  glossopharyngeal  nerves.  (3)  The  parotid  gland  is  displaced 
upward — the  submaxillary  gland  forward — and  the  internal  carotid  artery 
and  internal  jugular  vein  outward — these  structures  being  held  out  of  the 
way  by  retraction.  (4)  The  pharyngeal  wall  is  now  exposed  and  opened — 
and  the  tonsil  removed,  together  with  as  much  of  the  pharyngeal  wall  and 
adjacent  tissues,  including  cervical  glands,  as  are  involved,  by  scissors  or 
knife.  (5)  The  pharyngeal  wall,  upon  completion  of  the  operation,  is  sutured 
as  well  as  possible,  and  a  temporary  drain  is  placed  from  the  pharyngeal  wall 


Fig. 546.— Incisions  for  Excision  of  Tonsil  and  Parotid  Gland  :— A,  Incision  for  complete  ton- 
sillectomy through  the  neck  (Cheever's  operation) ;  B,  Incision  for  excision  of  the  parotid  gland. 


through  the  lower  part  of  the  cervical  wound,  the  remainder  of  the  outer 
wound  being  sutured. 

Comment. — The  operation  may  be  aided  by  a  finger  in  the  mouth,  out- 
lining the  growth  and  pressing  it  outward.  The  cheek  may  also  be  split 
and  the  tonsil  attacked  from  both  sides. 

Other  Methods  of  Pharyngotomy  for  Exposure  of  the  Tonsil. — 

Czerny's  Method — a  preliminary  tracheotomy  is  performed,  a  tampon- 
cannula  being  used — the  inferior  maxilla  is  then  divided  and  its  parts  tem- 
porarily turned  aside. 

Mikulicz's  Method — a  preliminary  tracheotomy,  with  a  tampon-cannula, 
is  performed — and  a  part  or  all  of  the  ascending  ramus  of  the  inferior  maxilla 
is  excised. 


SURGICAL  ANATOMY  OF  THE  PAROTID  GLAND.  721 

VI.  THE  PAROTID  GLAND  AND  STENSON'S  DUCT. 
SURGICAL  ANATOMY. 

Situation. — The  parotid  gland  lies  upon  the  side  of  the  face  just  below 
and  in  front  of  the  ear,  overlapping  the  angle  of  the  ramus  of  the  inferior 
maxilla  anteriorly,  and  extending  behind  it  posteriorly. 

Boundaries. — Superiorly;  root  of  zygoma.  Inferiorly;  angle  of  in- 
ferior maxilla,  and  line  drawn  thence  to  mastoid  process.  Anteriorly ; 
overlaps  masseter  muscle  to  a  variable  extent.  Posteriorly ;  external  auditory 
meatus;  mastoid  process;  sternomastoid;  posterior  belly  of  digastric  (some- 
what overlapping  it). 

Relations  of  Surfaces. — Anterior  surface;  grooved  by  posterior 
border  of  ascending  ramus  of  inferior  maxilla — lying,  in  front  of  ramus, 
over  masseter  muscle — and  passing,  behind  ramus,  between  external  and 
internal  pterygoid  muscles.  External  surface ;  lobulated  and  covered  by 
parotid  fascia,  platysma,  and  skin,  with  several  lymphatic  glands  resting 
upon  it,  as  well  as  facial  branches  of  auricularis  magnus  nerve.  Internal 
surface ;  in  relation  with  styloid  process  and  its  muscles,  and  with  internal 
carotid  arterv  and  internal  jugular  vein — and  passes  deeply  into  neck  by 
three  large  processes — (1)  Pterygoid  process,  running  forward  under  ramus 
of  inferior  maxilla,  between  external  and  internal  pterygoids — (2)  Glenoid 
process,  running  inward  under  temporomaxillary  articulation  into  back  of 
glenoid  cavitv — (3)  Carotid  process,  running  inward  to  surround  styloid 
process  and  pass  between  carotid  vessels.  Separated  from  submaxillary 
gland  by  stylomaxillary  ligament. 

Arteries. — From  the  external  carotid  and  from  its  branches. 

Veins. — Empty  into  the  external  jugular. 

Lymphatics. — Empty  into  the  superficial  and  deep  cervical  glands. 

Nerves. — From  carotid  plexus;  facial;  auriculotemporal;  auricularis 
magnus. 

Structures  Passing  through  the  Parotid  Gland. — Arteries;  external 
carotid  passes  deeplv  into  gland  from  below  and  posteriorly,  and  gives  off 
within  the  gland — transverse  facial,  emerging  from  front  of  gland — temporal, 
emerging  from  above — posterior  auricular,  emerging  from  behind — and 
internal  maxillary,  passing  inward  between  neck  of  jaw  and  internal  lateral 
ligament.  Veins;  temporomaxillary;  connecting  vein  from  temporomaxillary 
to  internal  jugular.  Nerves;  facial,  entering  gland  at  its  posterior  border, 
crossing  external  carotid  in  its  passage  forward,  and  dividing  in  the  gland 
into — temporofacial  division,  emerging  upward  and  forward  from  anterior 
border  of  gland — and  cervicofacial  division,  emerging  downward  and  forward 
from  anterior  border  of  gland;  branches  of  auricularis  magnus,  entering  from 
below  to  join  facial;  auriculotemporal  branch  of  inferior  maxillary,  emerging 
from  upper  part  of  gland. 

Structures  in  Proximity  to  Bed  of  Parotid  Gland. — Internal  carotid 
arterv;  internal  jugular  vein;  spinal  accessory,  glossopharyngeal,  and  pneu- 
mogastric  nerves. 

Stenson's  Duct. — Formed  by  branches  converging  from  anterior  part 
of  gland — runs  transversely  forward,  crossing  masseter  muscle,  piercing 
buccinator  muscle,  and  passing  obliquely  forward  between  this  muscle  and 
the  mucous  membrane  of  the  mouth,  to  open  upon  the  inner  aspect  of  cheek 
opposite  the  crown  of  the  second  upper  molar  tooth.  Its  general  course  is 
about  a  finger's-breadth  below  the  zygoma.  The  transverse  facial  artery 
passes  above  it,  and  branches  of  the  facial  nerve  below  it. 
46 


722  OPERATIONS  UPON  THE  NECK. 

Socia  Parotidis. — Sometimes  exists  as  a  separate  gland,  lying  upon  the 
masseter  between  the  zygoma  and  Stenson's  duct. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  PAROTID  GLANDS. 

See  those  mentioned  under  the  Esophagus  (page  712)  and  Tonsils  (page 
717) — especially  those  used  in  exposing  these  structures. 


EXCISION  OF  THE  PAROTID  GLAND. 

Description. — The  total  removal  of  even  the  normal  parotid  gland  is 
very  difficult — and  when  involved  by  a  large,  adherent  tumor,  it  is  practically 
impossible  to  remove  the  entire  gland.  When  the  tumor  is  small  and  the 
combined  mass  of  tumor  and  gland  is  movable,  the  excision  is  somewhat 
less  difficult. 

Preparation. — Neck  and  side  of  face  are  shaved,  if  necessary. 

Position. — Patient  supine,  shoulders  elevated,  neck  prominent,  head 
turned  to  opposite  side.  Surgeon  on  side  of  operation.  Assistant  opposite 
surgeon. 

Landmarks. — Anatomical  boundaries  of  the  parotid,  and  the  contour 
of  the  tumor. 

Incision. — Vertical  incision  beginning  midway  between  mastoid  process 
and  condyle  of  jaw — extending  downward  parallel  with  the  ascending  ramus 
of  the  jaw  to  just  below  its  angle — rounding  thence  forward  just  beneath 
the  lower  border  of  the  inferior  maxilla  to  the  anterior  border  of  the  masseter 
muscle.  Additional  room  may  be  gotten  by  adding  a  posterior  incision  to 
the  vertical  one  opposite  the  forward  curve  just  described.  Also  the  vertical 
incision  may  be  continued  on  downward  along  the  anterior  border  of  the 
sternomastoid  below  the  point  at  which  the  anterior  or  posterior  addition  to 
the  vertical  incision  comes  off,  as  determined  by  the  size  and  nature  of  the 
tumor.     (See  Fig.  546,  B.) 

Operation. — (1)  The  flap  of  integuments  marked  out  by  the  vertical 
incision  with  the  forward  curve  beneath  the  inferior  maxilla,  should  be  raised 
and  turned  upward  upon  the  face  and  stitched  to  the  cheek — and  the  posterior 
margin  of  the  wound  drawn  well  backward.  Doubly  iigate  the  superficial 
veins  as  encountered,  and  divide  them  between  the  ligatures.  (See  Fig.  547.) 
(2)  The  chief  hemorrhage  may  be  controlled  in  one  of  three  ways,  dependent 
upon  the  nature  and  extent  of  the  operation  and  the  judgment  of  the  operator 
—  (a)  By  the  ligation  of  the  vessels  as  encountered  in  the  steps  of  the  operation 
— (b)  By  the  early  exposure  and  double  ligation  of  the  external  carotid  with 
its  division  between  the  ligatures — (c)  By  the  early  exposure  and  temporary 
ligation  of  the  common  carotid.  The  first  method  may  be  resorted  to  in  the 
simplest  cases — the  third  in  the  most  difficult.  (3)  The  gland  and  tumor 
are  approached  from  the  inferior  and  posterior  aspect — dissected  from  their 
bed  and  drawn  upward  and  forward  and  held  under  traction  of  vulsella. 
During  this  step  the  external  carotid  will  be  brought  into  view  and  should 
be  doubly  ligated  and  divided  between  the  ligatures  (unless  done  as  a  pre- 
liminary operation — and  should  be  done  even  if  the  common  carotid  have 
had  a  temporary  ligature  thrown  around  it,  as  the  branches  of  the  external 
carotid  help  to  hold  the  gland  in  its  bed).  And  all  arterial  and  venous  branches 
subsequently  encountered  entering  or  leaving  the  gland,  as  it  is  raised  from 
its  bed,  are  to  be  similarly  divided  between  double  ligatures.     (4)  The  treat- 


EXCISION  OF  THE  PAROTID  GLAND. 


723 


ment  of  the  facial  nerve  is  difficult.  If  the  nerve  be  involved  in  large,  ad- 
herent tumor-growth,  its  sacrifice  is  almost  certain — and,  under  these  circum- 
stances, it  is  often  deliberately  divided.  If  the  tumor  be  more  friable,  and 
danger  of  leaving  infecting  material  not  thereby  materially  increased,  one 
should  endeavor,  by  means  of  a  blunt  dissector  and  the  fingers,  to  break 
away  overlying  and  encompassing  gland  and  free  the  main  divisions  (temporo- 
facial  and  cervicofacial)  of  the  nerve  and  preserve  them  intact.  In  any 
event,  where  possible  and  not  contraindicated,  an  attempt  should  be  made 
to  save  the  branches  of  the  nerve  as  long  as  possible — and,  where  they  have 
been  divided,  after  the  removal  of  the  gland,  to  gut-suture  the  proximal  and 
distal  ends  of  those  severed  (neurorrhaphy).  (5)  The  deeper  portions  of  the 
gland  (pterygoid,  glenoid,  and  carotid  lobes)  are  to  be  now  dissected  from 


Fig.547.— Excision  of  Parotid  Gland: — A.  Parotid  gland;  B,  Stc-nson's  duct;  C,  Masseter 
muscle;  D,  Stylohyoid  muscle;  E,  Sternomastoid  muscle;  F,  External  carotid  artery;  G,  Jugular 
vein  ;  H,  Hypoglossal  nerve  ;  I,  Posterior  auricular  artery  and  vein  ;  J,  Temporal  artery  and  vein  and 
auriculotemporal  nerve;  K.  Transverse  facial  artery  and  vein.  Temporofacial  branches  of  facial 
nerve  are  seen  emerging  upward  and  forward  from  the  gland — and  cervicofacial  branches  downward 
and  forward.  The  pterygoid,  glenoid,  and  carotid  processes  of  the  gland  are  hidden  from  view.  L 
The  flap  stitched  back  to  the  cheek. 


their  beds  chiefly  by  means  of  a  blunt  dissector  and  curved  scissors,  with 
extreme  care — remembering  that  these  processes  of  the  gland  rest  upon  the 
internal  carotid  artery  and  internal  jugular  vein — and  that  the  pneumo- 
gastric,  glossopharyngeal,  spinal  accessory,  and  hypoglossal  nerves  lie  in 
comparatively  close  proximity.  Injury  to  the  internal  jugular  vein  is  the 
chief  danger  here.  Slight  additional  room  is  gained  at  this  difficult  stage, 
in  the  deep  wound  between  the  jaw  and  the  mastoid  process,  by  pushing  the 
jaw  well  forward  and  to  the  opposite  side.  Where  difficulties  appear  in- 
surmountable, the  deeper  lobes,  or  parts  of  them,  must  be  cut  off  and  left 
behind.  (6)  The  tumor  is  now  drawn  upward  and  the  facial  portion  dissected 
out.     (7)   Stenson's  duct  is  ligated  with  chromic  gut  and  severed  a  short 


724  OPERATIONS  UPON  THE  NECK. 

distance  from  the  gland — its  distal  end  being  touched  with  the  actual  cautery, 
or  carbolic  acid,  and  left  in  situ.  (8)  All  hemorrhage  having  been  controlled, 
a  dependent  drainage  is  temporarily  introduced  and  the  remainder  of  the 
wound  sutured  and  a  firm  compress  applied. 

Comment. — The  vessels  from  which  hemorrhage  is  to  be  expected  are 
the  superficial  temporal,  transverse  facial,  occipital,  posterior  auricular, 
internal  maxillary,  and  external  carotid  arteries;  the  external  jugular  and 
temporomaxillary  veins,  and  branches  between  the  external  and  internal 
jugular  veins;  and  numerous  unnamed  and  enlarged  anastomoses. 

The  ramus  of  the  lower  jaw  may  be  turned  aside  in  an  osteoplastic  flap 
to  give  more  room. 

Where  the  tumor  of  the  parotid  is  encapsulated,  the  tumor  alone  may  be 
removed  and  the  gland  left  intact,  except  for  the  incision  into  the  gland  for 
the  enucleation  of  the  growth. 


VII.  THE  SUBMAXILLARY  GLAND  AND  WHARTON'S   DUCT. 
SURGICAL  ANATOMY. 

Situation. — The  submaxillary  gland  lies  below  the  base  and  internal 
surface  of  the  inferior  maxilla  and  above  the  digastric  muscle — occupying 
the  anterior  part  of  the  submaxillary  triangle. 

Relations. — Covered  by;  skin;  platysma;  superficial  cervical  fascia, 
facial  vein,  inframaxillary  branches  of  facial  nerve;  deep  cervical  fascia; 
submaxillary  fossa  of  body  of  inferior  maxilla;  lymphatic  glands.  Rests 
upon;  mylohyoid  in  front;  hyoglossus  behind;  styloglossus  above;  and  also 
upon  facial  artery,  mylohyoid  branch  of  inferior  dental  artery,  and  mylohyoid 
branch  of  inferior  dental  nerve.  Anteriorly ;  anterior  belly  of  digastric. 
Posteriorly ;  stylomaxillary  ligament,  which  separates  it  from  parotid  gland. 

Other  Relations. — (a)  Bulk  of  submaxillary  gland  is  separated  from 
sublingual  gland  by  mylohyoid  muscle,  (b)  Facial  artery  grooves  posterior 
and  superior  aspects  of  the  gland,  (c)  Lingual  branch  of  fifth  and  hypo- 
glossal nerves  lie  between  the  gland  and  hyoglossus  muscle.  The  glosso- 
pharyngeal nerve  lies  beneath  the  hyoglossus  muscle,  (d)  Deep  portion  of 
submaxillary  gland  passes  around  posterior  free  border  of  mylohyoid  muscle 
on  to  the  hyoglossus  muscle. 

Arteries. — Submaxillary  and  submental  branches  of  facial,  and  branches 
of  lingual. 

Veins. — Branches  corresponding  with  arteries. 

Nerves. — From  submaxillary  ganglion;  mylohyoid  branch  of  inferior 
dental;  sympathetic. 

Wharton's  Duct. — Runs  inward  between  mylohyoid  and  hyoglossus — 
then  between  mylohyoid  and  geniohyoglossus — and  finally  under  mucous 
membrane  of  mouth,  between  geniohyoglossus  and  sublingual  gland — to 
empty  at  side  of  fraenum  linguae.  It  runs  between  the  lingual  of  fifth  and 
hypoglossal  nerves  on  hyoglossus  muscle — passing  under  lingual  nerve  at 
anterior  border  of  hyoglossus,  and  then  lying  above  it. 


INSTRUMENTS. 
See  those  used  in  exposing  Esophagus  and  Tonsils. 


EXCISION    OF    SUBMAXILLARY    GLAND. 


7^5 


Fig.  548. — Incisions  for  Operations  upon  Larynx,  Submaxillary  Gland,  and  Thyroid 
Gland: — A,  Curved  submaxillary  incision  for  excision  of  submaxillary  gland;  B,  T-shaped 
incision  for  total  laryngectomy;  F,  E,  Kocher's  curved  transverse  incision  for  total  thyroidectomy; 
D,  H,  G,  Kocher's  triangular  incision  for  partial  thyroidectomy;  F,  E,  H,  G,  Author's  combined 
transverse  curved  and  median  vertical  incision  for  total  thvroidectomv. 


EXCISION  OF  SUBMAXILLARY  GLAND. 

Description. — The  submaxillary  gland  is  frequently  removed  for  tumor 

Preparation — Position. — As  for  the  Parotid  Gland  (page  722). 

Landmarks. — Anatomical  boundaries  of  the  gland,  and  the  contour  of 
the  tumor. 

Incision. — Curved  incision,  with  downward  convexity,  extending  from 
just  below  median  line  of  inferior  maxilla  to  just  below  angle  of  inferior 
maxilla — reaching  below  to  hyoid  bone.     (See  Fig.  548,  A.) 

Operation. — (1)  Incise  skin,  platysma,  superficial  fascia  along  above 
line — dividing,  between  double  ligatures,  the  superficial  veins  encountered 
(tributaries  of  facial,  anterior  jugular,  external  jugular).  The  inframaxillary 
branches  of  the  facial  nerve  are  encountered  crossing  the  line  of  incision 
and  are  safeguarded  as  far  as  possible  by  retraction.  (2)  The  flap  of  super- 
ficial structures  thus  formed  is  dissected  back — retracted  upward  toward  the 
face — and  either  held  out  of  the  way,  or  stitched  to  the  cheek.  (3)  The 
special  compartment  of  deep  cervical  fascia  enclosing  the  submaxillary  gland 
is  now  incised  transversely  at  its  lower  part  and  the  gland  exposed.  The 
connective  tissue  attachments  of  the  gland  to  the  hyoid  bone  and  digastric 
tendon  are  divided.  (4)  The  gland  is  now  raised  from  the  mylohyoid  and 
hyoglossus  and  retracted  upward  over  the  lower  border  of  the  jaw.  (5) 
The  facial  artery  is  tied  and  cut  between  two  ligatures  as  soon  as  it  presents 
in  the  field.  The  hypoglossal  nerve  is  guarded  as  it  lies  between  the  sub- 
maxillary gland  and  the  lower  part  of  the  hyoglossus;  and  the  lingual  of  the 
fifth  as  it  lies  between  the  gland  and  the  upper  part  of  the  hyoglossus  and 
styloglossus;  (the  glossopharyngeal  lying  beneath  the  hyoglossus  and  out  of 
the  way)-  (6)  The  gland  is  now  drawn  downward  and  outward  and  separated 
from  the  submaxillary  fossa  of  the  inferior  maxilla  by  blunt  dissection — and 


726  OPERATIONS    UPON    THE    NECK. 

its  deep  portion  drawn  and  dissected  out  from  behind  the  mylohyoid  muscle. 
(7)  Wharton's  duct  is  ligated  a  short  distance  from  the  gland  and  divided — 
and  its  distal  end  touched  with  the  actual  cautery  or  carbolic  acid.  (8) 
Temporary  drainage  may  be  used  at  the  dependent  angle  of  the  wound — which 
is  elsewhere  closed — and  a  firm  compress  applied. 

VIII.   THE    SUBLINGUAL   GLAND   AND   DUCT  OF   BAR- 
THOLIN. 

SURGICAL  ANATOMY. 

Situation. — The  sublingual  gland  lies  beneath  mucous  membrane  of 
forepart  of  mouth,  near  to  fraenum  linguae,  in  contact  with  sublingual  fossa 
of  inferior  maxilla,  and  rests  upon  mylohyoid  and  geniohyoglossus  muscles. 

Relations. — Superiorly;  mucous  membrane  of  mouth.  Inferiorly; 
mylohyoid  muscle.  Anteriorly;  sublingual  fossa  of  inferior  maxilla;  its 
opposite  fellow.  Posteriorly;  deep  part  of  submaxillary  gland  (mylohyoid 
separating  it  from  bulk  of  submaxillary  gland) .  Internally ;  geniohyoglossus, 
from  which  lingual  nerve  and  Wharton's  duct  separate  it. 

Arteries. — Sublingual  and  submental. 

Veins. — Correspond  with  arteries. 

Nerves. — From  gustatory  and  sympathetic. 

Duct  of  Bartholin. — The  main  duct  of  the  gland — running  along  with, 
and  opening  in  common  with,  Wharton's  duct. 

Ducts  of  Rivinus. — Eight  to  twenty  secondary  ducts — opening  on  floor 
of  mouth. 

INSTRUMENTS. 

See  those  used  in  exposing  the  Esophagus  (page  712)  and  Tonsils  (page 
7i7)- 

EXCISION  OF  SUBLINGUAL  GLAND 

THROUGH    FLOOR   OF   MOUTH. 

Description. — The  sublingual  gland  may  require  removal  for  tumor, 
or  for  embedded  calculus. 

Preparation. — Frequent  antiseptic  rinsings  of  mouth. 

Position. — Patient  supine,  shoulders  and  head  elevated,  mouth  gagged 
open  and  tongue  held  to  opposite  side — Surgeon  on  side  of  operation— 
Assistant  opposite. 

Landmarks. — Anatomical  relations  of  gland,  and  outline  of  tumor. 

Incision. — A  straight  incision  made  in  floor  of  mouth,  beginning  at  the 
median  line,  a  short  distance  back  of  the  alveolar  margin,  and  carried  obliquely 
backward  and  outward,  parallel  with  the  alveolar  margin,  for  about  4  cm. 
(about  ij  inches). 

Operation. — (1)  Having  incised  mucous  membrane  of  mouth  and  re- 
tracted margins  of  wound,  the  upper  aspect  of  the  gland  is  exposed  imme- 
diately beneath  it.  (2)  Having  well  exposed  the  upper  portion  of  the  gland 
by  retraction  of  the  margins  of  the  wound,  the  gland  is  seized  with  toothed 
forceps  and  drawn  upward,  while  being  separated  by  means  of  a  blunt  dis- 
sector— from  the  mylohyoid  muscle  below — from  the  geniohyoglossus  muscle, 
lingual  nerve,  and  Wharton's  duct  internally — from  its  opposite  fellow  in 
front  and  on  the  opposite  side — and  from  the  deep  part  of  the  submaxillary 
gland  behind.  (3)  Having  raised  it  from  its  bed,  its  ducts  are  divided.  (4) 
The  mucous  membrane  is  sutured  over  its  site — one  end  being  left  open  for 
temporary  drainage,  if  thought  necessary. 


PARTIAL  THYROIDECTOMY.  727 

Comment. — The  gland  may  be  partially  excised  (in  cystic  enlargements) 
by  picking  up  its  upper  wall  with  toothed  forceps  and  cutting  out  a  large 
piece  of  the  wall  and  gland  with  curved  scissors. 


IX.   THE  THYROID  GLAND. 
SURGICAL  ANATOMY. 

Situation. — The  thyroid  gland  is  situated  at  the  upper  part  of  the  trachea 
— consisting  of  two  lateral  lobes,  which  extend  from  nearly  as  high  as  the 
oblique  line  on  the  ala  of  thyroid  cartilage,  down  to  fifth  or  sixth  tracheal 
ring — and  of  an  isthmus  from  0.5  to  2  cm.  (about  j  to  f  inch)  broad,  which 
generally  covers  the  second  and  third  (and  sometimes  fourth)  tracheal  rings. 

Relations. — Anteriorly;  covered  by  sternohyoid;  sternothyroid;  omo- 
hyoid; and  slightly  overlapped  by  anterior  border  of  sternomastoid.  Later- 
ally ;  sheath  of  great  vessels.  Upper  part  of  lateral  lobe  lies  between  the 
sternothyroid  and  inferior  constrictor,  the  latter  separating  it  from  the  ala 
of  thyroid  cartilage.  Posteriorly;  embraces  trachea  and  larynx,  reaching 
backward  to  lower  part  of  pharynx,  and,  especially  on  left,  to  esophagus; 
recurrent  laryngeal  nerves;  branches  of  inferior  thyroid  artery. 

Middle  or  Pyramidal  Process. — May  be  developed  in  connection  with 
the  thyroglossal  duct — extending  upward  from  the  isthmus  or  left  lobe — 
and  connected  to  the  thyrohyoid  membrane  or  body  of  the  hyoid  bone. 

Suspensory  Ligaments  of  the  Thyreoid  Gland. — Two  ligaments  pass 
from  inner  and  posterior  aspect  of  lobes  upward  to  sides  of  cricoid  cartilage. 
Recurrent  laryngeal  nerves  lie  in  contact  with  their  outer  surface. 

Arteries. — Two  superior  thyroid  arteries  from  external  carotid  to  superior, 
internal  and  anterior  parts  of  lateral  lobes;  two  inferior  thyroids  from  thyroid 
axis  to  external  and  posterior  parts  of  lateral  lobes;  and  sometimes  thyroidea 
ima  from  innominate  or  aorta. 

Veins. — Two  superior  and  two  middle  thyroid  emptying  into  internal 
jugular;  two  inferior  thyroid,  emptying  into  innominate.  These  veins  form 
a  plexus  upon  the  surface  of  the  gland  and  trachea. 

Lymphatics. — Empty  into  thoracic  duct  and  right  lymphatic  duct. 

Nerves. — From  inferior  and  middle  cervical  ganglion. 

Other  Relations. — Recurrent  laryngeal  nerves  ascend  obliquely  to  side 
of  trachea,  running  eitner  behind  or  in  front  of  inferior  thyroid  arteries — 
requiring,  therefore,  special  care  to  avoid  them. 

Middle  cervical  ganglion — lies  opposite  sixth  cervical  vertebra — generally 
lying  upon  or  near  the  inferior  thyroid  artery. 

It  is  necessary  to  distinguish  the  deep  cervical  fascia  surrounding  the 
thyroid  gland  from  the  capsule  of  the  gland  itself. 


INSTRUMENTS. 
See  those  used  in  exposing  the  Esophagus  (page  712)  and  Tonsils  (page 
717). 

PARTIAL  THYROIDECTOMY 

BY  ANGULAR   INCISION  —  KOCHER'S  OPERATIOX. 

Description. — Consists  in  the  removal  of  one  lobe  of  the  thyroid  gland. 
The  features  of    the  removal  of    a  larsje  goitrous  thyroid  can  be  but  very 


728  OPERATIONS   UPON  THE  NECK. 

imperfectly  illustrated  upon  a  normal  thyroid  gland — but  the  steps  of  the 
operation  for  the  former  condition  will  be  given. 

Preparation. — Neck  shaved. 

Position. — Patient  supine,  shoulders  elevated,  neck  prominent,  head  at 
first  slightly  to  opposite  side  and  then  held  in  median  line.  Surgeon  in  front 
of  neck,  on  side  of  lobe  to  be  removed  (or  on  opposite  side  leaning  over). 
Assistant  opposite  surgeon. 

Landmarks. — Outline  of  sternomastoid  muscle;  upper  border  of  thyroid 
cartilage;  anatomical  position  of  thyroid  gland;  contour  of  tumor. 

Incision. — Begins  over  the  prominence  of  the  sternomastoid  muscle,  on 
a  level  with  the  thyroid  cartilage — runs  forward  nearly  transversely,  to 
median  line,  inclining  slightly  downward  in  the  crease  of  the  neck — thence 
passes  vertically  downward  to  the  suprasternal  notch,  or,  in  large  tumors, 
on  to  the  manubrium.     (See  Fig.  548.  D,  H,  C.) 

Operation. — (1)  The  above  incision  passes  through  skin,  superficial 
fascia,  and  platysma.  (2)  In  the  Horizontal  Portion  of  the  Wound; — the 
anterior  jugular  and  connecting  branch  between  it  and  the  external  jugular 
are  divided  between  double  ligatures.  (The  external  jugular  lies  behind 
the  posterior  end  of  this  incision.)  Branches  of  the  superficial  cervical  and 
inframaxillary  nerves  are  encountered  and  are  guarded  as  well  as  possible 
by  retraction.  Externally,  the  anterior  edge  of  the  sternomastoid  is  exposed, 
freed,  and  drawn  backward.  Internally,  the  sternohyoid  and  sternothyroid 
are  exposed,  the  overlying  fascia  being  displaced  upward.  (3)  In  the  Vertical 
Portion  of  the  Wound; — the  cervical  fascia  between  the  sternohyoid  and 
sternothyroid  is  divided.  The  transverse  vein  above  the  suprasternal  notch 
is  divided  between  double  ligatures.  The  inner  margins  of  the  two  above 
muscles  are  freed  and  partly  divided  toward  their  upper  ends,  with  double 
ligature  and  division  of  the  vessels  encountered.  (4)  The  Outer  Capsule  of 
the  Goitre  now  alone  intervenes  between  the  Gland ; — divide  this  and  separate 
it  from  the  lateral  aspects  of  the  goitre  with  blunt  dissector — dividing  between 
double  ligature  the  superior  and  inferior  accessory  veins  which  may  pass 
from  the  capsule  to  the  goitre.  Displace  the  outer  capsule  of  the  goitre, 
with  the  overlying  muscles,  by  passing  a  finger  beneath  the  goitre  from  the 
outer  side.  (5)  Dislocation  of  the  Goitre  is  now  done;  which  is  accomplished, 
after  inserting  a  finger  beneath  the  goitre,  by  lifting  it  forward  out  of  its  bed 
and  turning  it  toward  the  opposite  side — exercising  care  that  the  vessels, 
especially  the  inferior  thyroids,  are  not  stretched  sufficiently  to  give  way. 
(6)  The  Chief  Vessels  are  now  Ligated  between  Double  Ligatures; — these  are 
brought  into  the  field  in  proportion  to  the  dislocation  of  the  tumor  from  its 
bed.  The  inferior  thyroid  artery  and  vein  are  first  sought  by  drawing  the 
tumor  upward  and  forward — the  artery  is  isolated  with  especial  care,  as  the 
recurrent  laryngeal  nerve  is  in  very  near  relation,  either  anteriorly  or  poste- 
riorly to  it — and  if  any  doubt  exist,  it  should  be  left  until  the  last.  The  supe- 
rior thyroid  artery  and  vein  are  sought  above  the  isthmus,  being  freed  with 
blunt  dissector  while  the  tumor  is  drawn  downward  and  forward.  The  middle 
thyroid  vein  and  the  branches  of  unnamed  enlarged  vessels  are  similarly  tied 
and  divided.  (7)  Isolation  of  the  Isthmus; — expose  if  possible,  and  divide 
between  double  ligatures,  a  superior  and  inferior  communicating  vein,  and 
probably  some  arteries,  at  the  upper  and  lower  borders  of  the  isthmus.  By 
means  of  a  director,  or  blunt  dissector,  the  isthmus  is  separated  from  the 
trachea — a  stout  double  ligature  is  passed  beneath,  tied  on  either  side,  and 
the  isthmus  divided  between  them — while  the  tumor  is  further  lifted  out  of 
its  bed  and  away  from  the  trachea  by  fingers  passed  beneath  the  growth. 


COMPLETE  THYROIDECTOMY 


729 


Be  especially  careful  of  the  recurrent  laryngeal  nerve  in  the  separation  of  the 
posterior  portion  of  the  gland  from  the  trachea — for  which  reason  it  is  well 
to  cut  through  the  posterior  portion  of  the  capsule  of  the  gland  in  order  to 
protect  the  recurrent  laryngeal  nerve.  (8)  The  depth  of  the  wound  is  tem- 
porarily drained — the  major  portion  of  the  wound  being  sutured — and  a  firm, 
compressing  dressing  applied. 

Comment. — Many    additional    unnamed  vessels    are    present    in    large 
goitres. 


Fig.  549. — Total  Thyroidectomy  by  Combined  Transverse  Curved  and  Median 
Vertical  Incision: — A,  Retracting  tissues  from  trachea;  B,  Retracting  left  margin  of  wound 
and  sternohyoid  muscle;  C,  Retracting  right  lobe  of  thyroid  gland,  which  is  in  the  >>.ct  of  being 
freed  from  its  bed;  D,  D,  Transversely  divided  sternohyoid  muscles;  E,  E,  E,  E,  Ligated  ends 
of  anterior  jugular  veins;  F,  F,  Superior  thyroid  arteries;  G,  G,  Thyroid  veins  ramifying  on 
surface  of  thyroid  gland. 


COMPLETE  THYROIDECTOMY 

BY   TRAXSYKRSF.   CURVED   INCISION  — KOCHKR'S   OPERATION. 

Description. — Where  both  lobes  of  the  thyroid  gland  are  involved,  both 
lobes  of  the  gland  are  removed — except  that  a  small  portion  of  the  healthy 
gland  tissue  is  left,  if  possible,  in  order  to  maintain  the  special  function  of  the 
gland  and  thus  prevent  the  cachexia  strumipriva  which  is  apt  to  supervene 
when  the  entire  thyreoid  gland  tissue  is  removed.  The  full  difficulties  of  the 
operation  are  very  imperfectly  appreciated  in  the  excision  of  a  normal  gland, 
as  compared  with  those  encountered  in  a  large  goitrous  tumor. 


730  OPERATIONS   UPON    THE    NECK. 

Preparation. — Neck  shaved. 

Position. — As  for  Partial  Thyreoidectomy,  except  that  the  position  of 
the  head  is  changed  from  time  to  time  to  meet  the  indications  of  the  steps  of 
the  operation. 

Landmarks. — Those  of  the  partial  operation. 

Incision. — Transverse  curved  incision,  with  slight  downward  convexity, 
is  made  across  the  prominence  of  the  tumor,  so  as  to  subsequently  fall  along 
the  cleavage  line  of  the  neck — extending  laterally  over  the  sternomastoids — 
and  extending  further  upward  and  backward  on  the  side  of  greater  enlarge- 
ment.    (See  Fig.  548,  F,  E.) 

Operation. — In  all  essential  features  the  operation  is  similar  to  the  one 
just  described,  with  such  modifications  as  the  larger  size  of  the  tumor  suggests. 
(I)  After  having  cut  through  skin,  superficial  fascia,  and  platysma,  and 
ligated  the  superficial  vessels,  the  sternohyoid,  sternothyroid,  and  omohyoid 
muscles  (which  are  often  thinned  over  the  tumor  by  pressure)  are  divided 
transverselv  over  the  tumor,  internally,  and  their  ends  drawn  upward  and 
downward, — and  the  sternomastoids  are  partly  cut  through  (entirely  if  neces- 
sary) from  their  anterior  border  and  the  uncut  portions  retracted  outward.  (2) 
The  tumor  is  thus  completely  exposed,  covered  by  its  outer  capsule — and  its 
further  removal  is  accomplished  practically  as  in  the  partial  thyroidectomy. 
First  one  lateral  lobe  and  then  the  other  is  attacked — dislocated — and  its 
vessels  tied — the  isthmus  isolated  and  divided  between  ligatures — the  details 
of  the  steps  and  the  termination  of  the  operation  being  similar  to  the  unilateral 
operation. 

Comment. — The  least  amount  of  transverse  division  of  muscles  done 
the  better,  as  marked  retraction  and  deformity  are  apt  to  follow  if  the  muscles 
do  not  reunite.  All  muscles  severed,  whether  wholly  or  in  part,  should  be 
repaired  with  catgut  suture  at  the  end  of  the  operation. 

The  transverse  curved  incision,  where  the  muscles  do  not  have  to  be 
divided,  makes  a  better  skin  scar — and  the  angular  incision  leaves  a  more 
marked  skin  scar  but  does  not  divide  the  muscies. 

Goitres  are  also  treated  by  Enucleation-resection — by  Enucleation — by 
Exothyropexv  (freeing  the  gland  from  the  capsule  and  fixing  superficially  in 
the  wound  to  granulate  and  shrink) — by  injection — etc. 

An  excellent  exposure  is  secured  by  turning  down  two  triangular  flaps 
raised  by  means  of  a  combined  transverse  curved  and  a  median  vertical  incision 
(Figs.  548,  F,  E,  H,  G,  and  549). 


CHAPTER  IV. 

OPERATIONS  UPON  THE  THORAX. 

I.  THE  THORACIC  WALL  AND  CONTENTS. 

SURGICAL  ANATOMY. 

Boundaries  of  Thorax. — Anteriorly;  manubrium,  gladiolus,  and  ensi- 
form  portions  of  sternum;  costal  cartilages;  muscles  of  anterior  thoracic 
region;  vessels  and  nerves.  Posteriorly;  dorsal  vertebra1;  ribs,  from  vertebral 
extremities  to  angles;  muscles  of  posterior  thoracic  and  spinal  regions;  vessels 
and  nerves.  Laterally;  ribs,  from  costal  cartilages  to  angles;  muscles  of 
lateral  thoracic  regions;  clavicles  and  their  muscles;  scapulae  and  their  muscles; 
vessels  and  nerves.  Superiorly,  upper  opening  of  thorax.  Interiorly,  lower 
opening  of  thorax,  closed  by  diaphragm. 

Contents  of  Thorax. — Heart  and  pericardium;  lungs  and  pleurae;  trachea 
and  bronchi;  esophagus;  thoracic  vessels  and  nerves;  thoracic  duct;  superior, 
anterior,  middle,  and  posterior  mediastina;  thoracic  aspect  of  diaphragm. 
(For  contents  of  mediastina,  see  each  mediastinum,  pages  747,  748,  and  752.) 

Boundaries  of  Upper  Opening  of  Thorax. — Anteriorly;  upper  border 
of  manubrium  sterni.  Posteriorly;  body  of  first  dorsal  vertebra.  Laterally; 
first  rib.  Dimensions;  averages  12.7  cm.  (5  inches)  transversely,  and  6.3 
cm.  (2j  inches)  antero-posteriorly. 

Structures  Passing  through  Upper  Thoracic  Opening. — (1)  Centrally; 
sternohyoid  and  sternothyroid  muscles;  thin  layer  of  deep  cervical  fascia; 
thymus  gland  (in  infants)  or  its  remains;  middle  thyroid  artery  (sometimes); 
trachea;  esophagus;  prevertebral  fascia;  longi  colli  muscles.  (2)  Laterally; 
innominate  artery  (on  right  side) ;  common  carotid  and  left  subclavian  arteries 
(on  left);  internal  mammary  and  superior  intercostal  (on  both  sides);  in- 
nominate and  inferior  thyroid  veins;  pneumogastric,  cardiac,  phrenic,  sympa- 
thetic, left  recurrent  laryngeal,  and  anterior  branches  of  first  dorsal  nerves; 
apices  of  lungs  and  their  pleurae;  thoracic  duct  (on  left);  right  lymphatic  duct 
(on  right). 

Boundaries  of  Lower  Thoracic  Opening. — Anteriorly;  ensiform  car- 
tilage; cartilages  of  seventh,  eighth,  ninth,  tenth,  and  eleventh  ribs.  Poste- 
riorly; body  of  twelfth  dorsal  vertebra.  Laterally;  twelfth  ribs.  Floor; 
formed  by  diaphragm,  varying  in  elevation  with  respiration. 

Structures  Passing  through  Floor  of  Thorax:  (Diaphragm).  - 
Through  Aortic  Opening  of  Diaphragm;  aorta;  vena  azygos  major;  thoracic 
duct;  left  sympathetic  nerve  (occasionally).  Through  Esophageal  Opening; 
esophagus;  pneumogastric  nerves;  esophageal  branches  of  thoracic  aorta. 
Through  ('aval  Opening;  vena  cava  inferior;  branches  of  phrenic  nerve. 
Through  Right  Crural  Opening;  greater  and  lesser  right  splanchnic  nerves; 
right  svmpathetic  nerve.  Through  Left  Crural  Opening;  greater  and  lesser 
left  splanchnic  nerves;  vena  azygos  minor;  left  sympathetic  nerve  (generally). 
(For  attachments,  relations,  and  position  of  diaphragm,  see  that  structure.) 

Structures  of  Thoracic  Wall  Opposite  an  Intercostal  Space  (between 
costal  cartilages  and  angles  of  ribs). — Integument;  superficial  fascia,   with 

73i 


732  OPERATIONS    UPON    THE    THORAX. 

superficial  arteries,  veins,  lymphatics,  and  nerves;  special  thoracic  muscles 
overlying  ribs  (dependent  upon  site);  dec])  fascia;  external  intercostal  muscles; 
intermuscular  areolar  tissue  between  intercostal  muscles,  with  intercostal 
arteries,  veins,  lymphatics,  and  nerves;  internal  intercostal  muscles;  endo- 
thoracic  fascia;  subpleural  areolar  tissue;  parietal  pleura.  (The  external 
intercostal  muscles  extend  from  tubercles  of  ribs,  posteriorly,  to  costal  car- 
tilages, anteriorly,  and  from  the  anterior  ends  of  the  external  intercostals 
the  external  intercostal  fascia  is  continued  to  the  sternum.  And  beneath  this 
fascia,  the  internal  intercostal  muscles  intervening,  lies  the  triangularis  sterni 
muscle,  extending  from  second  or  third  costal  cartilage  above,  to  seventh 
costal  cartilage  below,  and  to  outer  end  of  costal  cartilages  externally.  The 
internal  intercostal  muscles  extend  from  the  sternum,  anteriorly,  to  the  angles 
of  the  ribs,  posteriorly,  and  from  the  posterior  ends  of  the  internal  intercostals 
the  internal  intercostal  fascia  is  continued  to  the  vertebral  column.  And 
beneath  this  fascia,  the  external  intercostal  muscles  intervening,  lie  the  infra- 
costales  muscles,  extending  from  the  angles  of  the  ribs  toward  the  vertebral 
column.) 

Structure  of  Thoracic  Wall  Opposite  a  Rib  (between  costal  cartilages 
and  angles  of  ribs). — Integument;  superficial  fascia,  with  superficial  arteries, 
veins,  lymphatics,  and  nerves;  special  thoracic  muscles  overlying  ribs  (de- 
pendent upon  site);  deep  fascia;  external  layer  of  costal  periosteum;  rib; 
internal  layer  of  costal  periosteum;  endothoracic  fascia;  subpleural  areolar 
tissue;  parietal  pleura. 

Relations  of  Overlying  Bones  to  Chest-wall. — Clavicle;  its  inner  end 
articulates  with  supero-external  aspect  of  manubrium  (forming  the  lateral 
boundaries  of  suprasternal  notch) .  The  inner  third  of  clavicle  passes  obliquely 
over  the  manubrium,  costal  cartilage,  and  inner  end  of  first  rib,  lying  0.6  to 
1.2  cm.  (|  to  \  inch)  above  rib,  and  passes  thence  outward  to  its  articulation 
with  acromion,  crossing  about  the  center  of  second  rib,  from  3.2  to  3.8  cm. 
(ij  to  i|  inches)  above  the  rib.  Scapula;  rests  upon  postero-external  aspect 
of  thorax,  from  second  to  eighth  ribs.  When  arms  are  by  side,  superior 
angle  is  on  level  with  upper  border  of  second  rib  (opposite  interval  between 
first  and  second  dorsal  spines),  inferior  angle  being  on  level  with  seventh 
intercostal  interval,  or  sometimes  upper  border  of  eighth  rib  (between  seventh 
and  eighth  dorsal  spines),  and  root  of  spine  on  level  with  interval  between 
third  and  fourth  dorsal  spines. 

Muscles  Covering  and  Forming  Thoracic  Wall  (extracostal,  inter- 
costal, and  infracostal  muscles). — Anteriorly;  pectoralis  major;  subclavius, 
internal  intercostals;  triangularis  sterni  (and  attachments  of  sternomastoid, 
sternohyoid,  and  sternothyroid  to  manubrium;  and  attachments  of  aponeuroses 
of  external  oblique,  internal  oblique,  and  transversalis  abdominis  and  dia- 
phragm to  ensiform  cartilage).  Laterally;  platysma  myoides;  pectoralis 
major;  pectoralis  minor;  latissimus  dorsi;  serratus  magnus;  external  inter- 
costals; internal  intercostals;  diaphragm  (and  parts  or  all  of  some  of  the 
more  particularly  clavicular  and  scapular  muscles — subclavius;  deltoid;  omo- 
hyoid; supraspinatus;  infraspinatus;  subscapularis;  teres  minor;  teres  major; 
trapezius, — and  parts  of  some  of  the  muscles  attached  to  the  upper  ribs — 
scalenus  anticus  and  medius, — and  parts  of  some  of  those  attached  to  the 
lower  ribs — external  oblique;  internal  oblique;  transversalis  abdominis). 
Posteriorly;  trapezius;  latissimus  dorsi;  quadratus  lumborum;  serratus 
magnus;  levator  anguli  scapuli;  rhomboideus  major  and  minor;  scalenus 
posticus;  serratus  posticus  superior  and  inferior;  splenius  capitis  and  colli; 
ilio-costalis;    musculus    accessorius    ad    ilio-costalem;    cervicalis   ascendens; 


SURFACE   FORM   AND    LANDMARKS.  733 

longissimus  dorsi;  transversalis  colli;  trachelomastoid ;  spinalis  dorsi;  corn- 
plexus;  biventer  cervicis;  semispinalis  dorsi  and  colli;  multindus  spinae; 
rotatores  spinae;  supraspinales;  interspinales;  intertransversales;  levatores 
costarum;  internal  intercostals;  infra costales;  diaphragm. 

Chief  Arteries  of  Thoracic  Wall. — Internal  Mammary  of  thyroid  axis, 
giving  off  following  branches — sternal;  anterior  intercostal  (two  in  each  of 
five  or  six  upper  spaces);  perforating  (five  or  six  branches  to  the 
five  or  six  upper  spaces) ;  musculophrenic  (furnishing  anterior  intercostal 
branches  for  five  or  six  lower  spaces).  Superior  Intercostal  of  thyroid  axis, 
to  first  intercostal  space.  Suprascapular  of  thyroid  axis.  From  Trans- 
versa lis  Colli  of  thyroid  axis — posterior  scapular.  From  Axillary — superior 
thoracic;  acromial  thoracic;  long  thoracic;  alar  thoracic;  subscapular.  From 
Thoracic  Aorta — ten  or  eleven  aortic  intercostals,  giving  off  anterior  and 
posterior  branches — the  anterior,  or  true  intercostal  arteries,  dividing  into 
superior  and  inferior,  supplying  each  intercostal  space  from  the  second  to 
the  space  below  twelfth  rib,  and  anastomosing  with  anterior  intercostals  of 
internal  mammary  and  musculophrenic.  From  Abdominal  Aorta — phrenic 
arteries. 

Chief  Veins  of  Thoracic  Wall. — Correspond  with  arteries. 

Chief  Nerves  of  Thoracic  Wall. — From  Posterior  Divisions  of  Cervical 
Nerves — branches  from  third,  fourth,  fifth,  sixth,  seventh,  and  eighth  nerves. 
From  Cervical  Plexus — supraclavicular  branches;  deep  muscular  branches. 
From  Brachial  Plexus — muscular  branches;  posterior  thoracic;  suprascapular; 
anterior  thoracic;  subscapular.  From  Dorsal  Nerves — anterior  branches  of 
upper  eleven  nerves  (the  intercostal  nerves) ;  posterior  branches  of  upper 
eleven  nerves. 


SURFACE  FORM  AND  LANDMARKS. 

Suprasternal  Notch  is  formed  by  upper  border  of  manubrium  and  inner 
aspects  of  non-articular  portions  of  inner  ends  of  clavicles. 

Superior  border  of  sternum  (during  inspiration)  is  on  level  with  carti- 
laginous disc  between  second  and  third  dorsal  vertebrae. 

Transverse  ridge  at  junction  of  manubrium  and  gladiolus  corresponds 
with  costal  cartilage  of  second  rib,  and  is  opposite  fifth  dorsal  vertebra. 

Lower  end  of  gladiolus  is  opposite  ninth  dorsal  vertebra,  and  corresponds 
with  termination  of  seventh  costal  cartilages. 

Infrasternal  depression  lies  between  seventh  costal  cartilages,  and  corre- 
sponds with  ensiform  cartilage. 

Structures  behind  manubrium  sterni — Left  innominate  vein  lies  slightly 
below  superior  border;  Innominate,  common  carotid,  and  subclavian  arteries 
come  off  from  aortic  arch  about  2.5  cm.  (one  inch)  below  upper  border; 
Trachea  bifurcates  opposite  manubrio-gladiolar  junction;  Esophagus. 

Pectoral  furrow  (sternal  furrow)  is  the  median  vertical  furrow  between 
pectoral  muscles,  its  bottom  corresponding  with  center  of  sternum. 

Subcostal  (abdominothoracic)  arch  is  formed  by  ensiform  cartilage  and 
cartilages  of  seventh,  eighth,  ninth,  and  tenth  ribs  and  extremities  of  eleventh 
and  twelfth  ribs.  The  subcostal  angle  varies  from  60  degrees  to  80  degrees, 
averaging  about  70  degrees  in  male  and  75  degrees  in  female. 

Apices  of  lungs,  with  their  pleurae,  rise  from  1.2  to  4.4  cm.  (h  to  if  inches) 
above  clavicle. 

Right  sterno-clavicular  articulation  is  in  relation  with  innominate  artery, 
right  innominate  vein,  and  pleura. 


734  OPERATIONS    UPON    THE    THORAX. 

Left  sterno-clavicular  articulation  is  in  relation  with  left  innominate  vein, 
left  carotid  and  pleura. 

First  rib  is  almost  covered  by  clavicle  and  scapula. 

Infraclavicular  fossa  is  the  space,  or  hollow,  between  lower  border  of 
clavicle  and  upper  border  of  second  rib. 

Coracoid  process  lies  about  i  inch  below  junction  of  outer  and  middle 
thirds  of  clavicle. 

Nipple,  in  male,  lies  over  infero-external  part  of  pectoralis  major,  gener- 
ally between  fourth  and  fifth  ribs,  about  -f  inch  to  outer  side  of  junction  of 
ribs  and  costal  cartilages,  and  a  little  more  than  4  inches  from  median  line. 

Inferior  border  of  pectoralis  major  corresponds  with  fifth  rib. 

Internal  mammary  artery  is  0.5  to  1.5  cm.  (\  to  f  inch)  from  outer  border 
of  sternum,  above — and  1  to  2  cm.  (T7g-  to  -ff  inch)  from  it  below. 

Costo-vertebral  groove  is  occupied  by  the  erector  spina.'  and  multifidus 
spina?,  and  their  subdivisions. 

Tips  of  the  spinous  processes  at  the  upper  and  lower  parts  of  thorax- 
correspond,  approximately,  with  the  neck  of  the  rib  below  the  particular 
spine,  but  the  tips  of  those  spines  near  the  center  of  the  series  about  correspond 
with  the  neck  of  the  second  rib  below. 

Distance  from  upper  central  incisor  teeth  to  bodies  of  first,  second,  third, 
fourth,  fifth,  and  tenth  dorsal  vertebras  is,  approximately,  20.3,  21.8,  23.8, 
25.7,  28,  and  38  cm.  (8,  8f,  9!,  io|,  n,  and  15  inches)  respectively,  in  the 
average  person  of  5  feet  8  inches,  as  measured  by  esophageal  route  (which 
data  are  of  use  in  locating  obstructions  of  the  esophagus). 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  THORAX. 

Exploratory  syringe;  cannula  and  trocar;  scalpels;  cartilage  knives;  probe- 
pointed  bistoury;  dissecting  forceps;  toothed  forceps;  artery-clamp  forceps; 
tracheal  and  esophageal  forceps;  scissors,  curved  and  straight;  retractors, 
various;  saws,  Gigli's,  chain,  Doyen's;  probe;  large  sound;  grooved  director; 
tenacula;  periosteal  elevators,  straight  and  curved;  costotome;  bone-cutting 
forceps;  rongeur  forceps;  bone-holding  forceps;  bone-drill;  wire;  aneurism- 
needles,  straight  and  curved;  needles,  various;  needle-holder;  sutures  and 
ligatures  of  silk,  plain  and  chromic  gut,  and  silkworm-gut;  drainage-tubes; 
gauze. 

CHONDROPLASTIC  RESECTION  OF  CHEST-WALL 

BY    SUBCOSTAL    INCISION    AND    TEMPORARY    DIVISION    OF    SEVENTH,    EIGHTH, 
NINTH,     AND     TENTH     COSTAL     CARTILAGES. 

Description. — Owing  to  the  rigidity  of  the  chest-wall  it  is  difficult  to  satis- 
factorily expose  the  dome  of  the  diaphragm,  the  upper  surface  of  the  liver,  the 
lower  end  of  the  esophagus,  and  the  cardiac  end  of  the  stomach.  By  the  tem- 
porary resection  of  the  costal  arch  of  either  the  left  or  right  side,  as  indicated, 
these  structures  are  much  more  readily  brought  into  the  operative  field. 

While  this  operation*  is  generally  resorted  to  in  connection  with  structures 
within  the  abdominal  cavity,  yet  as  it  involves  the  chest-wall,  it  is  here  described 
among  the  thoracic  operations. 

Preparation. — As   for   an   intra-abdominal   operation. 

Position. — The  reversed  Trendelenburg  position  causes  the  abdominal 


CHONDROPLASTIC    RESECTION    OF    CHEST-WALL. 


735 


viscera  to  gravitate  away  from  the  dome  of  the  diaphragm — and  hence  render 
the  operation  site  more  accessible. 

Landmarks. — The  costal  arch  of  the  side  involved  and  the  position  of  the 
seventh,  eighth,  ninth,  and  tenth  ribs. 

Incision. — In  the  case,  for  instance,  of  operating  upon  the  upper  surface  of 
the  liver,  the  incision  is  a  curved  one  placed  just  below  the  right  costal  arch  and 
extending  from  the  ensiform  cartilage  to  the  tenth  rib  (Fig.  550). 


Fig.  550. — Chondroplastic  Resection  of  Chest-wall: — Subcostal  incision  of  soft  parts 
seen  just  below  costal  arch,  from  ensiform  cartilage  to  tenth  rib.  Costal  cartilages  of  seventh, 
eighth,  ninth,  and  tenth  ribs  are  divided  at  each  end  of  darkened  part — which  latter  represents 
the  portion  of  costal  arch  temporarily  turned  back.     (Thorax  modified  from  Bock.) 

Operation. — In  the  upper  aspect  of  this  wound  the  rectus  and  external 
oblique  muscles  are  separated  from  the  internal  oblique  and  transversalis — 
thus  exposing  the  lower  margin  of  the  costal  arch,  represented  by  the  cartilages 
of  the  seventh,  eighth,  ninth,  and  tenth  costal  cartilages.  The  cartilage  of  the 
seventh  rib  is  divided  near  its  junction  with  the  sternum.  Carrying  the  blunt 
dissection  downward  and  outward,  the  junction  of  the  seventh,  eighth,  ninth, 
and  tenth  ribs  with  their  cartilages  are  exposed — and  the  cartilages  divided  just 
internal  to  their  junctions  with  the  corresponding  ribs  (Fig.  550,  the  darkened 
area) .  The  flap  thus  composed  of  these  cartilages  and  their  overlying  soft  parts 
is  retracted  upward  and  outward — giving  free  access  to  the  hypochondrium. 
At  the  end  of  the  operation  the  cartilages  are  dropped  back  into  place — where 
their  divided  ends  may  be  sutured  with  catgut  through  holes  previously  pierced 
— and  the  wound  sutured. 


736  OPERATIONS    UPON   THE    THORAX. 

OPERATIONS  UPON  THE  THORACIC  WALL  AND  CONTENTS. 

For  operations  upon  the  Thoracic  Viscera,  Mediastina,  Diaphragm,  and 
Mammary  Gland,  see  those  structures  in  the  following  sections.  For  opera- 
tions upon  the  Bones,  Joints,  Arteries,  and  Nerves  of  the  Thorax,  see  those 
structures  in  Part  I,  General  Surgery. 


II.   THE  FEMALE   MAMMARY  GLAND. 
SURGICAL  ANATOMY. 

Description  and  Position. — A  hemispherical  eminence  consisting  of 
glandular,  fatty,  and  areolar  tissue,  lying  between  the  two  layers  of  the  super- 
ficial pectoral  fascia,  the  lower  layer  resting  upon  the  sheaths  of  the  pectoralis 
major  and  serratus  magnus  muscles,  and  the  upper  layer  being  covered  by 
the  skin.  The  superficial  pectoral  fascia  (continuous  above  with  the  super- 
ficial cervical  fascia)  divides,  opposite  the  upper  border  of  the  mamma,  into 
anterior  and  posterior  layers,  passing,  respectively,  in  front  and  behind  the 
gland,  and  holding  it,  as  it  were,  in  a  sling.  From  the  anterior  layer  of  this 
superficial  pectoral  fascia  numerous  processes  pass  into  the  gland  and  support 
its  parenchyma.  The  posterior  layer  of  this  fascia  is  separated  from  the 
deep  thoracic  fascia  by  a  loose,  easily  separable  layer  of  areolar  tissue. 

Arteries  of  Mammary  Gland. — Anterior  intercostals  of  internal  mam- 
mary, of  second,  third,  fourth,  and  fifth  spaces;  perforating  branches  of 
internal  mammary,  of  second,  third,  fourth,  and  fifth  spaces;  intercostals 
of  thoracic  aorta,  of  second,  third,  fourth,  and  fifth  spaces;  long  thoracic  of 
axillary;  external  mammary,  of  axillary  (if  present). 

Veins  of  Mammary  Gland. — Form  circulus  venosus  around  base  of 
gland  and  empty  into  branches  corresponding  with  arteries. 

Lymphatics  of  Mammary  Gland. — Empty  into  axillary  and  anterior 
mediastinal  glands.  (For  position  of  axillary  glands,  see  Axilla,  under 
Lymphatic  Glands  and  Vessels,  page  154.) 

Nerves  of  Mammary  Gland. — Anterior  and  lateral  cutaneous  branches 
of  second,  third,  fourth,  and  fifth  intercostal  nerves;  supraclavicular  branches 
of  cervical  plexus. 

SURFACE  FORM  AND  LANDMARKS. 

The  female  mammary  gland  extends  vertically  generally  over  the  third, 
fourth,  fifth,  and  sixth  (and  sometimes  seventh)  ribs,  and  transversely  from 
the  border  of  the  sternum  to  the  anterior  axillarv  margin. 


GENERAL  SURGICAL  CONSIDERATIONS. 

Three  grades  of  excision  for  the  removal  of  the  female  breast  may  be 
done; — (1)  Radical  excision  of  the  entire  breast,  with  the  removal  of  the 
entire  lymphatic  and  areolar  tissue  of  the  axillary  region,  and  of  the  thoracic 
wall  between  the  breast  and  axilla  (whether  visibly  or  palpably  diseased  or 
not),  with  or  without  removal  of  parts  of  the  pectoral  muscles.  Indicated 
in  cases  of  malignant  disease  of  mammary  gland.  (2)  Ordinary  or  non- 
radical excision  of  entire  breast,  either  without  opening  of  axilla,  or  with 
limited  opening  of  axilla  for  the  removal  of  only  the  palpably  enlarged  glands. 
Indicated  in  non-malignant  growth  of  the  mammary  gland,  and  also  used  by 


PARTIAL    EXCISION    OF    MAMMARY    GLAND.  737 

some  operators  for  malignancy  of  the  gland.  (3)  Partial  excision  of  the  breast. 
Indicated  where  a  benign  growth  is  limited  to  a  comparatively  small  portion 
of  the  breast. 

For  instruments  used  in  operating  upon  the  breast,  see  those  mentioned 
under  "The  Thoracic  Wall  and  Contents"  (page  734). 


INCISION  OF  BREAST. 

Description. — Division  of  mammary  gland  tissue.  Most  frequently  in- 
dicated in  abscesses  which  may  be  antemammary  (in  areolar  tissue  between 
skin  and  gland),  intramammary  (within  the  glandular  tissue),  or  postmam- 
mary  (in  areolar  tissue  between  gland  and  pectoral  muscle).  In  the  first  and 
third  varieties  the  abscess  should  be  opened  by  a  route  not  involving  the 
gland.  In  the  second  variety  (which  is  here  considered)  the  gland  substance 
itself  is  incised. 

Preparation. — Site  of  incision  and  irregularities  of  nipple  are  scrubbed. 
Axilla  is  shielded  from  operation-site. 

Position. — Patient  supine,  at  edge  of  table.     Surgeon  on  side  of  operation. 

Landmarks. — Contour  of  breast,  together  with  situation  of  abscess. 

Incision. — All  incisions  into  gland  substance  should  be  straight,  and 
made  somewhere  in  a  straight  line  radiating  from  nipple  to  circumference 
of  gland,  so  as  to  damage  lactiferous  ducts  as  little  as  possible.  Incision 
should  not  extend  too  near  nipple. 

Operation. — Incise  skin,  superficial  fascia,  and  the  gland  substance 
intervening  between  fascia  and  outer  wall  of  abscess,  generally  with  one  cut 
of  knife.  Having  laid  open  cavity  of  abscess,  and  controlled  hemorrhage 
with  clamp-forceps,  if  necessary,  its  walls  are  well  curetted,  so  as  to  leave 
clean,  raw  surfaces.  The  resulting  walls  of  cavity  may  then  be  approximated 
by  deeply  buried  gut  sutures,  followed  by  closure  of  more  superficial  wound. 
Or  cavity  may  be  temporarily  packed  with  gauze,  after  curettage  and  irriga- 
tion, and  the  superficial  wound  closed  up  to  the  exit  of  gauze  drainage.  The 
latter  course  is  better  in  acute  and  the  former  in  chronic  abscesses. 

Comment. — It  is  sometimes  possible  to  excise  the  entire  abscess,  without 
opening  its  cavity,  and  close  the  entire  wound  at  once  by  deeply  buried  and 
superficial  cutaneous  sutures. 


PARTIAL  EXCISION  OF  MAMMARY  GLAND 

BV   ELLIPTICAL    INCISION. 

Description. — Removal  of  a  limited  portion  of  the  breast. 

Preparation. — Breast  and  nipple  scoured;  breast  shaved,  if  necessary; 
axilla  protected  from  field  of  operation. 

Position. — Patient  supine,  at  edge  of  table.     Surgeon  on  side  of  operation. 
Assistant  opposite  Surgeon. 

Landmarks. — Contour  of  breast,  together  with  position  of  growth;  plane 
of  pectoral  muscle. 

Incision. — An  ellipse  is  outlined  so  as  to  include  the  growth  by  a  wide 
margin,  with  the  two  arms  of  the  incision  meeting  between  the  inner  aspect 
of  the  growth  and  the  nipple,  and  between  the  outer  aspect  of  the  growth 
and  the  periphery  of  the  gland,  the  general  direction  of  the  ellipse  radiating 
from  nipple  to  circumference.  When  indicated,  the  nipple  is  also  included 
in  the  ellipse  and  removed  (Fig.  551,  B). 
47 


738  OPERATIONS    UPON    THE    THORAX. 

Operation. — Incise  skin  and  superficial  fascia,  first  along  one  side  of 
ellipse,  then  along  opposite  side,  controlling  bleeding  with  clamp-forceps. 
Slightly  retracting  tissues  in  a  direction  away  from  the  ellipse,  incise  through 
the  glandular  tissue  along  the  lines  of  the  original  incision,  passing  downward 
toward  the  base  <>f  the  gland,  with  a  tendency  for  the  incisions  to  approach 
as  they  deepen.  The  part  to  he  removed  is  thus  entirely  surrounded  and  it:; 
depth  finally  reached,  either  before  the  entire  thickness  of  the  mammary  gland 
has  been  traversed,  or  at  the  pectoral  muscle,  after  traversing  its  entire  thick- 
ness, and  is  removed  en  masse.  All  bleeding  vessels  are  tied  with  gut.  The 
depths  of  the  wound  are  approximated  by  buried  gut  sutures,  and  the  margins 
of  the  wound  united  with  silk  or  silkworm-gut. 

Comment. — When  the  part  removed  is  considerable,  it  may  be  necessary 
to  undercut  the  tissues  laterally  to  enable  the  walls  and  surface  of  the  wound 
to  be  approximated  without  too  great  tension.  The  principle  of  the  subcu- 
taneous excision  of  the  mammary  gland  (7.  v.)  may  also  be  applied  to  the 
excision  of  a  part  of  the  gland  (page  746). 


RADICAL  EXCISION  OF  MAMMARY  GLAND,  TOGETHER  WITH  ENTIRE 
BELLY   OF    PECTORALIS    MAJOR    AND    PECTORALIS  MINOR 
MUSCLES,   AND    AXILLARY    GLANDULAR    AND    CON- 
NECTIVE TISSUES,    IN   ONE  MASS. 

willy    meyer's    operation. 

Description. — The  entire  breast  and  the  pectoralis  major  and  pectoralis 
minor  muscles  are  removed,  together  with  the  lymphatic  glandular  and  the 
connective  tissues  of  the  axilla.  The  special  feature  of  the  operation  is  that, 
after  division  of  the  tendons  of  the  two  pectoral  muscles,  the  structures  of 
the  axilla  are  first  exposed  and  the  necessary  vessels  ligated — in  the  act  of 
dissecting  out  the  glandular  and  areolar  tissues — after  which  the  axillary 
mass  and  the  breast,  with  the  two  muscles,  are  removed  en  masse  in  a 
direction  from  the  axilla  toward  the  sternum — thus  minimizing  the  pressure 
of  infectious  material  from  the  site  of  malignancy  toward  the  axilla  and 
thence  into  the  general  system,  and  also  materially  lessening  hemorrhage  by 
the  early  clamping  and  dividing  of  vessels  near  their  origin. 

Preparation. — The  entire  anterior  aspect  of  the  thorax,  axilla,  arm,  and 
lateral  and  part  of  posterior  aspects  of  thorax  are  shaven.  The  anterior  sur- 
faces of  both  thighs  are  also  shaven  (to  provide  surfaces  from  which  grafts 
may  be  needed). 

Position. — The  patient  rests  upon  two  horsehair  pillows  placed  parallel 
to  the  spine  under  the  back — thus  rendering  the  sides  of  the  thorax  more 
accessible  by  elevation.  The  involved  arm  is  held  slightly  above  a  right  angle 
with  the  longitudinal  axis  of  the  body,  with  the  elbow  flexed  at  an  angle  of  90 
degrees. 

Landmarks. — Humeral  attachment  of  pectoralis  major  muscle;  lower 
border  of  pectoralis  major;  border  of  latissimus  dorsi,  sternal  and  thoracic 
origins  of  pectoral  muscles;  sternum;  contour  of  breast;  cephalic  vein;  clavicle. 

Incision. — An  incision  is  so  planned  as  to  allow  two  flaps  to  be  raised:- — 
(1)  The  lower  flap  is  formed  by  an  incision  that  begins  at  the  humeral  attach- 
ment of  the  pectoralis  major — the  incision  passing  downward  and  inward, 
parallel  with  and  about  2.5  cm.  (1  inch)  above  the  lower  border  of  the  pectoral 
muscle,  to  the  base  of  the  breast — thence  is  continued  along  the  lower  margin 
of  the  breast,  to  end  over  the  sternum  slightly  beyond  the  median  line.     (2)   The 


RADICAL    EXCISION    OF    MAMMARY    GLAXD. 


739 


upper  flap  is  formed  by  an  incision  which  simply  follows  the  upper  contour 
of  the  breast,  joining  the  upper  and  lower  ends  of  the  preceding  incision 
(Fig.  SSi,  A). 

Operation. — (i)  Freeing  the  flaps; — The  lower  flap  is  loosened  and 
retracted  downward,  until  the  border  of  the  latissimus  dorsi  and  the  chest-wall 
are  exposed  in  the  axilla — freeing  the  fat  by  incision  and  blunt  dissection  in 
such  a  way  as  to  leave  as  much  of  it  as  possible  adherent  to  the  breast.  The 
border  of  the  latissimus  dorsi  is  freed  down  to  the  serratus  anticus  major  and 
up  to  the  bicipital  sulcus  of  the  arm.  In  freeing  and  retracting  the  upper  flap 
as  much  fat  is  here,  too,  left  adherent  to  the  breast  as  possible,  guarding  against 
endangering  the  nutrition  of  the  skin.  Care  is  taken  not  to  include  the  pectoral 
fascia.  The  breast  and  pectoralis  major  are  now  retracted  downward  and  the 
upper  flap  upward — and  the  cephalic  vein,  lower  border  of  the  clavicle,  and 
sternoclavicular  articulation  exposed;  (2)  Division  of  tendons  of  pectoral 
muscles  and  exposure  of  axilla  and  subclavian  vein  (Fig.  552).     The  cephalic 


-eSc    i 


/7f 


Fig.  551. — Incisions  for  the  Removal  of  the  Breast,  in  Whole  or  in  Part: — A, 
Incision  for  Meyer's  radical  excision  of  the  breast;  B,  Elliptical  incision  for  excision  of  small 
benign  tumor. 


vein,  running  in  the  groove  between  the  pectoralis  major  and  minor,  is  followed 
up  to  the  humeral  attachment  of  the  pectoral  muscle.  The  tendon  of  the 
muscle  is  then  freed  and  divided  close  to  the  humerus.  The  pectoral  muscle 
is  retracted  downward  and  inward  with  a  sharp  retractor  and  is  severed  from 
the  lower  border  of  the  clavicle  and  the  sternoclavicular  articulation.  The 
vessels  in  the  lines  of  incision  are  doubly  clamped  and  divided  and  the  nerves 
to  the  pectoral  muscle  cut.  The  thoracic  wall  and  the  pectoralis  minor  are 
thus  exposed.  The  pectoralis  minor  is  traced  up  to  the  coracoid  process, 
encircled  by  the  finger  (to  guard  the  subclavian  vein)  and  divided,  and  also 
retracted  downward  and  inward.  The  axillary  fascia  is  divided  in  a  line  with 
the  vessels  and  the  axillary  artery  and  vein  exposed  by  blunt  dissection.  (3) 
Extirpation  of  axillary  glands  and  fatty  areolar  tissue.  The  gauze  packing 
that  had  been  placed  under  the  lower  flap  earlier  in  the  operation  is  removed. 
The  axillary  connective  tissue  and  fat  over  the  upper  part  of  the  latissimus 
dorsi  is  divided  up  to  the  axillary  vein,  the  left  forefinger  surrounding  it,  its 


74o 


OPERATIONS    UPON   THE   THORAX. 


tip  resting  on  the  vein,  thus  severing  it  from  the  fatty  areolar  tissue  in  the  sulcus 
bicipitalis  brachii,  and  is  then  also  drawn  downward.  The  lower  part  of  the 
axillary  artery  and  vein  are  exposed  and  cleared  up  to  the  site  where  the  sub- 
clavian vein  disappears  beneath  the  clavicle — doubly  ligating  and  dividing 
vascular  branches  as  encountered.  Preserve  the  two  superior  subscapular 
nerves — sacrificing  the  third  (to  the  latissimus  dorsi)  in  order  to  expose  all 
infected  tissue.  (4)  The  formation  of  a  pedicle  of  the  entire  mass  over  the 
sternum  and  removal  of  the  breast,  muscles,  glands,  and  fat.  The  mass  of 
loosened  tissues  is  carefully  lifted  away  from  the  axilla  and  thoracic  wall, 
avoiding  the  tearing  away  of  periosteum  and  perichondrium.  Returning  to 
the  already  exposed  subscapular  space,  the  knife  is  made  to  cut  perpendicularly 
down  to  the  thoracic  wall,  avoiding  the  fibers  of  the  serratus  anticus  major 
muscle.      The  pectoralis  major  is  cut  close  to  the  chest-wall  by   incisions 


Fig.  552. — Radical  Excision  of  the  Breast,  showing  Features  of  the  Meyer  Opera- 
tion:— The  general  method  of  removal  is  the  primary  freeing  and  division  of  the  origins  of  the 
pectoral  muscles  and  dissection  of  the  axilla  and  subsequent  freeing  of  the  mass  toward  the 
thoracic  wall.  The  severed  muscles  are  the  pectoralis  major  and  minor.  The  clavicular  portion 
of  the  former  muscle  is  not  here  divided.  The  axillary  vein  and  branches  are  seen.  The  proper 
incision  for  this  exposure  is  shown  at  A,  Fig.   551. 


underneath  its  belly  and  parallel  with  and  almost  on  a  level  with  the  ribs 
and  intercostal  muscles.  All  vessels  encountered  are  clamped  and  ligated. 
The  last  remaining  connection  of  the  tumor  mass  with  the  chest  wall  is  now 
divided  close  to  the  sternum,  clamping  and  tying  the  perforating  arteries. 
(5)  Ligation,  drainage,  and  suturing.  Throughout  the  operation  vessels  are 
preferably  clamped  by  two  hemostats  and  divided  between  them.  At  the  end 
of  the  operation  the  clamped  vessels  are  taken  up  and  ligated.  The  axillary 
space  is  drained  through  a  separate  opening  at  its  bottom,  made  in  the  final 
steps  of  the  operation — through  which  two  halves  of  a  divided  large  rubber 
drainage-tube  are  put.  A  small  gutter  drain  is  placed  in  the  upper  angle  of 
the  wound  down  to  the  severed  tendon  of  the  pectoralis  major,  the  end  of 
which  has  been  whipped  over  with  a  suture.  The  upper  and  lower  angles  of 
the  wound  are  now  sutured,  continuously  or  interruptedly,  as  far  toward  the 


RADICAL    EXCISION    OF    MAMMARY    GLAND.  741 

site  of  the  former  breast  as  possible.  An  uncovered  area  of  varying  size 
remains,  representing  the  base  of  the  breast.  If  the  thoracic  stump  of  the 
pectoralis  minor  (about  \  cm. — \  inch  long)  be  left  (and  this  portion  of  that 
muscle  is  very  rarely  involved)  part  of  the  lower  flap  can  often  be  stitched  to 
this  stump  and  thus  the  area  is  prepared  for  grafting.  (6)  The  raw  area  left 
by  the  unapproximated  edges  is  immediately  grafted  by  long,  thin,  wide  grafts 
taken  from  the  previously  prepared  thighs.  These  are  placed  longitudinally 
with  the  axis  of  the  body,  the  ends  of  the  grafts  resting  upon  the  skin  surfaces 
and  the  thin  margins  overlapping  each  other.  (7)  Dressing  of  the  wound. 
The  grafted  area  is  covered  by  long  strips  of  sterilized  rubber  tissue  placed 
horizontally.  Gauze  fluffs  and  compresses  are  put  over  this.  The  exits  of 
drains  are  protected  by  split  gauze  compresses.  The  entire  wound  is  now 
covered  by  abundant  gauze  fluffs  and  compresses — the  arm  is  carried  across 
the  chest,  the  axilla  having  been  filled  with  sterile  cotton — the  whole  dressing 
being  held  in  place  by  a  Desault  bandage.  The  patient  is  put  in  bed,  with  the 
elbow  supported  upon  a  small  pillow. 

After-treatment. — The  patient  is  kept  upon  her  back  for  twenty-four 
hours,  after  which  she  is  raised  by  one  or  more  pillows.  The  elbow  remains 
supported.  The  dressing  is  removed  on  the  sixth  day.  One  of  the  split 
drainage-tubes  is  then  removed.  The  other  split  tube  and  the  smaller  tube 
at  the  upper  angle  of  the  wound  are  shortened — and  a  wet  dressing  with 
Thiersch's  solution  is  applied.  The  second  dressing  is  changed  two  days 
later,  when  all  drains  are  removed.  Beginning  with  the  tenth  to  twelfth  day, 
the  patient  is  later  taught  how  to  exercise  the  arm.  The  patient  is  expected 
to  have  perfect  use  of  the  arm,  including  perpendicular  erection.  In  this 
operation  the  supraclavicular  space  is  invaded  only  when  glands  are  palpable. 


RADICAL  EXCISION  OF  MAMMARY  GLAND,  THE  AXILLARY,  GLANDU- 
LAR,   AND    CONNECTIVE    TISSUES,    AND    PARTS    OF   THE 
PECTORAL   MUSCLES. 

HALSTED'S     OPERATION. 

Description. — Consists  in  complete  excision  of  breast,  together  with 
removal  of  the  entire  pectoralis  major  (or  all  save  its  clavicular  portion),  as 
well  as  a  transverse  division  of  the  pectoralis  minor,  with  the  turning  outward 
of  its  outer  part,  and  clearing,  en  masse,  of  fatty-areolar-glandular  tissue 
from  axilla.  The  substance  of  the  operation,  as  described  by  Halsted,  is 
given  in  the  following  account.  The  removal  is  made  from  the  chest  toward 
the  axilla. 

Preparation. — Breast,  nipple,  and  axilla  scrubbed;  chest-wall  and  axilla 
shaved. 

Position. — Patient  supine,  at  edge  of  table,  with  head  and  shoulders 
elevated  and  arm  held  at  right  angle  to  side.  Surgeon  on  side  of  operation. 
Assistant  opposite. 

Landmarks. — Contour  of  breast  and  growth;  landmarks  of  axilla  and 
pectoral  muscles. 

Incision. — Begins  directly  above  the  upper  circumference  of  mammary 
gland,  well  beyond  all  detectable  involvement,  and  passes  outward  and  down- 
ward along  outer  border  of  gland;  curves  below  around  breast  and  ascends 
upon  inner  side  upward  in  a  curve  to  point  of  beginning,  thus  entirely  en- 
circling gland;  and  thence,  without  stopping,  is  continued  in  a  curved  direction 
along  anterior  surface  of  pectoralis  major,  to  and  slightly  down  upon  the 
anterior  fold  of  the  axilla  (Fig.  553,  M  N  L). 


742 


OPERATIONS    UPON    THE    THORAX. 


Operation. — (I)  Incise,  throughout,  through  skin  and  fatty  areolar 
tissue,  clamping  or  tying  all  bleeding  vessels.  (2)  Reflect  the  triangular  flap 
of  skin  only  (L  M  N)  outward  to  base-line  (L  N).  Dissect  back,  as  a 
separate  flap,  the  fattv  areolar  tissue  (corresponding  to  this  triangle  of  skin) 
to  inferior  border  of  pectoralis  major,  where  it  becomes  a  part  of  the  axillary 
areolar-fattv  tissue.  (3)  Divide  costal  insertions  of  pectoralis  major,  and 
split  the  muscle  itself  in  the  groove  between  costal  and  clavicular  portions 
outward  to  about  opposite  scalenus  anticus  tubercle  on  first  rib  (which  lies 
nearly  opposite  junction  of  inner  and  middle  thirds  of  clavicle).  (4)  Cut 
through  (opposite  scalenus  tubercle  on  first  rib)  the  clavicular  portion  of 
pectoralis  major,  directly  to  clavicle,  cutting  at  right  angle  to  fibers  of  clavicular 
portion,  thus  exposing  apex  of  axillary  space.  (5)  Retract  pectoralis  major 
upward  and  dissect  out  areolar  tissue  from  under  its  clavicular  portion.     (6) 


Fig.  553. — Operations  upon  the  Mammary  Gland:—  R,  Radical  excision  of  the  breast,  Hal- 
sted's  operation;  S,  Incision  for  radical  excision  of  the  breast,  Warren's  operation. 

Continue  splitting  of  pectoralis  major,  in  original  line,  out  to  humerus  and 
sever  the  humeral  attachment  of  the  costal  (sternal)  portion.  (7)  Raise  the 
entire  mass  of  integument,  mamma,  and  fatty-areolar  tissue  upward  and 
outward,  and  while  the  submuscular  fascia  is  thus  put  upon  the  stretch,  this 
mass  is  stripped  from  the  chest-wall  and  pectoralis  minor,  closely  hugging 
the  ribs  and  removing,  if  possible,  the  fascial  sheath  of  the  pectoralis  minor, 
beginning  above  at  the  upper  and  inner  part  of  the  wound  and  proceeding 
downward  and  outward.  (8)  Having  reached  in  this  clearing,  and  well 
exposed,  the  lower  (outer)  margin  of  pectoralis  minor,  divide  that  muscle 
just  below  its  center,  at  right  angle  to  its  fibers.  (9)  Divide  fascia  and  areolar 
tissue  over  coracoid  attachment  of  pectoralis  minor  and  turn  them  inward, 
preparatory  to  the  upward  reflection  of  outer  part  of  pectoralis  minor.  (10) 
Retract  upward  and  outward  the  severed  outer  part  of  pectoralis  minor  with 
the    retractor   that   had   heretofore   retracted   pectoralis   major   alone,     (n) 


RADICAL    EXCISION    OF    MAMMARY    GLAND. 


743 


Dissect  out  the  loose  fatty-areolar  tissue  beneath  pectoralis  minor  near  its 
insertion,  carefully  clearing  the  small  vessels  (mainly  veins)  and  ligating 
them  off  close  to  axillary  vein.  (12)  Expose  subclavian  vein  at  its  highest 
subclavicular  point  and  dissect  away  the  entire  contents  (fat,  areolar  tissue, 
glands,  and  many  small  vessels)  of  the  axilla,  with  extremest  care  and  thor- 
oughness and  with  a  sharp  knife,  aided  by  forceps.  Expose  and  strip  axillary 
vein  absolutely  clean  of  all  extraneous  tissue,  ligating  its  branches  close  to 
main  trunk,  holding  the  tissues  and  pushing  the  vein  from  them,  rather  than 
the  reverse.  Expose  axillary  artery,  in  the  majority  of  cases,  and  remove 
all  loose  tissue  above  the  axillary  vessels  and  axillary  plexus  of  nerves.  (13) 
Having  cleared  axillary  region,  grasp  mass  of  tissues  to  be  removed,  drawing 
;t  outward  and  somewhat  upward  with  left  hand,  to  put  upon  slight  stretch, 


Fig.  554. — Halsted's  Radical  Excision  of  the  Breast: — Showing  the  primary  detach- 
ment of  the  breast  and  pectoral  muscles  from  the  thoracic  wall  and  subsequent  freeing  of  the 
mass  toward  the  axillary  structures.  The  thoracic  end  of  the  severed  pectoralis  minor  is  shown. 
The  separated  pectoralis  major  and  proximal  end  of  the  pectoralis  minor  have  retracted  toward 
their  origins.     The  breast  retains  its  connection  to  these  and  to  the  axillary  connective  tissue. 

and  cut  away  the  mass  of  fascia  from  the  lateral  thoracic  wall  (inner  axillary 
wall),  closely  hugging  ribs  and  serratus  magnus.  (14)  Just  prior  to  reaching 
junction  of  posterior  and  lateral  axillary  walls,  the  original  triangle  of  skin 
(freed  early  in  the  operation)  (R)  is  drawn  outward  by  an  assistant,  to  aid 
in  exposing  the  tissues  lying  upon  the  subscapularis,  teres  major,  and 
latissimus  dorsi.  The  surgeon,  taking  a  new  hold  upon  the  mass  to  be 
removed,  now  cleans  out  the  posterior  axillary  wall,  from  within  outward. 
Thus  the  subscapular  vessels  are  conveniently  exposed,  and  are  tied  or  clamped 
before  being  cut.  The  subscapular  nerves  are  exposed,  and  may  or  may  not 
be  removed,  their  retention  being  preferable.  (15)  Turn  the  mass  of  tissues 
back  into  their  original  position  and  divide  their  connection  with  the  thorax 
by  a  single  stroke  of  the  knife  passing  along  the  first  incision  made,  namely, 


744  OPERATIONS    UPON   THE   THORAX. 

from  L  to  N,  removing  everything  in  one  piece.  (16)  Approximate  circum- 
ference of  wound  by  a  buried  purse-string  suture  of  strong  silk.  Only 
the  base,  L  N,  of  the  triangular  skin-flap  (L  M  N)  is  included  in  the 
purse-string.  The  apex  and  rest  of  the  triangular  flap  are  shifted 
to  a  new  and  lower  position  so  as  to  form  a  lining  for  the  fornix  of  the 
axilla.  (17)  No  drainage  is  established.  Uncovered  portion  of  wound 
frequently  heals  by  organization  of  the  blood-clot  and  should  be  covered 
with  rubber  tissue. 

Comment. — Every  bleeding  point  in  this  extensive  field  of  operation  is 
immediately  clamped.  The  divided  pectoralis  minor  should  be  sutured  with 
chromic  gut. 

RADICAL  EXCISION  OF  MAMMARY  GLAND. 

WARREN'S  OPERATION. 

Description. — Consists  in  complete  excision  of  breast,  together  with 
removal  of  sternal  part  of  pectoralis  major  entirely;  and  also  in  removal  of 
entire  pectoralis  minor,  or  a  simple  turning  back  of  its  divided  ends;  with 
clearing  out,  en  masse,  of  fatty-areolar-glandular  tissues  of  axilla,  aided  by 
a  transverse  division  of  clavicular  portion  of  pectoralis  major;  and  the  forma- 
tion of  one  or  two  cutaneo-areolar  flaps  from  the  lateral  thoracic  wall  to  cover 
over  the  main  wound,  in  conjunction  with  its  own  margins. 

Preparation — Position — Landmarks. — Same  as  in  the  Radical  Excision 
of  the  Breast  by  Halsted's  method  (page  741). 

Incisions. — (1)  Outer  Primary  Incision  (Fig.  553,  S)  begins  at  anterior 
margin  of  axilla,  at  its  junction  with  the  arm,  and  passes  along  just  above 
anterior  border  of  axilla  and  the  lower  margin  of  pectoralis  major,  encircling 
the  lower  circumference  of  the  breast  to  its  inner  and  lower  quadrant.  (2j 
Inner  Primary  Incision  (D  C)  begins  at  center  of  anterior  axillary  border 
(D)  and,  passing  inward  and  downward,  diverges  from  first  incision  to 
encircle  upper  and  inner  part  of  circumference  of  breast  and  meet  first 
incision  at  point  of  its  ending  (C).  (3)  Upper  Secondary  Incision  (E  F)  is 
made  later,  passing  from  point  E,  on  upper  primary  incision,  to  clavicle  (F), 
dividing  the  clavicular  portion  of  pectoralis  major  at  right  angle  to  its  fibers. 
(4)  Lower  Secondary  Incisions  (H  and  I)  are  made  at  end  of  operation,  for 
the  purpose  of  raising  flaps  to  cover  the  main  wound,  the  incisions  (one,  or 
both  if  necessary)  begin  from  lower  primary  incision  at  point  G  (not  shown 
in  figure),  and  pass  upward  (I)  and  downward  (H). 

Operation. — (1)  Incise  through  skin  and  fatty-areolar  tissue  along  above 
primary  lines,  clamping  all  bleeding  vessels.  (2)  Dissect  back  margins  of 
wound  so  as  to  expose  base  of  gland  in  its  entire  circumference,  carrying 
incision  to  pectoralis  major,  which  is  freely  exposed  along  entire  upper  inci- 
sion. (3)  Divide  sternal  portion  of  pectoralis  major  from  thorax,  and  throw 
entire  mass  outward  and  downward.  (4)  Sever  humeral  insertion  of  pectoralis 
major,  exposing  pectoralis  minor  and  axilla.  (5)  Upper  secondary  incision 
is  now  made,  to  expose  axillary  vessels  up  to  where  they  pass  beneath  the 
clavicle.  (6)  Divide  the  pectoralis  minor  transversely  and  reflect  halves 
outward  and  inward,  or  entirely  remove  them.  (7)  Clear,  by  careful  dis- 
section, axilla  of  all  extraneous  tissues  and  unimportant  vessels,  from  clavicle 
to  lower  part  of  axilla,  including  all  fatty,  glandular,  and  areolar  tissue  lying 
in  front  and  behind  the  vessels,  as  well  as  the  areolar  tissue  between  serratus 
magnus  and  subscapularis.  Branches  of  axillary  vein  and  artery  are  tied 
close  to  their  vessels,  and  any  thoracic  or  scapular  nerves  which  are  in  the 
way  of  thorough  clearing  of  the  axilla  are  sacrificed,  unless  they  can  be  tern- 


ORDINARY    EXCISION    OF    MAMMARY    GLAND. 


745 


porarily  displaced.  (8)  Reflect  mamma,  with  pectoral  muscles  and  adherent 
axillary  contents,  outward  and  sever  them  from  thorax  in  one  continuous  mass 
by  a  few  sweeps  of  the  knife  along  the  outer  primary  incision.  (9)  Lower 
secondary  incisions  are  now  made,  and  the  cutaneo-areolar  flaps  represented 
by  them  are  raised  by  undercutting,  and  are  ready  to  be  shifted  inward,  (io) 
Margins  of  original  primary  incisions,  together  with  the  margins  of  the  flaps 
raised  for  that  purpose,  are  approximated  by  suture,  so  as  to  entirely,  if 
possible,  cover  in  the  whole  wound  and  secure  primary  union,  (n)  Tem- 
porary horsehair  or  gauze  drainage  is  used  for  twenty-four  hours.  (12) 
Voluminous  dressings,  including  binding  of  arm  to  chest,  are  used. 

Comment. — Whatever  muscle  tissue  has  been  divided  and  not  subse- 
quently removed,  should  be  repaired  by  chromic  catgut  suturing  at  the  end 
of  the  operation.  If  indicated,  the  upper  secondary  incision  may  be  con- 
tinued above  the  clavicle  and  the  supraclavicular  glands  removed  from  the 
posterior  cervical  triangle. 

ORDINARY  EXCISION  OF  MAMMARY  GLAND 

BY  ELLIPTICAL  INCISION. 

Description. — Breast  is  circumscribed  by  an  elliptical  incision,  with  a 
straight  continuation  outward  to  the  center  of  the  axilla,  and  another  straight 


Fig.  555. — Excisions  of  the  Mammary  Gland:— A,  Excision  of  the  breast  by  the  ordinary 
elliptical  incision,  the  upper  end  of  the  ellipse  being  extended  into  the  axilla;  B,  Excision  of  the 
breast  subcutaneously,  by  an  inferior  curved  incision. 


incision  continued  downward  toward  the  sternum.  Mamma  is  simply  dis- 
sected from  pectoralis  major  muscle.  Axilla  is  not  invaded  unless  glands  are 
felt  through  upper  end  of  wound,  and,  if  so,  these  glands  are  removed  by 
blunt  dissection  through  a  limited  exposure  of  axilla. 

Preparation. — Same  as  for  Radical  Excision  (page  741); 


746  OPERATIONS    UPON    THE    THORAX. 

Position. — Same  as  for  Radical  Excision  (q.  v.).  Or  patient's  hand  may 
be  placed  behind  nape  of  neck.  Surgeon  may  stand  on  side  of  operation, 
cutting  from  above  downward  on  right,  and  from  below  upward  on  left;  or 
may  stand  on  right  side  for  either  breast,  leaning  over  thorax  and  cutting 
from  above  downward  when  operating  on  left  side. 

Landmarks. — Same  as  for  Radical  Excision  (q.  v.). 

Incision. — An  elliptical  incision  is  made,  with  its  long  axis  parallel  with 
anterior  axillary  fold  (with  arm  in  above  position) ;  its  center  corresponding 
with  nipple;  its  width  regulated  by  size  of  breast  (or  tumor);  its  upper  and 
lower  angles  being  just  beyond  the  mamma.  The  ellipse  itself  does  not 
extend  the  full  length  of  the  incision.  From  the  upper  angle  of  the  ellipse 
a  straight  incision  is  carried  up  to  opposite  the  center  of  the  axilla.  From 
the  lower  angle  of  the  ellipse  another  straight  incision  is  also  carried  down- 
ward a  short  distance  below  the  breast.     (See  Fig.  555,  A.) 

Operation. — (1)  Keeping  parts  tense  by  left  hand,  the  full  length  of  the 
incision,  including  upper  curve  of  ellipse,  is  completed  at  one  stroke.  The 
lower  curve  of  the  ellipse  is  made  with  a  second  stroke  of  the  knife,  joining 
the  straight  portions  of  the  first  incision  at  upper  and  outer  and  at  lower  and 
inner  circumference  of  breast,  respectively.  Incise  through  skin  and  super- 
ficial connective  tissue  throughout.  (2)  Having  clamped  bleeding  vessels, 
the  incision  is  carried  down  to  pectoral  muscle  along  upper  line  of  ellipse, 
while  skin  above  is  drawn  upward  by  assistant  and  breast  downward  by 
surgeon's  left  hand,  the  incision  passing  well  above  the  upper  limit  of  the 
breast.  (3)  Drawing  breast  away  from  thoracic  wall,  surgeon  frees  it  from 
pectoralis  major,  beginning  along  the  upper  line.  (4)  Assistant  now  draws 
breast  upward,  and  surgeon,  retracting  skin  downward  with  left  hand,  cuts 
down  to  thoracic  muscles  along  lower  line  of  ellipse,  the  incision  passing 
well  below  the  lower  limit  of  the  breast.  (5)  While  under  traction,  the  con- 
nective tissue  of  breast  to  thorax  is  now  severed  toward  its  axillary  aspect, 
together  with  the  vascular  connections,  which  are  the  last  cut,  and  the  breast 
thus  freed  from  chest.  All  vessels  cut  are  at  once  clamped,  and  clamped  in 
advance  of  section,  where  possible.  The  pectoralis  major  is  left  bare.  (6) 
Right  index-finger  is  inserted  into  axilla  through  upper  end  of  wound  and 
enlarged  glands  felt  for.  If  none  be  found,  axilla  is  not  opened  up  further. 
(7)  If  enlarged  axillary  glands  be  felt,  the  incision  is  continued  upward  into 
armpit,  the  axillary  space  exposed,  and  the  glands  removed  with  as  little 
disturbance  and  damage  to  neighboring  tissues  as  possible,  and  generally  by 
blunt  dissection.  (8)  Margins  of  wound,  even  the  elliptical  portion,  are 
generally  capable  of  being  brought  into  apposition,  and  are  sutured 
throughout.  (9)  If  temporary  drainage  be  indicated,  it  is  provided  for 
at  the  lower  angle  of  wound.  Abundant  dressing  is  applied  and  arm 
bound  to  side. 

Comment. — Where  breast  is  involved  by  small  innocent  tumor,  merely 
the  elliptical  portion  of  the  above  incision  is  used,  the  straight  portions  ex- 
tending above  into  axilla  and  below  toward  sternum  being  omitted. 

SUBCUTANEOUS  EXCISION  OF  MAMMARY  GLAND 

BY  INFERIOR  CURVED  INCISION. 

Description. — Through  a  curved  incision  made  in  the  inferior  mammary 
fold,  the  breast  is  turned  upward  and  dissected  (enucleated)  in  whole  or  in 
part  from  out  of  its  overlying  capsule  of  skin  and  fascia,  generally  leaving 
the  nipple  intact.  Indicated  in  non-malignant  conditions  for  partial  or  com- 
plete removal  of  the  mamma. 


GENERAL    SURGICAL    CONSIDERATIONS.  747 

Preparation — Position. — Same  as  for  Radical  Excision. 

Landmarks. — Inferior  mammary  fold  (at  junction  of  lower  circumference 
of  breast  with  chest-wall). 

Incision. — -Curved  incision  passing  around  beneath  the  lower  margin  of 
breast  in  the  mammary  fold,  extending  sufficiently  far  up  on  either  side  to 
enable  breast  to  be  turned  upward  and  backward.     (See  Fig.  555,  B.) 

Operation. — Incise  through  skin  and  fascia  down  to  pectoral  fascia. 
Having  gotten  between  the  deep  layer  of  the  superficial  pectoral  fascia  and 
the  sheath  of  the  pectoralis  major,  the  breast  is  readily  detached  by  blunt 
dissection  and  turned  upward  and  outward — and  then  freed  from  its  cutaneo- 
areolar  covering  from  behind  forward.  The  nipple  is  left,  if  possible,  to 
lessen  disfigurement.  All  bleeding  vessels  are  ligated  with  gut.  The  remain- 
ing portion  of  the  breast,  if  any,  is  returned  to  its  normal  site  (otherwise  the 
cutaneo-areolar  capsule  of  the  enucleated  breast  is  turned  back  into  place) 
and  the  margins  of  the  wound  are  carefully  sutured  to  avoid  scarring.  No 
drainage  is  used.     A  snug  dressing  is  applied,  to  obliterate  dead  spaces. 


III.    THE  SUPERIOR  MEDIASTINUM. 
SURGICAL  ANATOMY. 

Description. — The  mediastinum  is  the  region  of  the  thoracic  cavity  be- 
tween the  pleura?  laterally,  and  the  thoracic  walls  anteriorly  and  posteriorly. 
That  portion  above  the  upper  level  of  the  heart  is  the  superior  mediastinum. 
That  portion  below  the  upper  level  of  the  heart  is  divided  into  anterior, 
middle,  and  posterior  mediastina,  the  anterior  being  in  front  of  the  heart,  the 
posterior  behind  the  heart,  and  the  middle  enclosing  the  heart. 

Boundaries  of  Superior  Mediastinum. — Anteriorly,  manubrium  sterni. 
Posteriorlv;  bodies  of  first,  second,  third,  and  fourth  dorsal  vertebrae.  Later- 
allv;  pleura\  Superiorly;  upper  opening  of  thorax.  Interiorly;  plane  passing 
horizontally  backward  from  manubrio-gladiolar  junction  to  lower  portion  of 
body  of  fourth  dorsal  vertebra — nearly  coinciding  with  upper  portion  of 
pericardium. 

Contents  of  Superior  Mediastinum. — Origins  of  sternohyoid  and 
sternothyroid,  and  lower  ends  of  longi  colli  muscles;  transverse  arch  of  aorta; 
innominate,  thyroidea  ima,  left  carotid,  and  left  subclavian  arteries;  in- 
nominate, superior  vena  cava,  and  left  superior  intercostal  veins;  pneumo- 
gastric,  left  recurrent  laryngeal,  phrenic,  and  cardiac  nerves;  trachea;  esopha- 
gus; thoracic  duct;  thymus  gland,  or  its  remains;  bronchial  lymphatic  glands; 
superior  sterno-pericardiac  ligaments. 

SURFACE  FORM  AND  LANDMARKS. 
The   planes   limiting   the   upper  and   lower   boundaries   of  the   superior 
mediastinum  are,  respectively,  those  corresponding  with  the  upper  opening 
of  the  thorax  above,  and  the  junction  of  the  manubrium  and  gladiolus  below. 


GENERAL  SURGICAL  CONSIDERATIONS. 

The  superior  mediastinum  (as  well  as  the  anterior  and  middle  mediastina) 
is  exposed  in  the  operation  of  anterior  mediastinal  thoracotomy  (page  748). 
It  is  also  exposed  in  the  operations  upon  the  innominate  artery,  in  excisions 
of  the  sterno-clavicular  articulation  and  of  the  manubrium. 


748  OPERATIONS    UPON    THE   THORAX. 

IV.   THE  ANTERIOR  MEDIASTINUM. 
SURGICAL  ANATOMY. 

Boundaries. — Anteriorly;  all  of  gladiolus  sterni,  with  parts  of  left 
fourth,  fifth,  sixth,  and  seventh  costal  cartilages.  Posteriorly;  pericardium. 
Laterally;  pleurae. 

Contents. — Origin  of  triangularis  sterni  muscle;  areolar  tissue;  lymphatic 
vessels  and  glands  (anterior  mediastinal  glands)  ;  thymus  gland  (or  its  remains)  ; 
inferior  sterno-pericardiac  ligaments. 

ANTERIOR  MEDIASTINAL  THORACOTOMY 

BY  LONG  MEDIAN  INCISION —  MILTON'S  OSTEOPLASTIC  ANTERIOR 
MEDIASTINOTOMY. 

Description. — Exposure  of  the  superior,  anterior,  and  middle  mediastina 
through  a  temporary  longitudinal  division  of  the  sternum  in  the  median 
line.  (The  posterior  mediastinum  may  also  be  reached,  in  part,  by  this 
incision,  but  is  better  approached  by  a  separate  operation.)  Resorted  to  for 
gaining  very  free  access  to  the  entire  contents  of  the  mediastina  mentioned, 
especially  for  the  removal  of  anterior  mediastinal  growths  and  pus, — the 
esophagus,  trachea,  and  bronchi  being  more  readily  reached  and  treated  from 
behind  (Posterior  Mediastinotomy). 

Preparation. — Beard  and  presternal  hair  shaved,  if  necessary. 

Position. — Patient  supine,  shoulders  elevated,  head  supported,  neck 
prominent — Surgeon  to  right — Assistant  opposite. 

Landmarks. — Median  line  of  neck  and  sternum;  thyroid  cartilage; 
ensiform  cartilage. 

Incision. — From  lower  part  of  thyroid  cartilage  to  base  of  ensiform 
cartilage,  made  in  median  line  of  neck  and  sternum.  (The  cervical  portion 
of  the  incision  is  to  give  room  for  the  lateral  retraction  of  the  split  sternum.) 
(See  Fig.  556,  A.) 

Operation. — (1)  Incise  through  the  skin  and  superficial  connective  tis- 
sue along  the  neck — and  down  to  the  bone  over  the  full  length  of  the  sternum. 
Clamp  or  ligate  superficial  vessels.  (2)  Deepen  the  cervical  incision  by  re- 
tracting the  sternohyoid  and  sternothyroid  muscles  and  dividing  the  deep 
cervical  fascia,  controlling  all  vessels  encountered.  The  trachea  is  thus 
exposed  from  the  thyroid  cartilage  to  the  episternal  notch,  except  that  the 
isthmus  of  the  thyroid  gland  is  not  divided.  If  necessary,  it  may  be  divided 
between  two  ligatures.  Expose  the  episternal  notch  by  separating  the  fascia 
from  it  outward  on  either  side  to  the  origins  of  the  sternomastoids.  (3)  Free 
the  posterior  surface  of  the  manubrium  sterni  downward  as  far  as  possible, 
by  means  of  curved  periosteal  elevator  and  finger,  depressing  the  important 
structures  downward.  The  more  nearly  this  is  done  subperiosteally,  the 
greater  the  protection  to  the  soft  parts  adjacent.  (4)  By  means  of  a  thin, 
special  saw,  divide  the  sternum  longitudinally  in  the  median  line,  from  above 
downward — dividing  it  through  its  entire  thickness  above,  where  the  saw- 
teeth can  be  protected  by  a  thin  metallic  guide  or  spatula  slipped  behind  the 
upper  portion  of  the  sternum — but  dividing  it  elsewhere,  at  first,  very  nearly 
but  not  quite  through,  and  not  extending  the  division  below  the  base  of  the 
ensiform  cartilage.  (5)  Detach  the  ensiform  cartilage  from  the  gladiolus  by 
stout,  curved,  blunt  scissors  or  bone-forceps,  avoiding  the  neighboring  struc- 
tures of  importance,  especially  the  peritoneum.  (6)  Grasp  the  margins  of 
the  sawed  sternum  on  both  sides  by  means  of  broad  retractors  with  teeth— 
and  steadily  and  carefully  draw  the  divided  bones  apart  by  outward  and 


ANTERIOR    MEDIASTINAL    THORACOTOMY. 


749 


slight  upward  traction.  Draw  the  ensiform  cartilage  downward.  Pass  a 
director  or  thin  spatula  upward,  inserting  it  between  the  lower  end  of  the 
gladiolus  and  the  disconnected  ensiform  cartilage,  hugging  the  posterior 
surface  of  the  lower  portion  of  the  gladiolus — and,  upon  this  protector,  com- 
plete the  division  of  the  lower  part  of  the  gladiolus  by  means  of  the  special 
saw  or  bone-cutting  forceps,  working  from  below  upward.  (7)  The  bony- 
division  having  been  completed,  additional  traction  is  made  upon  the  divided 
edges  of  the  sternum,  the  separation  being  started  by  prizing  the  split  sides 
of  the  sternum  asunder  with  some  stout,  blunt  instrument — detaching  by 


Fit;.  556. — Incisions  for  Exposing  the  Mediastina: — A,  A,  Milton's  anterior  mediastinal 
thoracotomy  for  exposing  superior,  anterior,  and  middle  mediastina;  B,  Incision  for  thoraco- 
plasty flap  exposing  anterior  and  middle  mediastina  (corresponding  with  sternum  and  third, 
fourth,  and  fifth  costal  cartilages);  C,  C,  Incision  for  vertical  thoracoplastic  flap  exposing  superior 
mediastinum  (corresponding  with  manubrium  and  first  and  second  costal  cartilages);  D,  D, 
Incision  for  horizontal  thoracoplastic  flap  exposing  superior  mediastinum  (corresponding  with 
manubrium  and  first  and  second  costal  cartilages).     (Thorax  modified  from  Spalteholz.) 

blunt  dissection  all  binding  tissues,  or  dividing  them  with  scissors,  as  soon 
as  revealed  by  the  gradual  separation  of  the  parts,  and,  where  necessary, 
taking  renewed  holds  upon  the  edges  of  bone  with  the  retractors,  as  the  gap 
increases.  (8)  An  interval  of  between  5  and  8  cm.  (about  2  to  3  inches)  is 
thus  ordinarily  attainable.  Through  this  opening  the  contents  of  the  superior, 
anterior,  and  middle  mediastina  are  readily  reached — and  even  the  posterior 
mediastinum  may  also,  though  of  course  less  easily,  be  thus  reached  on  the 
right  side,  after  separating  the  pericardium  and  pleura.  The  further  steps 
of  the  operation  will  depend  upon  the  object  for  which  performed — but,  in 
any  case,  should  be  carried  on  with  exceptional  care,  owing  to  the  unusually 
important  nature  of  the  parts  involved,  and  should  be  done  chiefly  by  means 


75°  OPERATIONS    UPON    THE    THORAX. 

of  blunt  dissection.  (9)  At  the  close  of  the  operation,  the  edges  of  the  sternum 
are  approximated  by  four  to  six  silver-wire  sutures  passed  through  drill-holes 
■ — gauze  or  other  drainage  having  been  temporarily  introduced  behind  the 
sternal  notch  and  below  the  lower  end  of  the  gladiolus — and  the  skin  wound 
closed  except  opposite  the  drainages. 

Comment. — The  pleura  and  peritoneum  are  both  in  great  danger  of 
injury — wounds  of  these  should  be  immediately  closed  by  circular  ligation 
of  their  mouth,  if  small;  and  by  suture,  if  large. 

The  principal  tissues  which  interfere  with  the  separation  of  the  parts  are 
those  about  the  left  innominate  vein,  crossing  behind  the  manubrium  sterni, 
in  the  line  of  the  division,  above;  and  about  the  ensiform  cartilage  below. 

Especial  care  is  necessary  as  to  respiration,  due  to  collapse  of  lungs,  and 
a  Fell-O'Dwyer  instrument  should  have  been  provided  previously  for  main- 
taining artificial  respiration.  Costal  breathing  ceases  with  division  and 
separation  of  the  sternum,  though  the  lungs  may  not  collapse  on  that  account 
alone.  In  special  cases  where  dyspnoea  may  be  anticipated,  a  preliminary 
tracheotomy  is  sometimes  done. 

ANTERIOR  MEDIASTINAL  THORACOTOMY 

BY  OSTEOPLASTIC  RESECTION  OF    PART  OF   STERNUM  CORRESPONDING  WITH 
THIRD,  FOURTH,  AND  FIFTH  COSTAL   CARTILAGES. 

Description. — The  anterior  mediastinum,  and  also  the  middle  medias- 
tinum, may  be  exposed  by  the  osteoplastic  resection  of  that  portion  of  the 
sternum  corresponding  with  the  third,  fourth,  and  fifth  costal  cartilages — 
which  portion  is  temporarily  turned  back,  exposing  a  large  part  of  the  anterior 
and  middle  mediastina  and  their  contents.  This  operation  is  less  extensive 
and  severe  than  Milton's,  and  is  indicated  where  a  more  limited  exposure 
will  suffice — especially  for  the  removal  of  glands,  small  growths,  evacuation 
of  pus;  and  for  the  exposure  of  the  heart  and  pericardium  in  the  treatment 
of  wounds  and  evacuation  of  pus. 

Preparation. — Chest-wall  shaved,  if  necessary. 

Position. — Patient  supine,  chest  elevated  and  resting  upon  some  object 
which  will  render  the  anterior  thoracic  aspect  prominent.  Surgeon  on  left. 
Assistant  opposite. 

Landmarks. — Gladiolus  sterni,  between  chondro-sternal  articulations  of 
third,  fourth,  and  fifth  costal  cartilages;  line  of  internal  mammary  artery 
(see  page  57). 

Incision. — (1)  Upper  transverse  incision  passes  on  a  level  with  the  upper 
border  of  third  costal  cartilages,  not  extending  more  than  1.2  cm.  (about 
\  inch)  beyond  either  sternal  border  (to  avoid  the  internal  mammary  artery). 
(2)  The  lower  transverse  incision  passes  similarly  on  a  level  with  the  lower 
border  of  the  fifth  costal  cartilages,  between  points  about  1.2  cm.  (about 
\  inch)  beyond  the  sternal  borders.  (3)  The  vertical  incision  joins  the  left 
ends  of  the  two  transverse  incisions,  passing  flown  between  the  left  internal 
mammary  artery  and  the  left  margin  of  the  sternum.  These  incisions  outline 
three  sides  of  a  square,  having  the  hinge  of  the  flap  at  the  right  margin  of  the 
sternum.     (See  Fig.  556,  B.) 

Operation. — (1)  Incise  through  skin,  fascia,  and  fibers  of  the  pectoralis 
major,  down  to  the  sternum  and  intercostal  membranes,  using  care  over  the 
intercostal  spaces  that  the  knife  does  not  penetrate  the  thorax.  Clamp  and 
ligate  the  superficial  vessels  cut  along  the  lines  of  incision — but  do  not  separate 
the  skin  and  fascia  from  the  sternum.  (See  Fig.  557.)  (2)  The  costal 
cartilages  are  well  exposed  where  the  vertical  incision  crosses  them  and  are 
divided  with  blunt-pointed  cartilage-pliers  with  great  care,  to  avoid  injury 


ANTERIOR    MEDIASTINAL    THORACOTOMY 


751 


to  pleura  and  pericardium.  This  having  been  dune,  the  left  margin  of  the 
sternum,  thus  freed  of  its  third,  fourth,  and  fifth  cartilages,  is  now  drawn 
slightly  forward  with  toothed  retractor,  and,  while  held  in  this  position,  the 
posterior  surface  of  that  portion  of  the  sternum  is  freed  of  triangularis  sterni 
muscle  and  connective  tissue  by  means  of  a  slightly  curved  periosteal  elevator. 
(3)  The  sternum  is  now  divided  where  the  upper  and  lower  transverse  inci- 
sions cross  it — and  this  is  best  accomplished,  in  those  cases  where  it  has  been 
possible  to  clear  the  posterior  surface  of  the  sternum  entirely  across  to  the 
opposite  border,  by  means  of  a  Gigli  saw  conducted  beneath  the  sternum, 
with  which  the  section  is  readily  made.  In  other  cases  the  section  may  be 
made  (though  with  less  neatness  and  precision  and  more  danger)  by  means 
of  stout,  curved,  blunt-pointed,  bone-cutting  pliers,  the  lower  blade  hugging 
the  sternum  closely.     (4)  This  section  of  the  sternum  having  been  freed  upon 


Fig. 557.— Anterior  Mediastinal  Thoracotomy,  by  an  Osteoplastic  Flap  Consisting  of 
Soft  Parts  and  Sternum  Corresponding  with  Third,  Fourth,  and  Fifth  Costal  Carti- 
lages :— A,  Osteoplastic  flap  turned  to  left  :  B.  Pectoralis  major  muscle  ;  C,  C,  Intercostal  arteries  ;  D, 
Costal  cartilage  divided  by  instrument;  I£.  Costal  cartilage  partly  broken  in  hinging  back  the  flap; 
F,  F,  Drill-holes;  ("».  Triangularis  sterni  muscle;  H.  H.  Lungs  and  pleura;,  the  latter  extending 
further  toward  the  middle  line;  I,  Heart  and  pericardium. 


three  of  its  sides,  its  posterior  surface  having  been  cleared,  and  with  the  soft 
parts  still  adherent  to  its  anterior  surface,  it  is  now  to  be  partly  turned,  parti} 
broken  back  upon  the  structures  along  its  right  margin,  as  upon  a  hinge,  the 
costal  cartilages  generally  snapping  in  part  or  entirely,  though  sometimes 
bending.  (5)  The  anterior  mediastinum,  and  also  the  middle  mediastinum 
(although  of  course  less  fully),  are  now  exposed — and  their  contained  struc- 
tures may  be  reached  by  gentle  manipulation  and  blunt  dissection — and  the 
special  object  of  the  operation  accomplished.  (6)  At  the  close  of  the  opera- 
tion, the  osteoplastic  flap  is  turned  back  into  place.  It  is  well  to  drill  holes 
(two  above  and  two  below)  for  chromic  gut  ligatures,  or  silver  wire,  along 
the  upper  and  lower  transverse  divisions  of  the  sternum,  before  replacing  the 
flap  (holding  the  detached  piece  of  sternum  with  strong  bone  forceps  while 
drilling;  and  protecting  the  inferior  surfaces  of  the  margins  of  the  upper  and 
lower  intact  pieces) — and  tightening  the  sutures  when  the  piece  is  in  place. 
If  thought  necessary,  the  costal  cartilages  may  be  similarly  drilled  and  tied 
on  either  side  of  the  line  of  section.  (7)  Temporary  drainage  should  be  pro 
vided — which    may  be  done   by  excising  a  small  portion  of  one  of  the  costal 


752  OPERATIONS    UPON    THE    THORAX. 

cartilages  at  its  articulation  with  the  sternum,  as  well  as  a  limited  portion 
of  the  margin  of  the  sternum  at  that  point,  in  the  form  of  a  semicircle.  The 
skin-portion  of  the  osteoplastic  flap  is  sutured  throughout  most  of  its  extent, 
leaving  an  opening  for  drainage. 

Comment. — Instead  of  the  above  window  opening  laterally  upon  a 
vertical  hinge,  one  may  be  (though  less  easily)  formed  opening  upward  or 
downward  upon  a  transverse  hinge  across  the  sternum,  by  making  two  vertical 
incisions  just  outside  of  the  borders  of  the  sternum  and  the  transverse  incision 
on  a  level  with  the  lower  border  of  the  fifth  costal  cartilage  (where  the  hinge 
is  to  be  above). 

The  window  may  be  placed  higher  or  lower  than  indicated  in  the  above 
operation. 

OTHER  OPERATIONS  UPON  THE  ANTERIOR  MEDIASTINUM. 

See  all  operations  upon  the  Heart  and  Pericardium — which,  lying  in  the 
middle  mediastinum,  are  reached  through  the  anterior  mediastinum, 

V.   THE  MIDDLE  MEDIASTINUM. 
SURGICAL  ANATOMY. 
Boundaries. — Anteriorly;    limits    of    anterior    mediastinum.      Poste- 
riorly; limits  of  posterior  mediastinum.     Laterally;  pleura'. 

Contents. — Heart  and  pericardium;  ascending  aorta;  pulmonary  artery 
and  its  two  branches;  arteries  of  the  phrenic  nerves;  superior  vena  cava; 
right  and  left  pulmonary  veins;  vena  azygos  major;  phrenic  nerves;  roots  of 
lungs;  bifurcation  of  trachea;  two  bronchi;  bronchial  lymphatic  glands. 

OPERATIONS  UPON  THE  MIDDLE  MEDIASTINUM. 

For  operations  upon  the  Middle  Mediastinum,  see  operations  upon  the 
Pericardium  and  Heart  (pages  780  and  785). 

For  other  operations  exposing  the  Middle  Mediastinum,  see  operations 
upon  the  Anterior  Mediastinum  (pages  748  to  752). 

For  operations  upon  the  thoracic  esophagus  and  trachea  and  upon  the 
bronchi,  see  Posterior  Mediastinal  Thoracotomy  (page  752) — the  first  being 
in  the  Posterior  Mediastinum — the  last  two  in  the  Middle  Mediastinum, 
but  best  reached  through  the  Posterior  Mediastinum. 

VI.   THE  POSTERIOR  MEDIASTINUM. 
SURGICAL  ANATOMY. 

Boundaries. — Anteriorly;  pericardium;  roots  of  lungs.  Posteriorly; 
vertebral  column  (below  inferior  border  of  fourth  dorsal  vertebra) .  Laterally ; 
pleura?. 

Contents. — Descending  aorta;  greater  and  lesser  azygos  veins;  pneumo- 
gastric  nerves;  splanchnic  nerves;  esophagus;  thoracic  duct;  posterior  medias- 
tinal lymphatic  glands. 

POSTERIOR  MEDIASTINAL  THORACOTOMY 

BV  THORACOPLASTY  FLAP  —  BRYANT'S  OPERATION. 

Description. — Exposure  of  the  posterior  mediastinum  by  means  of  an 
osteoplastic  flap  about  8  to  10  cm.  (about  3  to  4  inches)  square,  and  generally 
including  the  width  of  three  ribs  raised  over  the  site  of  the  operation — part 
of  the  central  rib  being  permanently  sacrificed  from  angle  to  outer  end  of 


POSTERIOR    MEDIASTINAL    THORACOTOMY.  753 

transverse  process,  and  similar  parts  of  the  other  two  returned.  Usually 
performed  for  the  removal  of  foreign  bodies  in  the  esophagus,  trachea,  and 
bronchi,  and  for  the  evacuation  of  pus.  Some  of  the  more  posterior  contents 
of  the  middle  mediastinum  are  thus  also  accessible  from  this  opening. 

Position. — Patient  partially  upon  side  and  chest,  with  the  side  of  opera- 
tion uppermost,  and  resting  upon  some  object  in  order  to  increase  the  width 
of  the  intercostal  intervals  at  the  site  of  operation.  The  scapula  is  drawn 
forward  to  increase  the  interval  between  the  vertebrae  and  the  vertebral  bor- 
der of  the  scapula.     Surgeon  on  side  of  operation.     Assistant  opposite. 

Landmarks. — Position  of  upper  ribs;  spinous  processes  of  upper  dorsal 
vertebra^  with  corresponding  ribs;  vertebral  border  of  scapula;  root  of  spine 
of  scapula  (which  generally  corresponds  to  the  interspace  between  third  and 


Fig.  558. — Operations  upon  the  Thoracic  Cavity: — A,  Posterior  mediastinal  thora- 
cotomy, by  thoracoplastic  flap;  B,  Position  for  paracentesis  thoracis  in  the  eighth  intercostal 
space  in  the  line  of  the  inferior  angle  of  the  scapula.  (Thorax  modified  from  Bardeleben, 
Haeckel,  and  Frohse.) 

fourth  dorsal  spines).  The  site  of  the  operation  is  determined  by  the  posi- 
tion of  the  foreign  body  to  be  removed.  Parts  of  three  ribs  are  generally  in- 
cluded in  the  operation,  the  central  one  being  at  the  center  of  the  field.  Some- 
what readier  access  is  gotten  to  the  esophagus  from  the  left  side,  though  at  the 
level  of  the  usual  operation  the  esophagus  is  practically  in  the  middle  line.  The 
trachea  usually  bifurcates  opposite  the  fourth  dorsal  vertebra  (sometimes  the 
fifth).  Where  the  site  of  the  operation  cannot  be  previously  determined,  the 
left  fourth,  fifth,  and  sixth  ribs  are  generally  chosen. 

Incision. — In  the  form  of  three  sides  of  approximately  a  three-inch 
square — the  fourth  side  being  represented  by  the  spinous  processes  of  the 
vertebrae.  This  area  is  so  placed  as  to  have  its  center  over  the  central  one 
of  the  three  ribs  to  be  removed — the  upper  and  lower  parallel  incisions  passing 
above  and  below  the  other  two  ribs  respectively.     (See  Fig.  558,  A.) 

Operation. — (i)  Incise  the  three  sides  of  the  outline  indicated  above, 
through  skin,  fascia,  and  muscles  down  to  the  ribs,  carefully  avoiding  pene- 
48 


754 


OPERATIONS  UPON  THE  THORAX. 


trating  the  intercostal  spaces.  Clamp  all  cut  vessels.  Free  up  the  thick 
flap  of  soft  parts  from  the  ribs  and  turn  it  over  the  spinous  processes  to  the 
opposite  side.  Ligate  the  previously  clamped  vessels,  and  others  as  exposed. 
(See  Fig.  559.)  (2)  Make  a  longitudinal  incision  over  the  center  of  the  outer 
aspect  of  the  central  one  of  the  three  ribs,  through  the  periosteum,  from  the 
outer  end  of  the  transverse  process  of  the  vertebra  to  the  angle  of  the  rib — 
free  it  subperiosteal!}-  with  curved  periosteotome  (or  by  a  piece  of  silk  con- 
ducted between  bone  and  periosteum) — pass  a  Gigli  saw  between  rib  and 
periosteum,  guarding  the  pleura,  and  remove  the  portion  of  rib  above  indi- 
cated, and  discard.  (3)  The  inner  and  outer  ends  of  the  exposed  portions 
of  the  upper  and  lower  ribs  are  now  similarly  exposed  subperiosteallv,  without 


Fig. 559.— Posterior  Mediastinal  Thoracotomy,  by  Thoracoplasty  Flap: — A,  Skin  and 
muscle  flap  turned  horizontally  backward  ;  B.  Flap  of  part  of  fourth  rib  and  intercostal  muscles 
turned  upward  ;  C,  Flap  of  part  of  sixth  rib  and  intercostal  muscles  turned  downward  ;  D,  D,  Verte- 
bral ends  of  fourth  and  sixth  ribs,  drilled  forwiring  ;  E,  Intercostal  artery,  vein,  and  nerve  ;  F,  F,  F 
Fourth,  fifth,  and  sixth  dorsal  nerves  exposed  and  retracted  ;  G,  Pleura  and  lung  ;  H,  Broad  retractor 
displacing  pleura  and  lung;  I,  Thoracic  aorta;  J,  Left  bronchus;  K,  Esophagus  protruded  into 
wound  by  sound  introduced  through  mouth.  The  operations  of  Bronchotomy  and  Thoracic  Esopha- 
gotomy  are  shown  at  J  and  K,  respectively.  The  pulmonary  and  bronchial  vessels  are  omitted,  for 
clearness. 

freeing  the  intervening  portions  more  than  can  be  helped,  and  especially 
without  isolating  the  upper  rib  from  its  upper  attachment  and  the  lower  rib 
from  its  lower  attachment.  Two  holes  are  drilled  at  either  end  of  the  yet 
undivided  ribs  for  future  wiring.  Both  ribs  are  then  divided  between  the 
pairs  of  drilled  holes,  by  means  of  a  Gigli  saw.  (4)  The  intercostal  arteries 
in  the  field  are  now  ligated  at  the  inner  and  outer  side  of  the  wound.  The 
intercostal  nerves  are  carefully  retracted  throughout  the  operation,  it  being 


SURGICAL    ANATOMY    OF    THE    DIAPHRAGM.  755 

unnecessary  to  divide  them.  The  periosteum  forming  the  bed  of  the  central 
rib  is  now  very  carefully  divided  lengthwise  of  its  course.  Through  this 
opening  the  pleura  is  carefully  detached  and  is  further  separated  by  the 
finger  from  the  muscular  and  bony  wall  of  the  thorax  corresponding  to  the 
extent  of  the  wound,  the  separation  being  accomplished  during  expiration. 
At  either  side  of  the  wound,  in  line  with  the  divided  ribs,  the  remaining 
chest-wall  is  divided  while  the  pleura  beneath  is  carefully  guarded  by  an 
instrument  or  the  finger.  These  two  vertical  incisions  last  made,  crossing 
the  transverse  one  through  the  bed  of  the  middle  rib's  periosteum,  make, 
by  an  H-shaped  incision,  two  small  flaps — the  upper  one,  containing  the 
upper  rib  as  extensively  adherent  as  possible  (for  nutrition),  is  now  turned 
upward  upon  its  hinge  of  soft  parts — and  the  lower  one,  with  the  lower  rib 
similarly  attached,  is  turned  downward  in  like  fashion — care  being  taken  not 
to  injure  the  intercostal  vessels  and  soft  tissues  above  the  upper  rib,  nor  below 
the  lower  rib.  (5)  The  posterior  mediastinum  is  thus  exposed — and  its 
contents,  as  well  as  some  of  the  more  posteriorly  situated  contents  of  the 
middle  mediastinum,  are  accessible  after  careful  separation  of  important 
structures  by  means  of  blunt  dissection,  instrumental  retraction,  and  the  use 
of  the  fingers.  The  pleura,  especially,  is  carefully  pushed  externally  out  of 
the  way  and  so  guarded  as  to  avoid  opening  it.  The  trachea,  bronchi,  and 
esophagus  may  be  both  felt  and  seen.  The  important  vessels  of  the  posterior 
and  middle  mediastinum  (see  Surgical  Anatomy)  are  to  be  carefully  guarded. 
When  trachea,  bronchi,  or  esophagus  are  to  be  opened,  thev  are  incised, 
after  being  steadied  with  toothed  forceps,  in  their  longitudinal  axis — and 
subsequently  not  sutured — but  the  wound  packed  down  to  the  incised  tube, 
for  the  escape  of  all  drainage  through  a  drainage-tube  placed  in  the  center 
of  the  gauze  packing.  (6)  In  completing  the  operation,  the  middle  one  of 
the  three  ribs  is  not  replaced — the  upper  and  lower  ribs  are  turned  back  into 
place  and  wired  (or  sutured  with  chromic  gut)  through  the  previouslv  drilled 
holes.  The  drainage  will  pass  out  of  chest  through  the  incision  in  the  bed 
of  the  middle  rib — and  will  escape  externally  through  a  convenient  opening 
left  beneath  the  skin  and  muscle  flap  which  is  only  partially  stitched  into 
place. 

Comment. — (1)  The  scapula  should  be  displaced  forward  out  of  the  way, 
and  so  held  by  an  assistant.  (2)  It  might  be  better  to  plan  the  skin  incision 
on  a  somewhat  larger  scale  (say  2.5  cm.,  or  about  1  inch,  larger)  so  that  the 
skin  suture-line  would  not  directly  coincide  with  the  bone-sections.  (3)  All 
bleeding  should  be  controlled  as  encountered — first  by  clamp,  then  by  liga- 
ture. (4)  The  pleura  is  to  be  widely  separated  around  the  margin  of  the 
opening  by  the  finger — to  enable  freer  displacement  of  the  mediastinal  con- 
tents. (5)  Below  the  arch  of  the  aorta  the  esophagus  is  more  readily  reached 
from  the  right — above  the  arch,  it  may  be  reached  from  either  side,  although 
somewhat  better  from  the  left.  (6)  Removal  of  a  body  from  the  esophagus 
below  the  body  of  the  ninth  dorsal  vertebra  is  very  difficult  and  hardly  justi- 
fiable. (7)  The  left  bronchus  is  reached  with  greater  difficulty  and  risk  of 
hemorrhage. 

VII.   THE  DIAPHRAGM. 
SURGICAL  ANATOMY. 

Attachments  of  Diaphragm. — Anterior  (sternal)  part;  inferior  and 
posterior  border  of  ensiform  cartilage;  neighboring  posterior  surface  of  ante- 
rior aponeurosis  of  transversalis  muscle.  Lateral  (costal)  part;  inferior 
border  and  inferior  surface  of  the  cartilages  and  bony  parts  of  the  sixth  or 


756  OPERATIONS  UPON    THE  THORAX. 

seventh  inferior  ribs.  Posterior  (vertebral)  part;  (a)  ligamentum  arcuatum 
externum  (the  thickened  anterior  layer  of  lumbar  fascia  extending  from  tip 
of  transverse  process  of  second  lumbar  vertebra  to  tip  of  twelfth  rib);  (b) 
ligamentum  arcuatum  internum  (the  thickened  iliac  fascia  arching  over  the 
psoas,  from  the  side  of  body  of  second  lumbar  vertebra  to  tip  of  transverse 
process  of  same  vertebra ) .  (c)  right  crus  of  diaphragm  (arising  from  anterior 
surface  of  bodies  of  first  to  third,  or  fourth,  lumbar  vertebra;  from  inter- 
vening fibro-cartilages;  from  anterior  common  ligament);  (d)  left  crus  of 
diaphragm  (arising  from  anterior  surface  of  bodies  of  first  to  second,  or 
third,  lumbar  vertebra;  from  intervening  fibro-cartilages;  from  anterior 
common  ligament).  The  insertion  of  these  various  origins  is  into  the  ante- 
rior, posterior,  and  lateral  aspects  of  the  central  tendon  of  the  diaphragm. 

Structures  in  Relation  with  Diaphragm. — Superiorly  (thoracic 
cavity);  pleura  and  lungs;  pericardium  and  heart.  Inferiorly  (abdominal 
cavity);  peritoneum;  liver;  stomach;  spleen;  pancreas;  kidneys;  suprarenal 
capsules. 

Upper  Limits  of  the  Diaphragm. — Right  Leaflet,  on  level  with  junction 
of  fifth  costal  cartilage  with  sternum  (about  2.5  cm.,  or  1  inch,  below  the 
nipple).  Left  Leaflet,  on  level  with  junction  of  sixth  costal  cartilage  with 
sternum.  Central  Tendon,  about  on  level  with  end  of  sternum,  or  seventh 
ch<  >ndro-sternal  articulation. 

Boundaries  of  Lower  Thoracic  Opening. — See  Thoracic  Wall,  page  731. 

Structures  Passing  through  Floor  of  Thorax  (Diaphragm). — See 
Thoracic  Wall,  page  731. 

Other  Relations  of  Diaphragm. — (a)  The  fibers  of  diaphragm  are 
absent  or  deficient  in  the  interval  between  the  sides  of  the  muscular  strip 
from  ensiform  cartilage  to  cartilages  of  neighboring  ribs — areolar  tissue 
occupies  this  position,  covered  above  by  pleura,  and  below  by  peritoneum. 

(b)  The  central  tendon  of  the  diaphragm  is  blended  with  the  pericardium. 

(c)  After  forced  expiration,  the  right  diaphragmatic  arch  is  on  a  level,  ante- 
riorly with  fourth  costal  cartilage;  laterally,  with  fifth,  sixth,  and  seventh 
ribs;  posteriorly,  with  eighth  rib;  similar  measurements  on  left  generally 
being  from  one  to  two  ribs'  width  lower.  In  forced  inspiration,  there  is  a 
descent  of  from  2.5  to  5  cm.  (about  1  to  2  inches),  (d)  Circumferentially, 
the  diaphragm  is  higher  in  the  median  line,  and  lower  at  the  sides — but  the 
central  tendon  supporting  the  heart  is  lower  than  the  sides,  (e)  For  a  narrow 
interval  around  the  lower  and  posterior  circumference,  the  diaphragm  is  not 
covered  by  pleura,  but  is  in  immediate  contact  with  the  chest-wall,  (f) 
The  costo-phrenic  sinus  is  that  area  over  which  the  parietal  and  visceral 
layers  of  the  pleura  are  in  constant  contact,  whether  in  inspiration  or  ex- 
piration— and  is  represented  by  the  line  of  reflection  of  the  diaphragmatic 
pleura  onto  the  intrathoracic  wall. 


TRANSTHORACIC  EXPOSURE  OF  DIAPHRAGM 

BY  PARTIAL  EXCISION  OF  TWO  OR  THREE   RIBS. 

Description. — The  upper  (thoracic)  surface  of  the  diaphragm  is  exposed 
(at  the  site  of  the  diaphragmatic  lesion)  by  means  of  the  partial  excision  of 
two  or  three  ribs  performed  subperiosteally,  through  a  single  incision  between 
them.  Or  the  site  may  be  exposed  by  turning  back  a  flap  of  overlying  soft 
parts  and  then  excising  the  indicated  parts  of  the  ribs, — or  an  osteo-thoraco- 
plastic  flap  may  be  temporarily  turned  aside  and  replaced  at  the  end  of  the 


TRANSTHORACIC  EXPOSURE  OF  DIAPHRAGM.  757 

operation.  (See  operations  upon  the  pleura  and  heart.)  Having  opened  the 
chest-wall  over  the  area,  the  diaphragm  may  be  approached  in  one  of  several 
ways — below  the  reflection  of  the  pleura, — subpleurally  (after  detaching  and 
pressing  back  the  unopened  pleura), — transpleural!}-  (the  pleura;  being  non- 
adherent),— or  through  adherent  pleural  surfaces.  Indicated  for  the  evacua- 
tion of  pus  in  subphrenic  abscess;  for  the  repair  of  wounds  of  the  diaphragm; 
for  hernia  through  the  diaphragm.  In  subphrenic  abscess,  the  approach  is 
usually  made  by  the  lumbar,  iliac,  or  lateral  thoracic  routes,  in  order  of 
preference — parts  of  the  ninth  and  tenth  ribs  being  incised  in  simple  sub- 
phrenic abscess — and  part  of  the  eighth  if  the  pleura  be  involved.  The  site 
of  the  operation  may  be  on  either  side  and  will  be  determined  by  the  lesion 
and  the  physical  signs.  Generally  from  7.5  to  10  cm.  (about  3  to  4  inches) 
of  the  ninth  and  tenth  ribs,  between  the  anterior  axillary  and  scapular  lines, 


Fig. 560.— Transthoracic  Exposure  of  Diaphragm  through  the  Right  Ninth  Inter- 
costal Space  : — A,  Latissimus  dorsi  muscle  ;  B,  Serratus  magnus  muscle  ;  C,  Obliquus  externus  ab- 
dominis muscle;  D,  D,  Resected  ends  of  ninth  and  tenth  ribs,  the  periosteal  bed  extending  between 
the  exposed  ends,  the  intercostal  vessels  and  nerves  showing  through  the  periosteum  ;  E,  Anterior 
layer  of  periosteum  retracted  and  everted  ;  F,  Posterior  layer  of  periosteum,  together  with  externa] 
and  internal  intercostal  muscles,  retracted  ;  G,  Pleura  displaced  upward  ;  H,  Diaphragm. 

as  indicated,  are  excised  through  a  single  incision  made  between  them,  in  the 
case  of  an  abscess  between  the  liver  and  diaphragm,  which  is  usually  ap- 
proached subpleurally.  Where  the  abscess  is  near  the  dome  of  the  diaphragm, 
the  transpleural  approach  at  a  higher  level  generally  must  be  used.  The 
excision  of  one  or  more  costal  cartilages  in  the  mammary  line  may  suffice. 

For  operations  for  hepatic  abscess  and  empyema,  see  Operations  upon 
the  Liver  and  Pleura. 

Position. — Determined  by  the  lesion — and  will  be  such  as  to  conve- 
nientlv  expose  the  area — in  this  case  in  the  semi-prone  position. 

Landmarks. — Site  of  lesion;  line  of  pleura;  line  of  diaphragm. 

Incision. — In  the  center  of  the  interspace  between  the  ninth  and  tenth 
ribs — the  center  of  the  incision  being  midway  between  the  anterior  axillary 
and  scapular  lines — and  about  13  cm.  (about  5  inches)  in  length,  so  as  to 
provide  for  the  removal  of  about  9  cm.  (about  3^  inches)  of  each  rib. 


758  OPERATIONS  UPON  THE  THORAX. 

Operation. — (i)  Incise  through  skin,  fascia,  and  overlying  thoracic 
muscles,  down  to  the  plane  of  intercostal  muscles,  clamping  all  bleeding 
vessels.  Free  back  the  upper  and  lower  lips  of  the  wound  upon  this  same 
plane,  until  the  ninth  and  tenth  ribs  are  reached  and  exposed  in  their  entire 
width — the  soft  parts  being  retracted  well  above  and  below  their  limits.  (2) 
Subperiosteally  excise  about  9  cm.  (about  3^  inches)  of  each  rib,  in  the  usual 
manner  (see  the  Subperiosteal  Excision  of  the  Ribs,  page  447) — carefully 
guarding  the  parietal  pleura  from  the  slightest  nicking  or  injury  (Fig.  350). 
(3)  Incise  the  intercostal  tissues  longitudinally  in  the  center  of  the  interspace 
between  the  two  excised  ribs.  If  necessary,  the  intercostal  arteries  of  the 
excised  ribs  may  be  ligated  at  both  ends,  though  this  may  be  omitted  generally, 
as  they  are  usually  not  in  the  way  unless  it  be  indicated  to  carry  an  incision 
across  their  course.  Preserve  the  intercostal  nerves  by  retraction.  The  re- 
moval of  these  two  ribs  generally  gives  ample  room  for  exposure  when  the 
upper  and  lower  limits  of  the  wound  are  well  retracted.  (4)  Five  methods 
of  reaching  the  diaphragm  are  now  open  to  the  operator;  (a)  If  the  site  of 
operation  be  below  the  level  of  the  reflected  pleura,  where  the  diaphragm 
and  chest-wall  are  in  contact,  the  diaphragm  may  be  approached  at  once, — 
(b)  If  the  pleura  be  encountered  as  soon  as  the  chest-cavity  is  opened,  its 
parietal  layer  should  be  most  carefully  detached  with  the  fingers  and  by 
means  of  blunt  dissection  and  peeled  back  from  its  connection  with  the  endo- 
thoracic  fascia  and  surface  of  the  diaphragm — peeling  it  backward  with  the 
tips  of  the  fingers  and  constantly  pushing  it  from  the  freed  area  with  the 
back  of  the  fingers — continue  this  freeing  back  of  the  unopened  pleura  until 
the  site  of  the  diaphragmatic  operation  is  reached — and  then  hold  the  pleura 
in  place  by  gauze  packing  (Fig.  560).  (c)  If  both  surfaces  of  the  pleura  are 
found  adherent,  thus  shutting  off  the  general  pleural  cavity,  the  incision  may 
be  carried  directly  down  to  the  diaphragmatic  site  without  danger  of  entering 
the  pleural  cavity  (unless  the  adhesions  be  pulled  apart  in  the  manipulations), 
— (d)  If  the  two  pleural  surfaces  are  not  adherent,  and  it  be  impracticable 
to  detach  the  pleura  as  described  under  (1)),  the  two  pleurae  may  be  united 
by  suture  around  an  area  sufficiently  large  to  admit  of  operating  within  and 
thus  reaching  the  diaphragm  at  once,  (e)  If  the  two  pleural  layers  be  found 
not  in  contact  by  adhesion,  and  cannot  be  separated  and  displaced  upward  as 
mentioned  under  (b),  and  if  time  be  to  spare,  adhesion  between  the  two 
surfaces  may  be  brought  about  by  gauze  packing,  with  the  accomplishment 
of  the  rest  of  the  operation  two  or  three  days  later,  when  the  cavity  will  have 
been  closed  off  by  adhesions.  Where  it  is  possible  to  choose  the  route,  it 
is  better  to  approach  the  diaphragm  either  below  the  level  of  the  pleural 
reflection — or  to  detach  the  unopened  pleura  and  reach  the  diaphragm 
beneath  the  pleural  cavity.  (5)  The  surface  of  the  diaphragm  having  been 
exposed,  the  special  object  of  the  operation  is  now  accomplished — the  abscess 
incised — the  wounded  diaphragm  sutured — or  the  hernial  opening  closed — 
upon  the  same  principles  practised  elsewhere.  Owing  to  the  constant  move- 
ment of  the  diaphragm,  it  is  somewhat  more  difficult  to  deal  with  its  struc- 
ture. An  abscess  cavity  should  be  evacuated  by  the  most  direct  route, 
especially  guarding  the  pleural  cavity  from  infection.  If  a  newly  made 
wound  exist,  it  is  sutured  at  once.  If  the  wound  be  old,  or  the  opening  be 
a  hernia,  the  edges  are  seized  with  toothed  forceps  to  steady  them  and  then 
freshened  with  curved  blunt  scissors — the  moving  lung  being  held  out  of  the 
way,  if  necessary,  by  gauze  packing — and  with  a  fully  curved  needle,  held 
in  special  needle-holder,  the  margins  of  the  wound  or  opening  are  brought 
together  with   chromic  gut   sutures.     (6)   The  pleural   sac,   previously  held 


SURGICAL  ANATOMY  OF  THE  PLEUR.l..  759 

out  of  the  way  by  packing,  is  now  allowed  to  fall  into  place.  Temporary 
drainage  is  established,  if  indicated,  through  an  unsutured  part  of  the  ex- 
ternal wound — the  remaining  portion  of  the  outer  wound  being  closed. 

Comment. — (a)  If  the  pleura  be  nicked,  ligate  or  suture  it  at  once,  (b) 
If  necessary  to  gain  more  room,  free  back  the  soft  parts  and  excise  the  same 
amount  of  the  rib  above  or  below — especially  is  this  the  case  when  it  is  needed 
to  reach  the  diaphragm  nearer  its  dome,  (c)  A  U-shaped  flap,  with  base 
forward  or  backward,  may  be  used  to  expose  the  ribs,  (d)  On  the  left  side 
all  calculations  are  made  somewhat  lower. 


VIII.   THE   PLEURA. 
SURGICAL  ANATOMY. 

Relations. — (1)  Pleura  costalic  (Parietal  Layer  of  Pleura);  beginning 
at  sternum,  pleura  lines  thoracic  cavity,  covering  inner  aspect  of  costal  car- 
tilages, ribs,  intercostal  muscles — passing,  posteriorly,  over  heads  of  ribs, 
thoracic  ganglia  and  branches,  lateral  surfaces  of  bodies  of  dorsal  vertebra? — 
thence  to  side  of  pericardium,  which  it  partially  covers — thence  to  root  of 
lung,  where  it  becomes  pleura  pulmonis.  (2)  Pleura  pulmonis  (Visceral 
Layer  of  Pleura);  beginning  at  root  of  lung,  pleura  passes  around  posterior 
border,  over  convex  outer  aspect,  from  base  to  summit — over  sides  of  fissures 
between  lobes — around  its  anterior  border — on  to  anterior  aspect  of  root — 
thence  upon  pericardium  to  inner  aspect  of  sternum.  (3)  Pleura  cervicalis; 
apex  of  pleura  closely  covers  apex  of  lung,  projecting,  with  it,  from  1.3  to 
4.5  cm.  (about  h  to  if  inches)  above  the  first  rib — but  not  above  level  of 
neck  of  first  rib.  Subclavian  artery  arches  over  it,  grooving  its  internal  and 
anterior  aspect  just  below  its  apex.  Scalenus  anticus  and  medius  muscles 
are  in  contact  with  it  externally.  (4)  Pleura  diaphragmatis ;  covers  superior 
surface  of  diaphragm,  except  narrow  interval  along  its  circumference,  which 
is  in  contact  with  costal  parietes.  (5)  Pleura  mediastinalis ;  forms  lateral 
boundaries  of  mediastina. 

Relations  of  Margins  of  Pleura?  to  Chest-wall. — (1)  Anterior  mar- 
gin ;  extending  from  apex  of  lung,  passes  from  sterno-clavicular  articulation 
downward  and  inward,  meeting  opposite  pleura  at  upper  border  of  sternum 
— thence  both  pleura?  descend  in  contact  to  upper  margin  of  fifth  costal 
cartilages,  whence  they  diverge.  Right  Pleura  continues  nearly  vertically 
downward  to  lower  end  of  gladiolus,  thence  turns  outward.  Left  Pleura 
diverges  from  median  line  at  upper  margin  of  fifth  costal  cartilage,  so  as  to 
be  1.5  cm.  (about  §  inch)  to  outer  side  of  left  border  of  sternum  at  level  of 
sternal  end  of  fifth  costal  cartilage — 2  cm.  (about  |f  inch)  at  level  of  sternal 
end  of  sixth — 3.5  cm.  (about  if  inches)  at  level  of  sternal  end  of  seventh 
(Luschka).  In  many  cases  this  deviation  of  left  pleura  is  not  so  marked, 
the  margin  lying  much  nearer  the  median  line.  (2)  Lower  margin;  reflected 
on  to  diaphragm  along  line  extending  from  lower  end  of  sternum  outward 
behind  seventh  costal  cartilage  nearly  to  sternal  end  of  rib.  (Melsome  says 
this  margin  follows  lower  border  of  sixth  costal  cartilage  on  left  side.)  The 
lower  border  of  the  pleura  corresponds  in  height  with  the  following  structures 
at  the  following  points: — In  the  Nipple  line,  with  eighth  rib, — In  Mid-axillary 
line,  with  tenth  rib  on  left,  and  ninth  rib  on  right, — In  Posterior  Scapular 
line  (vertical  line  from  tip  of  inferior  angle  of  scapula),  with  twelfth  rib, — 
At  Spine,  with  vertebral  end  of  twelfth  rib;  sometimes  with  transverse  process 
of  first  lumbar  vertebra.  The  lower  margin  of  the  lung  will  correspond  with 
a  point  two  ribs  higher  in  each  case. 


760  OPERATIONS  UPON  THE  THORAX. 

Attachments  of  Pleurae. — (i)  Ligamentum  latum  pulmonis,  passes 
from  lower  portion  of  posterior  part  of  root  of  lung  to  diaphragm — formed 
by  two  layers  of  pleura?  continuous  above  with  the  layers  in  front  and  behind 
root  of  lung.  (2)  Expansion  of  fascia  covering  and  strengthening  apex,  and 
extending  across  from  posterior  border  of  first  rib  to  anterior  border  of  trans- 
verse process  of  seventh  cervical  vertebra — and  further  strengthened  by 
few  fibers  of  scalenus  anticus.  (3)  Interpleural  Ligament,  passing  between 
two  pleura?  behind  esophagus  and  in  front  of  aorta. 

Supplemental  or  Complemental  Pleural  Spaces. — These  spaces  are 
situations  where  two  portions  of  parietal  pleura?  are  in  contact,  even  during 
forcible  inspiration — (1)  Between  Chest-wall  and  Diaphragm  (Costo-phrenic 
sinus),  where  costal  pleura  is  reflected  on  to  diaphragm,  best  marked  poste- 
riorly, where  costal  and  diaphragmatic  parts  of  pleura?  are  in  contact  from 
about  tenth  to  twelfth  ribs, — (2)  Between  Chest-wall  and  Pericardium  on 
left,  opposite  lower  portion  of  gladiolus. 

Arteries. — From  intercostal,  internal  mammary,  musculophrenic,  thymic, 
pericardiac,  bronchial. 

Veins. — Correspond  with  arteries. 

Nerves. — From  phrenic  and  sympathetic. 


SURFACE  FORM  AND  LANDMARKS. 

The  interval  between  the  two  pleura?  is  considerable  above  and  below, 
but  opposite  the  gladiolus  (second,  third,  and  fourth  costal  cartilages)  they 
are  more  nearly  approximated,  or  are  in  contact. 

The  anterior  margins  of  the  two  pleura?  are  more  nearly  parallel  and  in 
a  vertical  line  than  the  corresponding  margins  of  the  lungs,  that  is,  the  left 
anterior  pleural  margin  extends  further  over  the  pericardium  than  does  the 
lung. 

The  right  pleura  is  shorter  and  wider  than  the  left  (owing  to  the  liver), 
though  it  reaches  slightly  higher  in  the  neck. 

There  is  a  tendency  for  the  left  pleura  to  extend  lower  down  than  the 
right — most  markedly  upon  the  lateral  aspect  of  the  chest-wall — somewhat 
so  upon  the  anterior  aspect — and  even  slightly  so  behind. 

In  some  cases  the  pleura  has  extended  into  the  abdomen,  beneath  the 
ligamentum  arcuatum  externum,  and  uncovered  by  diaphragm  at  this  site. 

The  outer  surface  of  the  pleura  is  firmly  adherent  to  the  surface  of  the 
lung,  to  the  pulmonary  vessels  emerging  from  the  pericardium,  to  the  upper 
surface  of  the  diaphragm,  and  to  the  triangularis  sterni — elsewhere  it  is  less 
firmly  adherent. 

If  the  twelfth  rib  be  well  developed  and  full  length,  the  pleura  is  generally 
in  contact  with  only  its  inner  half.  If  the  twelfth  rib  be  very  short,  the  pleura 
may  be  in  contact  with  all  of  its  anterior  surface — and  the  pleura  may  extend 
to  the  transverse  process  of  the  first  lumbar  vertebra. 

The  outer  margin  of  the  erector  spina?  muscle  cuts  the  twelfth  rib  about 
its  middle.  Where  the  twelfth  rib  is  present  and  extends  beyond  the  outer 
border  of  the  erector  spina?,  the  lower  border  of  that  portion  of  the  rib  ex- 
ternal to  the  border  of  the  muscle  can  be  cut  upon  with  reasonable  certainty 
of  not  opening  the  pleura.  Where  the  twelfth  rib  is  absent  or  short,  the 
above  is  not  available. 

Never  take  for  granted  that  the  last  rib  is  the  twelfth  rib — always  count 
from  the  first  rib.     If  the  twelfth  were  absent  and  one  were  to  cut  down 


INTERCOSTAL  THORACOTOMY.  761 

upon  the  eleventh  (mistaking  it  for  the  twelfth),  the  pleura  would  almost 
certainly  be  opened. 

Where  the  twelfth  rib  is  absent  or  short,  one  may  cut  to  within  2.5  cm. 
(about  1  inch)  of  the  apex  of  the  angle  formed  by  the  outer  margin  of  the 
erector  spinas  and  the  lower  border  of  that  portion  of  the  eleventh  rib  pro- 
jecting to  the  outer  side  of  the  muscle — that  is,  one  should  not  cut  higher 
than  the  position  the  twelfth  rib  would  occupy  if  present  (Melsome). 


PARACENTESIS  THORACIS. 

Description. — Paracentesis  thoracis  (thoracentesis,  or  pleuracentesis) 
consists  in  the  penetration  of  the  pleural  cavity  by  means  of  a  hollow  needle 
or  cannula,  for  the  purpose  of  exploratory  aspiration  or  the  evacuation  of 
fluid. 

Sites  usually  Selected  for  Thoracentesis. — Sixth  (or  seventh)  inter- 
costal space  in  the  mid-axillary  line;  eighth  (or  ninth,  especially  on  left) 
intercostal  space  in  the  posterior  scapular  line. 

Position. — Patient  supine  at  edge  of  table  for  lateral  punctures — and 
rolled  slightly  forward  for  posterior  punctures — with  arm  of  affected  side 
elevated  above  head  (to  widen  intercostal  spaces,  and  draw  skin  upward, 
which  will  subsequently  come  back  into  place  valve-like  over  the  opening). 
For  simple  puncture,  if  patient  can  sit  upright  in  a  chair,  this  position  will 
better  enable  fluid  to  gravitate  downward. 

Landmarks. — Sixth  (or  seventh)  intercostal  space  in  the  mid-axillary 
line — or  the  eighth  (or  ninth)  space  in  the  line  of  the  inferior  angle  of  the 
scapula.  The  posterior  puncture  secures  better  drainage.  (See  Figs.  563, 
C,  and  558,  B.) 

Operation. — Having  cocainized  the  part,  grasp  a  needle,  or  cannula 
and  trocar,  so  as  to  control  its  progress  and  limit  the  depth  of  the  puncture 
— and  having  displaced  the  skin  upward  with  the  left  thumb  and  forefinger, 
so  as  subsequently  to  form  a  valve — the  point  is  entered  nearer  the  upper 
than  the  lower  border  of  the  ribs  limiting  the  special  interspace  (in  order 
to  escape  the  more  important  lower  intercostal  artery,  while  also  missing  the 
upper  one) — and  is  made  to  pass  inward  and  upward  (so  as  to  avoid  wound- 
ing the  lung  and  diaphragm) — passing  through  skin,  fascia,  thoracic  muscles, 
intercostal  muscles,  endothoracic  fascia,  and  parietal  layer  of  pleura — its 
entrance  into  the  free  pleural  cavity  being  recognized  by  the  sensation  imparted 
to  the  finger  guarding  its  onward  progress.  When  the  needle,  or  cannula 
point,  is  felt  to  be  within  the  pleural  cavity,  the  contents  are  slowly  withdrawn, 
the  opening  being  subsequently  sealed  with  sterilized  cotton  and  collodion. 

Comment. — Puncture  may  be  made  wherever  physical  signs  indicate 
fluid  within  the  area  of  the  pleura — but  the  above  sites  are  the  most  usual. 
The  puncture  may  be  preceded  by  a  limited  incision  of  the  skin  alone — or,  if 
difficulty  occur,  the  incision  may  extend  down  to  the  intercostal  muscles. 
To  avoid  the  intercostal  arteries,  the  puncture  should  not  be  made  posteriorly 
to  the  angle  of  the  ribs. 


INTERCOSTAL  THORACOTOMY. 

Description. — Intercostal  thoracotomy,  or  pleurotomy,  consists  in  the 
exposure  and  incision  of  the  pleura  in  an  intercostal  space  for  the  evacuation 
of  fluid.     A  simpler  though  generally  less  satisfactory  operation  than  thora- 


762 


OPERATIONS  UPON  THE  THORAX. 


cotomy  through  the  partial  excision  of  a  rib,  though  often  sufficient  in  minor 
cases. 

Sites  Usually  Selected  for  Intercostal  Thoracotomy. — In  the  sixth 
(or  seventh)  intercostal  space  in  the  mid-axillary  line;  in  the  eighth  (or  ninth, 
especially  on  the  left)  intercostal  space  in  the  posterior  scapular  line — i.  e., 
in  the  same  sites  as  for  paracentesis,  avoiding  a  position  in  which  the  dia- 
phragm or  scapula  would  interfere  with  free  drainage. 

Position. — As  for  paracentesis  thoracis — except  that  here  the  opening 
must  not  be  valulvar,  but,  on  the  contrary,  it  is  planned  that  the  cutaneous 
and  pleural  openings  are  opposite. 


Fig.  561. — Operations  for  the  Exposure  of  the  Pleura: — A,  Incision  for  intercostal 
pleurotomv;  B,  Intercostal  incision  for  the  partial  excision  of  two  adjacent  ribs;  C,  Incision  over 
a  rib  for  either  the  partial  excision  of  one  rib  or  of  three  ribs  (the  one  beneath  the  incision  and 
those  immediately  above  and  below).      (Thorax  modified  from  Spalteholz.) 

Landmarks. — As  for  paracentesis  thoracis. 

Incision. — Midway  between  the  two  ribs,  in  the  long  axis  of  the  inter- 
costal space — extending  about  5  cm.  (about  2  inches)  in  a  thin  chest-wall, 
and  about  7.5  cm.  (about  3  inches)  in  a  thick  chest-wall — the  center  of  the 
incision  being,  as  above  indicated,  generally  in  the  mid-axillary  line  for  the 
sixth  intercostal  space,  and  in  the  posterior  scapular  line  for  the  eighth  inter- 
space.    (Fig.  561,  A.) 

Operation. —  (1)  Incise  through  skin,  fascia,  external  thoracic  muscles 
(serratus  magnus  in  sixth  space;  chiefly  the  latissimus  dorsi  in  eighth  space), 


THORACOTOMY    BY    PARTIAL   EXCISION   OF   RIBS.  763 

and  intercostal  muscles  down  to  the  endothoracic  fascia.  Clamp  and  ligate 
all  bleeding  vessels  encountered — the  incision  lying  between  the  upper  and 
lower  intercostal  arteries  and  not  generally  involving  them.  Retract  the  soft 
parts  upward  and  downward,  including  the  ribs  bounding  the  space — and 
the  parietal  pleura  is  exposed.  (2)  The  tense  pleura  is  then  deliberately 
incised  in  the  axis  of  the  intercostal  space  (not  by  stabbing) — preceded,  if 
necessary,  by  an  exploratory  puncture — the  opening  being  increased,  if 
indicated,  upon  a  grooved  director,  or  with  blunt  scissors  or  blunt  bistoury 
— and  the  fluid  evacuated.  (3)  Drainage  is  then  established  by  some  form 
of  not  easily  collapsible  drain  (to  withstand  the  tendency  of  the  adjacent 
ribs  to  narrow  the  opening).  The  ends  of  the  external  wound  are  sutured, 
leaving  room  for  the  exit  of  the  drain. 

Comment. — Where  the  incision  can  be  made  to  the  outer  margin  of  the 
latissimus  dorsi,  lesser  thickness  of  muscle  presents. 


THORACOTOMY    BY    PARTIAL    EXCISION    OF    ONE    OR    MORE    RIBS. 

Description. — Exposure  and  incision  of  pleura  through  a  thoracic  open- 
ing made  by  the  excision  of  parts  of  one  or  two  (or  more)  ribs.  Generally 
resorted  to  for  the  evacuation  of  intrapleural  fluids  where  a  larger  opening 
is  required  than  furnished  by  an  intercostal  thoracotomv.  Part  of  one  rib 
alone  is  generally  excised — where  more  room  is  required  part  of  the  rib  above 
or  below,  or  both,  may  be  excised.  From  2.5  to  5  cm.  (about  1  to  2  inches) 
of  bone  are  ordinarily  removed — and  more  if  necessary. 

Sites  usually  Selected  for  the  Excision  of  Ribs. — Wherever  a  collec- 
tion of  fluid  is  indicated  by  physical  signs  (that  is,  determined  by  the  physical 
signs  of  localized  collection) — where  the  collection  is  a  localized  one.  Where 
the  fluid  is  in  the  free  pleural  cavity,  the  site  generally  chosen  is  the  sixth 
or  seventh  rib  in  the  mid-axillary  line — or  the  eighth  or  ninth  rib  just  external 
to  the  posterior  scapular  line — the  latter  situation  usually  being  preferable. 
(Kocher  gives  the  sixth  rib  in  the  mammary  line — the  ninth  rib  on  the  right, 
and  the  tenth  on  the  left,  in  the  lateral  line — and  the  twelfth  on  both  sides 
posteriorly  in  the  scapular  line.)  But  the  position  should  be  so  chosen  that 
the  drainage  will  not  be  interfered  with  by  either  diaphragm  or  scapula  in  the 
functioning  of  these  structures. 

Position. — As  for  Intercostal  Thoracotomv  (page  761). 

Operation  by  Partial  Excision  of  One  Rib. — (1)  An  incision  of  about 
8  cm.  (about  3  inches)  is  made  directly  over  the  center  of  the  chosen  rib, 
passing  through  skin,  fascia,  overlying  muscles,  and  periosteum.  (See  Fig. 
561,  C,  and  562.)  (2)  The  rib  is  then  freed  subperiosteal^  for  nearly  5  cm. 
(about  2  inches),  carefully  avoiding  injury  to  the  intercostal  vessels  and  pleura 
— which  are  in  safety  as  long  as  the  operation  is  subperiosteal.  About  2.5  to 
4  cm.  (about  1  to  1  \  inches)  is  now  removed  with  a  Gigli  saw,  as  in  the  ordinary 
partial  excision  of  a  rib.  (3)  The  intercostal  vessels  are  then  easily  isolated 
in  the  bed  of  the  rib,  and  are  treated  according  to  circumstances — they  may 
be  tied  at  both  ends  of  the  wound  and  divided,  where  they  are  likely  to  be 
injured — or  they  may  be  left  intact,  the  incision  into  the  pleura  being  made 
between  and  parallel  with  the  upper  and  lower  intercostal  vessels.  (4)  An 
incision  of  about  2.5  to  4  cm.  (about  1  to  ij  inches)  is  now  carefully  made 
through  the  center  of  the  periosteal  bed  and  in  the  axis  of  the  former  rib, 
passing  through  the  costal  periosteum,  endothoracic  fascia,  and  parietal 
pleura  into  the  pleural  cavity — and  drainage   thus  established — the  drain 


764 


OPERATIONS    UPON    THE    THORAX. 


used  being  so  placed  and  of  such  a  nature  as  not  to  impinge  upon  the  lungs 
during  respiration. 

Operation  by  Partial  Excision  of  Two  or  More  Ribs. — (1)  If  it  be 
found,  after  excising  part  of  one  rib,  that  it  is  desirable  to  excise  part  of  the 
rib  above  or  below,  or  both,  add  two  vertical  incisions  to  the  horizontal  one, 
extending  from  the  ends  of  the  former  horizontal  incision  upward  to  the 
upper  border  of  the  rib  above — or  two  vertical  incisions  extending  downward 


Fig.  562. — Thoracotomy  by  Partial  Excision  of  a  Rib: — A,  Thoracic  muscles  divided  down 
to  rib,  directly  over  its  center;  B,  Periosteum  raised  and  turned  back,  in  the  subperiosteal  exposure 
of  the  rib  ;  C,  Transverse  section  of  rib,  indicating;  portion  of  rib  removed  by  means  of  a  Gigli  or  chain 
saw  conducted  between  rib  and  periosteum  ;  D,  Knife  incising  through  periosteal  bed  and  endotho- 
racic  fascia  into  pleural  cavity. 

to  the  lower  border  of  the  rib  below — or  both.  A  flap  of  overlying  soft 
parts  may  thus  be  turned  upward  or  downward,  or  in  both  directions, 
exposing  the  two  or  three  ribs — which  are  then  partially  excised  just  as  a 
single  rib  in  the  above  operation.  (2)  Where  it  is  wished,  from  the  first,  to 
excise  parts  of  two  ribs — make  an  incision  of  about  10  cm.  (about  4  inches) 
midway  between  the  two  ribs — passing  through  skin,  fascia,  and  overlying 
muscles,  down  to  the  level  of  the  outer  surface  of  the  ribs  and  intercostal 
muscles — then  retract  the  upper  lip  of  the  wound  upward  until  the  upper 
rib  is  well  exposed — and  the  lower  lip  downward  until  the  lower  rib  is  similarly 
exposed — incising  muscle  tissue,  or  separating  by  blunt  dissection,  in  the 
approach  toward  the  upper  border  of  the  rib  below  and  the  lower  border  of 
the  rib  above,  maintaining  an  even  thickness  of  soft  covering  everywhere. 
The  ribs  thus  exposed  are  partially  resected  as  in  the  single  rib  operation. 
(See  Figs.  561,  B,  560,  and  562.)  (3)  Where  it  is  wished  to  excise  parts  of 
three  ribs  from  the  first,  make  an  incision  in  the  long  axis  of  the  middle  one  of 
the  three  ribs — join  this  by  a  vertical  incision  at  either  end  of  the  transverse 
incision,  from  the  upper  border  of  the  rib  above  to  the  lower  border  of  the  rib 
below  (making  an  H -shaped  incision) — and  turn  one  flap  upward  and  the 
other  downward  (as  explained  in  (1)  above).     Parts  of  three  ribs  are  then 


PARTIAL    PLEURECTOMY ESTLANDER'S    OPERATION.  765 

excised — the  intercostal  arteries  are  ligated  at  both  ends — the  nerves  are 
retracted — and  an  incision  made  vertically  in  the  center  of  the  area.  At 
the  end  of  the  operation,  the  external  wound  is  clcsed  along  the  lines  of 
incision,  except  that  drainage  is  provided  for  through  an  unsutured  part 
of  the  wound.  (4)  Where  more  than  part  of  a  single  rib  is  excised,  the 
soft  parts  which  intervene  between  the  beds  of  the  excised  ribs,  and  includ- 
ing the  beds,  are  carefully  incised  in  a  vertical  direction,  down  to  the 
endothoracic  fascia — and  the  pleura  is  then  incised  in  the  same  direction. 
Prior  to  this,  the  intercostal  vessels  corresponding  to  each  rib  are  ligated  at 
either  end  of  the  original  wound,  so  that  when  divided  in  their  center  no 
bleeding  of  any  consequence  occurs.  The  nerves  are  drawn  out  of  their  beds 
and  retracted  upward  and  downward,  out  of  the  way,  if  possible. 

Comment. — Parts  of  three  ribs  may  be  excised  by  a  single  incision  (about 
15  cm.,  or  6  inches,  long),  made  over  the  central  rib,  followed  by  good  retraction. 

After  making  a  thoracic  opening  at  the  chosen  site,  lower  openings,  or 
counter-openings,  for  better  drainage,  can  be  made  by  cutting  down  upon 
a  curved  sound  introduced  through  the  original  opening  and  directed  to  a 
lower  part  of  the  cavity 


PARTIAL  PLEURECTOMY. 

ESTLANDER'S     THORACOPLASTIC     OPERATION. 

Description — This  operation,  suggested  by  Warren  Stone,  and  estab- 
lished by  Estlaender,  consists,  as  now  practised,  in  the  subperiosteal  excision 
of  parts  of  several  contiguous  ribs  over  a  pleural  cavity,  together  with  the 
removal  of  their  periosteum,  the  intercostal  tissues,  endothoracic  fascia,  and 
the  parietal  pleura — thereby  allowing  the  corresponding  soft  thoracic  wall  to 
sink  in  and  obliterate  the  abnormal  cavity  by  the  approximation  and  union 
of  this  thoracic  wall  of  integumentary  and  muscular  tissues  to  the  visceral 
pleura,  which  has  been  freshened  by  curettage.  The  number  of  ribs  which 
are  partially  excised,  and  the  amount  of  each  rib  removed,  will  depend  upon 
the  position  and  extent  of  the  involved  area,  as  determined  by  the  physical 
signs  before  operation;  or  by  probing,  or  by  the  amount  of  fluid  contained, 
after  opening  the  cavity — and  usually  corresponds  with  that  area.  From 
the  second  to  the  ninth  ribs,  inclusive,  have  been  excised — but  generally 
from  the  second  to  the  seventh,  inclusive,  are  the  ones  taken.  From  the 
costal  cartilages  to  the  tubercles,  in  amount,  has  been  resected — but  the 
average  is  from  about  13  to  15  cm.  (about  5  to  6  inches)— the  amount  being 
greatest  where  the  cavity  is  widest,  and  vice  versa.  The  operation  is  appli- 
cable to  long-standing  cases  of  empyaema  which  have  resisted  drainage,  and 
in  which  the  lung  no  longer  expands  and  the  pleura  is  much  thickened. 
Originally  Estlaender  did  not  remove  the  costal  periosteum  and  intercostal 
tissues,  nor  the  parietal  pleura.  The  pleural  surfaces  were  allowed  to  fall 
into  contact  if  possible.  The  pleura  was  not  opened,  other  than  for  the 
drainage  which  may  have  been  previously  resorted  to — but  the  external  wall, 
with  its  parietal  pleura,  minus  ribs,  was  merely  allowed  to  come  into  contact 
with  the  visceral  pleura.  Now  both  the  costal  periosteum  is  excised  (to  pre- 
vent regrowth  of  bone),  together  with  the  intercostal  muscles  and  fascia,  and 
the  parietal  pleura  and  endothoracic  fascia  removed,  and  even  the  visceral 
pleura  scraped  (to  destroy  pyogenic  membrane  and  to  approximate  fresh  sur- 
faces for  union) — and  the  outer  wall  held  in  contact  with  the  visceral  pleura 
by  dressings,  as  far  as  possible. 


766 


OPERATIONS  UPON  THE  THORAX. 


Preparation. — The  thoracic  wall  is  shaved,  where  necessary. 

Position. — Patient  is  so  placed  as  to  best  expose  the  special  site  involved, 
generally  resting  upon  one  side — surgeon  usually  stands  in  front  in  operating 
upon  the  left  side,  and  behind  in  operating  upon  the  right  side — assistant 
stands  opposite  surgeon. 

Landmarks. — Outline  of  the  empya'mic  cavity  to  be  obliterated,  as 
determined  by  physical  signs;  normal  limits  of  lung  and  pleura;  relation  of 
important  adjacent  organs. 

Incision. — Supposing  that  parts  of  the  second  to  seventh  ribs,  inclusive, 
are  to  be  removed,  from  the  right  antero-lateral  aspect  of  the  chest-wall — say 
8  cm.  (about  3  inches)  of  second  rib — 10  cm.  (about  4  inches)  of  third — 13 


Fig.  563. — Operations  upon  the  Pleural  Cavity: — C,  Incision  for  Estlander's  thor- 
acoplasty (removing,  in  this  case,  parts  of  third  to  eighth  ribs,  inclusive,  through  three  in- 
tercostal incisions);  A,  Schede's  thoracoplasty  (removing  nearly  all  of  the  second  to  ninth 
ribs,  inclusive);  D,  Position  for  paracentesis  thoracis  in  the  sixth  intercostal  space,  in  the  mid- 
axillary  line.      (Thorax  modified  from  Spalteholz.) 

cm.  (about  5  inches)  of  fourth — 15  cm.  (about  6  inches)  of  fifth — 18  cm. 
(about  7  inches)  of  sixth,  and  20  cm.  (about  8  inches)  of  seventh — then 
transverse  incisions  somewhat  longer  than  the  length  of  the  part  of  the  rib  to 
be  removed  (to  allow  for  sufficient  retraction  of  soft  parts  to  get  at  the  required 
length  of  rib)  are  made  in  the  center  of  the  long  axis  of  each  alternate  inter- 
space, as  follows — between  the  second  and  third  ribs,  for  removal  of  those 
ribs — between  the  fourth  and  fifth  ribs,  for  the  removal  of  those  ribs — between 
the  sixth  and  seventh  ribs,  for  the  removal  of  those.  If  an  uneven  number 
of  ribs  were  to  be  removed,  three  of  them  could  be  removed  through  an 


PARTIAL    PLEURECTOMY — ESTLANDER'S    OPERATION.  767 

incision  placed  over  the  central  one  of  the  three.  The  greatest  length  will 
be  removed  from  that  rib  which  spans  the  greatest  width  of  cavity,  whether 
at  the  middle  or  either  end — and  narrower  lengths  toward  the  tapering  or 
narrowing  aspects  of  the  cavity.  An  equal  length  of  each  rib  is  sometimes 
removed.     (See  Fig.  563,  A,  where  a  kite-shaped  excision  is  shown.) 

Operation. — (i)  Incise  through  skin,  fascia,  and  overlving  thoracic 
muscles,  until  down  to  the  external  intercostal  muscles  (on  a  level  with  the 
ribs).  Tie  all  bleeding  vessels.  Retract  upper  lip  of  wound,  in  its  full 
thickness,  upward,  exposing  the  rib  above — cutting,  where  necessary,  muscular 
fibers  close  to  the  level  of  the  external  intercostal  muscles  and  external  aspect 
of  the  rib  (so  as  to  keep  as  thick  a  flap  of  soft  parts  as  possible).  The  lower 
lip  of  the  wound  is  similarly  retracted,  exposing  the  lower  rib.  (2)  The 
upper  and  lower  ribs  are  now  excised  subperiosteally  to  the  requisite  extent. 
(3)  The  above  steps  are  repeated  for  the  second  and  third  pairs  of  ribs.  (4) 
The  intercostal  vessels  are  now  tied  at  both  ends  of  each  intercostal  bed. 
(5)  There  are  now  three  long  incisions,  and  two  bridge-like  strips  of  external 
soft  parts,  composed  of  skin,  fascia,  and  outer  thoracic  muscles.  These 
bridgedike  parts  are  carefully  preserved.  Beneath  these  lie  a  deeper  con- 
tinuous layer  of  soft  parts  composed  of  costal  periosteum  (beds  of  ribs), 
external  and  internal  intercostal  muscles,  endothoracic  fascia,  and  parietal 
pleura  (the  last  often  very  much  thickened) — all  forming  the  outer  wall  of 
the  empyaemic  cavity.  Having  retracted  upward  (/".  e.,  outward),  out  of  the 
way,  the  above-described  bridge-like  strips  of  soft  parts,  this  deeper  layer  of 
soft  parts  just  mentioned  is  all  cut  away  with  scissors — well  within  the  ligated 
intercostal  arteries,  on  either  side — and  along  the  highest  and  lowest  inter- 
costal space  of  the  involved  and  freed  area.  (6)  The  visceral  pleura,  espe- 
cially if  much  thickened,  is  advantageously  curetted.  (7)  The  three  original 
incisions  are  now  sutured  throughout,  except  a  part  of  the  lowest  is  left  open 
for  drainage,  where  drainage  is  instituted.  The  new  outer  wall  of  soft  thoracic 
tissues  is  now  allowed  to  come  into  contact  with  the  freshened  visceral  pleura 
— and  is  held  in  contact  by  dressings  as  far  as  possible,  to  promote  union 
and  obliteration  of  the  cavity. 

Comment. — Considerable  hemorrhage  occurs  throughout  the  operation. 
which  is  controlled  by  clamp,  ligature,  pressure,  and  hot  solution. 

There  is  not,  as  now  practised,  as  distinct  a  difference  between  Est- 
laender's  and  Schede's  operations  of  Thoracoplasty  as  formerly — modern 
operators  using  the  good  features  of  both  in  each. 

The  second  rib  is  left  where  possible. 

The  external  soft  parts  may  be  raised  as  one  flap  (as  Schede  does) — or 
as  several  smaller  flaps  (as  Tacobson  advises) — or  the  necessary  amount  of 
ribs  over  a  small  cavity  may  be  exposed  by  a  vertical  incision  over  the  desig- 
nated ribs,  followed  by  firm  retraction  (as  Pearce  Gould  suggests). 

A  cavity  wider  than  long  requires  the  excision  of  more  of  fewer  ribs — 
a  cavity  longer  than  wide  requiring  the  excision  of  less  of  more  ribs. 

Where  the  cavity  involves  the  posterior  part  of  the  upper  ribs  (those 
behind  the  scapula),  their  anterior  ends  may  be  severed  in  the  usual  way — 
the  posterior  ends  being  severed  from  the  interior  of  the  chest  with  stout, 
curved  cutting-pliers — after  freeing  the  rib  of  soft  parts. 


768  OPERATIONS    UPON    THE    THORAX. 

PARTIAL  PLEURECTOMY. 
schede's    tiioracoplastic    operation. 

Description. — This  operation,  more  extensive  than  Estlaender's,  differs 
in  detail  from  the  latter,  while  being  conducted  upon  the  same  general  prin- 
ciple, and  in  the  same  general  type  of  cases.  A  large  U-shaped  flap  is  raised, 
corresponding  in  extent  to  the  underlying  cavity  (sometimes  to  nearly  the 
entire  pleural  cavity)  and  consisting  of  all  the  soft  parts  overlying  the  ribs. 
The  ribs,  intercostal  tissues,  endothoracic  fascia,  and  parietal  pleura  outlined 
by  this  incision  are  then  excised  en  masse — the  visceral  pleura  scraped — and 
the  external  flap  allowed  to  fall  into  contact  with  the  freshened  pleura,  being 
sutured  back  in  place  and  held  in  contact  with  the  visceral  pleura  by  the 
dressings — opening  for  drainage  being  left.  Generally  resorted  to  in  old 
empyasmic  cases  of  the  worst  type,  especially  where  the  pleura'  are  very  much 
thickened,  and  which  have  resisted  all  other  measures,  and  represents  the 
most  radical  operation  of  its  kind  available,  consisting,  practically,  of  the 
removal  of  nearly  the  entire  chest-wall  of  one  side  beneath  the  plane  of  the 
thoracic  muscles.  The  number  of  ribs  removed  is  determined  by  the  vertical 
extent  of  the  cavity,  but  is  generally  from  the  second  to  the  ninth  inclusive. 
The  amount  of  each  rib  removed  is  likewise  determined  by  the  width  of  the 
cavity,  but  is  often  from  the  costal  cartilages  to  the  tubercles  of  the  ribs. 

Preparation — Position. — As  for  Estlaender's  Thoracoplasty  (page  765). 

Landmarks. — Where  adapted  to  a  localized  cavity,  the  outline  of  that 
cavity  and  the  position  of  important  adjacent  structures  will  determine  the 
landmarks.  Where  the  maximum  removal  of  the  thoracic  wall  is  indicated, 
that  amount  of  each  rib  (from  and  including  the  second  downward)  which 
is  in  contact  with  the  pleural  cavity — in  the  average  case,  from  the  second  to 
the  ninth,  inclusive,  and  from  the  costal  cartilage  to  the  tubercle.  This  latter 
extent  will  be  understood  in  the  following  operation. 

Incision. — Begins  anteriorly  at  the  upper  border  of  the  second  costo- 
chondral  articulation  (about  2.5  cm.,  or  1  inch,  from  the  sternal  border) — 
passes  downward  following  the  curve  of  the  ehondro-costal  articulations 
slightly  outward  (the  cartilages  increasing  in  length  as  they  descend)  to  the 
eighth  rib  in  the  nipple-line — to  the  ninth  rib  in  the  mid-axillary  line  on  the 
right  side  (the  tenth  on  the  left) — thence  transversely  backward  to  the  poste- 
rior scapular  line — thence  upward  along  a  line  midway  between  the  vertebral 
border  of  the  scapula  and  the  spinous  processes  of  the  vertebrae,  to  the  second 
rib.  (Some  surgeons  begin  the  incision  at  the  outer  border  of  the  pectoralis 
major,  above  the  level  of  the  fourth  rib — and  retract  from  this  point  upward 
to  expose  the  third  and  second  ribs.)     (See  Fig.  563,  A.) 

Operation. — (1)  Incise  down  to  and  upon  the  ribs  and  intercostal  muscles 
throughout  the  line  of  incision — bearing  lightly  over  the  intercostal  spaces 
to  avoid  penetrating  the  thorax.  (2)  This  entire  flap  of  overlying  soft  parts 
is  dissected  en  masse  from  the  bony  and  intercostal  muscular  wall  of  the 
thorax,  hugging  the  ribs  and  intercostal  muscles  closely  (so  that  the  extensive 
flap  may  be  as  thick  and  well  nourished  as  possible).  The  scapula,  with  the 
subscapularis  muscle,  are  drawn  upward  and  away  from  the  trunk  so  as  to 
give  access  to  the  upper  ribs  and  to  enable  the  anterior  part  of  the  upper 
ribs,  especially  where  the  incision  only  extends  upward  anteriorly  to  the 
fourth,  to  be  freed.  (3)  The  ribs  are  now  to  be  divided  in  front  and  behind, 
about  1.5  cm.  (about  ^  inch)  within  the  line  of  division  of  the  soft  parts  (so 
that  the  cicatrix  will  not  fall  directly  over  the  line  of  the  ends  of  the  divided 
ribs).     This  division  is  best  accomplished  in  the  following  way,  devised  by 


PARTIAL    PLEURECTOMY SCHEDE'S    OPERATION.  769 

Hartley, — Where  each  rib  is  to  be  divided,  anteriorly  and  posteriorly,  the 
periosteum  is  divided  over  the  center  of  the  rib,  midway  between  upper  and 
lower  borders,  by  an  incision  about  4  cm.  (about  1^  inches)  long,  with  the 
center  of  the  incision  at  the  point  where  each  section  of  rib  is  to  be  made. 
To  this  more  or  less  horizontal  incision,  at  the  two  ends  of  the  ribs,  add  a 
vertical  incision  through  the  periosteum,  beginning  at  the  center  of  the  hori- 
zontal incision,  or  at  both  of  its  ends,  and  ending  at  the  lower  border  of 
the  rib.  \Yith  a  curved  periosteal  elevator,  free  the  lower  half  of  anterior 
and  posterior  ends  of  the  ribs  where  the  sections  are  to  be  made,  for  the 
extent  of  about  1.5  cm.  (about  \  inch) — especially  freeing  the  intercostal 
groove  with  the  intercostal  vessels.  Complete  this  process  of  freeing  at  each 
end  of  each  rib  before  proceeding  to  the  next  step.  Now  grasp  the  lower 
half  of  each  rib,  where  cleared  of  periosteum,  with  rongeur  forceps,  inserting 
the  lower  lip  of  the  rongeur  forceps,  between  bone  and  periosteum,  and 
bite  out  a  half-button  of  bone  (Oi),  which  will  include  the  subcostal  groove, 
and  the  removal  of  which  will  well  expose  the  intercostal  vessels.  Complete 
this  half-button  excision  at  the  inner  and  outer  ends  of  each  rib  before 
proceeding  further  in  the  operation.  (4)  The  intercostal  vessels  are  all 
now  ligated  at  both  ends  of  the  exposed  part  of  each  rib,  being  easily 
accomplished  by  passing  a  curved  needle  armed  with  chromic  catgut, 
beneath  them  as  they  lie  fully  exposed — plainly  in  view,  or  very  accessible 
in  their  beds,  or  are  made  accessible  by  a  very  little  dissection.  The 
arteries  and  veins  should  be  picked  up  separately  or  together — but  especial 
care  should  be  exercised  not  to  include  the  intercostal  nerves.  The  vessels 
thus  tied  are  the  inferior  intercostal  vessels.  The  upper  intercostal  vessels 
are  generally  much  smaller  and  may  usually  be  taken  up  with  clamp 
forceps  and  tied  as  divided  in  the  osseo-periosteo-muscular  nap.  If  con- 
sidered necessary,  the  superior  intercostal  vessels  may  be  exposed  in  the 
same  manner  as  the  lower  ones,  by  biting  out  part  of  the  upper  border  of  the 
rib  with  rongeur  forceps.  (5)  The  ribs  may  now  be  freely  divided  at  both 
ends  by  passing  a  Gigli  saw  between  periosteum  and  bone — the  saw-carrier 
easily  passing  between  the  rib  and  the  separated  part  of  the  pericsteum  which 
had  been  freed  in  excising  the  half-buttons  of  bone,  and  for  the  balance  of 
the  way  from  the  end  of  the  separated  area  up  to  the  upper  border  of  the 
bone,  hugging  the  rib  closely  on  its  inner  aspect  and  emerging  between  the 
upper  border  of  the  rib  and  the  position  of  the  superior  intercostal  vessels. 
Both  ends  of  all  the  ribs  are  thus  divided.  (6)  Nothing  now  remains  but  to 
divide  with  blunt-pointed  scissors  the  intercostal  tissues  in  the  line  of  the 
severed  ribs  on  both  sides,  along  the  upper  border  of  the  second  rib  above, 
and  along  the  lower  border  of  the  ninth  rib  below — thus  removing  the  entire 
lot  of  ribs,  intercostal  tissues,  endothoracic  fascia,  and  parietal  pleura  en  masse 
in  a  single  sheet.  (7)  The  thickened  visceral  pleura  covering  the  remnant 
of  contracted  lung  is  thoroughly  scraped  and  as  much  adventitious  tissue 
removed  as  possible.  (8)  The  flap  of  skin,  fascia,  and  muscles  is  now  allowed 
to  fall  into  contact  with  the  freshened  visceral  pleura — its  margin  being 
sutured  to  the  margin  of  the  thoracic  opening,  except  a  dependent  opening 
left  for  drainage.  The  region  is  so  dressed  as  to  keep  the  flap  in  contact 
with  the  freshened  visceral  pleura  and  aid  in  early  union  of  the  surfaces  and 
obliteration  of  the  cavity — the  arm  being  bound  to  the  side.  In  this  step 
of  closing  the  wound,  all  divided  thoracic  muscles  along  the  line  of  incision 
are  quilted  together  by  means  of  a  buried  row  of  chromic  gut  sutures,  before 
placing  the  final  tier  of  sutures. 

Comment. — (1)  After  the  flap  of  soft  parts  has  been  turned  back  each 

49 


770  OPERATIONS    UPON   THE   THORAX. 

rib  may  be  excised  subperiosteally  and  then  the  intercostal  tissues  cut  away, 
as  in  Estlaender's  operation — but  much  more  time  is  consumed.  (2)  While 
removing  the  deeper  flap  composed  of  ribs,  intercostal  muscles,  endothoracic 
fascia,  and  parietal  pleura,  a  sound  or  a  finger  within  the  cavity  should  guide 
the  scissors  along  the  contour  of  the  portion  being  excised.  (3)  The  second 
rib  is  left  where  possible.  (4)  The  scapula  is  displaced  forward  during  the 
posterior  incision.  (5)  The  upper  ribs  may  be  removed  from  within  the 
cavity,  after  division  at  both  ends,  as  explained  in  Estlander's  operation. 


TOTAL  PLEURECTOMY. 

fowler's    thoracoplastic    operation. 

Description. — The  operation  consists  in  the  removal  of  the  entire  pleura 
of  one  side.  It  is  indicated  in  those  cases  where  the  lung  does  not  expand  but 
is  bound  down  by  firm,  dense  adhesions — and  where  Estlander's  operation  has 


Fig.  564. — Operations  upon  the  Pleura: — A,  Incision  for  Fowler's  total  pleurectomy; 
B,  Incisions  for  one  of  the  methods  of  exposure  in  Ransohoff 's  discission  of  the  pleura.  (Tho- 
rax modified  from  Bardeleben,  Haeckel,  and  Frohse.) 

failed  to  accomplish  relief.  There  is  less  destruction  of  rib  structure  than  in 
Schede's  operation.  The  operation  is  sometimes  called  decortication  of  the 
lung. 

Preparation — Position. — As  in  Estlander's  operation,  page  765. 

Landmarks. — A  pre-existing  sinus,  or  the  recognized  site  of  a  pyothorax. 

Incision. — In  those  cases  where  a  previous  sinus  exists,  this  is  incised  along 


OTHER    OPERATIONS    UPON    THE    PLEUR.E.  77 1 

the  intercostal  space  corresponding  with  its  position,  anteriorly  and  posteriorly, 
to  the  extent  of  about  20  to  22.5  cm.  (8  to  9  inches) .  At  the  posterior  extremity 
of  this  incision  another  incision  is  made  vertically  downward  to  the  extent  of 
two  ribs — and  similarly  at  the  anterior  extremity  of  the  horizontal  incision 
another  incision  is  made  vertically  upward  to  the  extent  of  two  ribs  (Fig. 
564,  A).  Where  no  sinus  exists,  the  horizontal  incision  is  made  in  an  inter- 
costal space  with  its  center  over  the  center  of  the  pyothorax. 

Operation. — Two  triangular  flaps  are  outlined  by  the  above  incisions. 
The  anterior  flap  (consisting  of  all  the  soft  parts  down  to  the  ribs)  is  reflected 
upward  and  forward.  The  posterior  flap  is  reflected  downward  and  back- 
ward. In  this  way  four  ribs  are  exposed.  About  20  cm.  (8  inches)  of  each  of 
these  ribs  is  excised.  The  cavity  is  then  entered — and  by  blunt  dissection  and 
"peeling"  the  entire  pleura  is  removed — beginning  with  the  parietal  and  end- 
ing with  the  visceral  layer.  By  carefully  incising  across  the  visceral  pleura 
that  layer  may  be  removed  with  les>&  danger  to  the  lung — which  partially 
expands  as  it  is  released.  At  the  end  of  the  operation  the  flaps  of  soft  part>  arc 
turned  into  position  and  sutured.  Provision  is  made  for  drainage,  if  indicated 
— otherwise,  not. 


DISCISSION  OF  PLEURA   IN   CHRONIC  EMPYEMA. 
ransohoff's    operation. 

Description. — Having  exposed  the  contracted  and  bound-down  lung,  the 
thickened  overlying  visceral  pleura  is  "gridironed  with  many  parallel  incisions 
removed  from  each  other  about  6  mm.  (j  inch),  and  by  others  crossing  these 
obliquely  or  at  right  angles.  Little  islands  of  thickened  pleura  are  thus  left 
on  the  surface  of  the  expanding  lung.  But  if  the  cuts  have  been  made  deep 
enough  they  shrivel  in  size,  while  the  discission  is  still  in  process  of  being  com- 
pleted."    This  technic  is  a  modification  of  the  operation  of  decortication. 

Preparation; — Position; — Landmarks. — As  in  the  preceding  operations 
upon  the  pleura. 

Incision. — An  incision  is  made  over  the  sinus,  or  cavity,  with  the  partial 
excision  of  one  or  two  ribs.  Through  this  opening  the  extent  of  the  involve- 
ment is  determined. 

Operation. — As  determined  by  the  nature  of  the  process  and  its  extent, 
multiple  subperiosteal  rib  excisions  are  made — either  through  several  parallel 
incisions — (Fig.  564,  B);  through  a  Schede  incision  (Fig.  563,  A);  or  through 
a  trap-door  incision  (Fig.  565).  Having  gotten  ample  exposure,  decortica- 
tion should  be  first  tried,  which  is  to  be  preferred  if  easily  and  satisfactorily 
accomplishable.  If  this  is  not  readily  accomplished,  gridironing  incisions,  as 
described  above,  are  made  over  the  visceral  pleura.  If  the  lung  does  not 
satisfactorily  expand  following  these  incisions,  an  incision  is  carefully  carried 
along  the  groove  of  reflexion  of  visceral  and  parietal  pleura — the  danger  being 
less  if  this  liberating  incision  is  carried  toward  the  chest-wall.  Drainage  is 
instituted  where  indicated — and  the  wound  otherwise  closed.  Often  several 
consecutive  operations  are  necessary. 

OTHER  OPERATIONS  UPON  THE  PLEURA. 

See  Operations  upon  the  Lungs  (pages  772  to  780) — and  Operations 
upon  the  Liver  (pages  1004  to  1021). 


772  OPERATIONS    UPON   THE   THORAX. 


IX.  THE  LUNGS. 
SURGICAL  ANATOMY. 

Relations. — Apex;  extends  from  1.2  to  4.5  cm.,  averaging  2.5  (from  \  to 
if  inches,  averaging  1),  above  level  of  first  rib  into  the  neck  (but  not  extending 
higher  than  the  neck  of  the  first  rib) — lying  beneath  subclavian  artery,  and 
behind  interval  between  two  heads  of  sternomastoid  and  inner  end  of  clavicle 
— and  covered  by  subclavian  artery  and  scalenus  anticus.  Right  apex  may 
project  slightly  higher  than  left.  Base;  rests-  upon  convexity  of  diaphragm. 
External  surface;  chiefly  corresponds  to  cavity  of  thoracic  wall.  Internal 
surface ;  in  contact  with  pericardium  and  lateral  pleural  wall  of  mediastina. 
Anterior  border;  overlaps  anterior  surface  of  pericardium  on  right,  and 
partially  so  on  left.  Posterior  border;  fits  into  concavity  on  either  side  of 
vertebral  column.  Inferior  border;  fits  into  space  between  inferior  ribs 
and  costal  attachment  of  diaphragm. 

Relations  of  Margins  of  Lungs  to  Chest-wall. — Anterior  margins; 
extend  from  their  apices  (at  an  average  point  of  2.5  cm.,  or  1  inch,  above 
the  first  rib,  and  nearer  posterior  than  anterior  border  of  sternomastoid) 
downward  and  inward  across  sternoclavicular  articulation  and  manubrium 
sterni  to  near  center  of  articulation  of  manubrium  and  gladiolus,  where  the 
two  margins  meet,  or  verv  nearlv  meet — thence  both  borders  descend  parallel 
to  each  other  and  just  bevond  the  middle  line  (the  right  sometimes  slightly 
overlapping  it)  to  midway  between  the  level  of  the  articulations  of  the  fourth 
costal  cartilages  with  the  sternum — from  which  point  they  diverge  unequally. 
Right  margin  continues  to  descend  almost  vertically  downward  to  sixth 
chondro-sternal  articulation  (sometimes  to  lower  end  of  gladiolus),  whence 
it  curves  downward  and  outward  along  that  cartilage  to  sixth  costo-chondral 
articulation.  Left  margin,  from  point  of  divergence,  passes  along  lower 
border  of  fourth  rib  outward  with  a  downward  inclination,  and  then  down- 
ward across  fourth  interspace  and  fifth  rib  with  an  outward  inclination  to 
apex  of  heart  (a  point  3.8  cm.,  or  1^  inches,  below,  and  2.5  cm.,  or  1  inch,  to 
inner  side  of  left  male  nipple  in  fifth  interspace) — thence  to  sixth  costo- 
chondral  articulation.  Lower  margins;  marked  by  a  slightly  curved  line. 
with  downward  convexity,  extending  from  sixth  costo-chondral  articulation 
to  spinous  process  of  tenth  dorsal  vertebra — crossing  (while  arms  are  elevated 
at  right  angle)  the  nipple-line  at  sixth  rib — mid-axillary  line  (arms  still  raised) 
at  eighth  rib — scapular  line  (arms  now  lowered)  at  tenth  rib.  Lower  margin 
of  left  lung  starts  on  level  with  sixth  costo-chondral  joint,  but  much  further 
out  than  right — about  7.5  cm.  (3  inches)  to  left  of  median  line  in  fifth  inter- 
space. Sometimes  lower  margin  of  left  lung  may  be  one  rib  lower  than  right. 
Posterior  margins ;  marked  by  line  from  level  of  spinous  process  of  seventh 
cervical  vertebra,  passing  vertically  downward  on  either  side  of  spine,  over 
the  costo-vertebral  articulations,  to  spinous  process  of  tenth  dorsal  vertebra. 

Excursion  of  Lower  Borders  of  Lungs  in  Forced  Respiration. — 
Extend  about  3.8  cm.  (ij  inches)  below  the  line  given  above  for  the  rela- 
tion of  the  lower  margin,  in  deep  inspiration — and  rise  above  it  in  forced 
expiration. 

Relations  of  Fissures  of  Lungs  to  Chest-wall. — (1)  Great  or  Lower 
Fissure  of  Right  Lung: — draw  line  from  fourth  dorsal  vertebra  forward  and 
downward  around  chest  to  intersection  of  anterior  margin  of  lung  and  seventh 
rib.  (2)  Lesser  or  Upper  Fissure  of  Right  Lung: — draw  line  from  point  of 
intersection   of  preceding   line   with    mid-axillary   line,   to   fourth   chondro- 


GENERAL    SURGICAL    CONSIDERATIONS.  773 

sternal  articulation.  (3)  Fissure  of  Left  Lung: — draw  line  from  third  dorsal 
vertebra  forward  and  downward  around  chest  to  intersection  of  anterior 
margin  of  lung  with  sixth  costal  cartilage. 

Structures  of  Roots  of  Lungs,  and  their  Relations. — Structures 
of  each  root ;  bronchial  tube,  pulmonary  artery,  pulmonary  veins,  bronchial 
artery  (generally  one  on  right  and  two  on  left),  two  bronchial  veins,  anterior 
pulmonary  plexus  of  nerves,  posterior  pulmonary  plexus  of  nerves,  bronchial 
lymphatic  glands,  areolar  tissue — all  being  enclosed  within  pleura.  Rela- 
tions of  right  root :  Anteriorly;  right  auricle,  superior  vena  cava,  ascending 
aorta,  phrenic  nerve,  anterior  pulmonary  plexus.  Superiorly;  vena  azygos 
major  arching  to  join  superior  vena  cava.  Posteriorly;  pneumogastric 
nerve,  posterior  pulmonary  plexus.  Inferiorly;  ligamentum  latum  pulmonis. 
Relations  of  left  root:  Anteriorly;  phrenic  nerve,  anterior  pulmonary 
plexus.  Superiorly;  arch  of  aorta.  Posteriorly;  descending  aorta,  pneumo- 
gastric nerve,  posterior  pulmonary  plexus.  Inferiorly;  ligamentum  latum 
pulmonis.  Order  of  structures  of  right  root:  From  Before  Backward; 
pulmonary  veins,  pulmonary  artery,  bronchus,  and  bronchial  vessels.  From 
Above  Downward;  bronchus,  pulmonary  artery,  pulmonary  veins.  Order 
of  structures  of  left  root:  From  Before  Backward;  pulmonary  veins, 
pulmonary  artery,  bronchus,  and  bronchial  vessels.  From  Above  Downward  ; 
pulmonary  artery,  bronchus,  pulmonary  veins. 

Position  of  Hilum  of  Lung. — Upon  inner  aspect,  slightly  above  middle, 
and  much  nearer  posterior  than  anterior  border — on  level  with  bodies  of 
fifth,  sixth,  seventh,  and  sometimes  eighth  dorsal  vertebra?. 

Bifurcation  of  Trachea  and  Bronchi. — Trachea  bifurcates  opposite 
the  spinous  process  of  fourth  dorsal  vertebra — right  bronchus  passing  nearlv 
horizontally  outward  and  dividing  into  three  chief  bronchial  tubes — left 
bronchus  passing  more  directly  downward  and  dividing  into  two  chief  bron- 
chial tubes. 

Arteries. — Pulmonary;  bronchial. 

Veins. — Pulmonary;  bronchial. 

Nerves. — From  anterior  and  posterior  pulmonary  plexus,  formed  mainly 
by  sympathetic  and  pneumogastric. 

Lymphatics. — End  in  bronchial  glands. 


GENERAL  SURGICAL  CONSIDERATIONS. 

Collapse  of  the  lung  is  one  of  the  chief  and  most  serious  of  the  possible 
dangers  in  intra-pleural  surgery.  This  possibility  should  be  guarded  against 
in  all  intra-thoracic  operations  in  one  of  the  following  ways; — by  the  accurate 
suturing  of  parietal  and  visceral  layers  of  the  pleura  together  prior  to  incising 
the  membrane, — the  maintenance  of  artificial  respiration  by  some  such  device 
as  Matas'  modification  of  the  Fell-O'Dwyer  instrument,— performance  of  the 
operation  under  negative  atmospheric  pressure  (Sauerbruch's  box),— or  the 
carrying  out  of  the  operation  under  increased  atmospheric  pressure  (Bauer's 
apparatus). 

The  lung  tissue  is  best  divided  by  the  thermocautery  at  red  heat,  especially 
vascular  and  comparatively  normal  portions.  The  tip  of  the  finger  may  also 
be  used.     Indurated  areas  are  best  divided  with  a  knife. 


774 


OPERATIONS    UPON    THE    THORAX. 


PNEUMOTOMY 


THROUGH     A     CUTANEOMUSCULAR     THORACOPLASTY     FLAP. 

Description. — Incision  of  lung  tissue  through  a  temporary  opening  made 
in  the  chest-wall.     This  opening  may  be  made  in  the  form  of  an  intercostal 

thoracotomy, — through  the  partial  re- 
section of  one  or  more  ribs, — or  through 
an  osteothoracoplastic  flap.  In  the 
present  instance,  a  partial  resection 
of  three  ribs  will  be  made,  after  raising 
a  thoracoplasty  flap.  Generally  re- 
sorted to  in  cases  of  abscess,  gangrene, 
hydatid  cyst,  and  sometimes  for  bron- 
chial dilatation  and  tuberculous  cavi- 
ties. The  flap  consists  of  soft  parts 
only. 

Preparation. — Chest-wall  is  shaved 
where  hairy  growth  exists. 

Position. — Patient  so  placed  as  to 
render  site  of  operation  accessible 
during  exposure  of  lung — but  placed 
so  as  to  render  site  dependent  before 
cutting  into  lung  tissue  (that  fluid  may 
not  flow  into  bronchial  tubes  opened 
by  incision,  in  addition  to  that  which 
may  be  drawn  into  them).  Surgeon 
on  side  of  operation — assistant  on  same 
side,  or  opposite. 

Landmarks. — Determined  by  phy- 
sical signs  locating  disease,  and  gener- 
ally verified  by  preliminary  explora- 
tion; known  position  of  important 
structures. 

Incision. — A  U-shaped  flap  is  out- 
lined, with  base  upward  and  convexity 
downward,  or  vice  versa — usually  ex- 
tending over  two  or  three  ribs,  and 
of  sufficient  size  to  well  include  the 
incision  into  the  lung  with  room  for 
manipulation  (Fig.  565,  A  and  C). 
(Vitality  of  flap  would  be  better  assured 
if  base  were  forward  or  backward  and 
Fig.  565.— Incisions  for  Pneumotomy  convexity  in  opposite  direction.  (Fig. 
or  Pneumectomy,  by  means  of  Cutaneo-     $6"] ,  A  and  C.) 

Operation. — (1)  This  U-shaped 
flap  of  all  the  soft  parts  down  to  the 
ribs  and  intercostal  muscles  is  raised. 
(2)  Having  controlled  hemorrhage,  the 
necessary  parts  of  the  indicated  ribs  are 
excised  subperiosteally  —  calculating 
that  the  line  of  division  of  the  ribs  will  fall  about  1  cm.  (nearly  \  inch)  within 
the  line  of  flap-incision  (that  cicatrix  of  latter  may  not  fall  over  ends  of  ribs). 
(3)  An  exploratory  needle  may  now  be  introduced  through  the  periosteal 


MUSCULAR      OR      CUTANEO-MUSCULO-OSSEOUS 

Flaps: — A,  Trap-door  flap  involving  two  ribs, 
hinging  upward;  C,  One  involving  three  ribs, 
hinging  downward.  The  continuous  line  re- 
presents the  skin  incision — the  broken  lines, 
the  rib  sections.  (Figure  redrawn  from 
Deaver.) 


PXKUMOTOMV. 


775 


bed  of  a  rib,  thus  avoiding  the  intercostal  vessels— and  the  needle  may  be 
left  in  situ  as  a  guide.  (4)  An  incision  is  now  carefulh  made  in  the  long 
axis  of  a  space,  or,  preferably,  in  the  bed  of  a  rib,  avoiding  intercostal  vessels, 
—if  in  a  space,  passing  through  intercostal  muscles  and  endothoracic  fascia. 
In  the  transverse  incisions  sufficient  room  can  usually  be  gotten  by  upward 
and  downward  retraction  of  the  soft  parts,  without  requiring  the  division  of 
the  vessels.  If  it  be  elected  to  make  a  vertical  opening,  after  removing  the 
ribs,  then  the  intercostal  vessels  are  ligated  at  both  ends  of  the  exposed  beds 
of  the  excised  ribs— so  that  when  the  vertical  incision  is  made  in  the  center 
of  the  exposed  area,  little  or  no  hemorrhage  will  occur.  This  vertical  incision 
is  in  the  center  of  the  area  from  which  the  ribs  have  been  partially  excised, 


Fig.  566. — Exposure  of  Pleura  and  Lung  by  means  of  a  Cutaxeo-muscular  Flap: — 
A  flap  of  skin,  fascia,  and  muscles  has  been  turned  back.  The  sites  of  excised  portions  of 
ribs  are  shown.  The  parietal  and  visceral  pleura?  are  stitched  together  by  a  continuous  suture 
ellipticallv  around  the  position  of  the  future  incision  into  the  lung.  An  incision  has  been 
carried  into  the  lung  substance. 


and  extends  between  the  intact  ribs  above  and  below.  In  any  event,  the 
incision  should  be  made,  if  possible,  down  to,  but  not  directly  through,  the 
parietal  pleura,  at  this  stage.  (5)  Here  one  of  two  conditions  will  be  found: — 
(A)  The  parietal  and  visceral  pleurae  may  be  adherent — the  general  pleural 
cavity  will  then  be  walled  off,  and  the  incision  may  be  made  directly  into  the 
lung  tissue — having  determined  its  depth  by  exploratory  puncture.  (B) 
Parietal  and  visceral  pleura?  may  be  non-adherent;  (a)  If  it  be  necessary 
to  proceed  with  the  operation  at  once,  suture  the  two  surfaces  of  the  pleurae 
together  with  catgut,  in  a  sufficiently  large  circle — thus  closing  off  the  general 
pleural  cavity  by  suture  and  by  packing  the  outer  circumference  of  the  circle 
with  gauze  (Fig.  566) .  The  incision  may  be  then  made  at  once  into  the  lung 
through  the  above  circle,     (b)   If  no  need  of  haste  exist,  pack  the  wound  with 


776  OPERATIONS    UPON   THE    THORAX. 

gauze  a  little  firmly,  so  that  the  pleural  surfaces  are  held  in  contact — and  in  two 
or  three  days  the  surfaces  will  be  united  for  some  distance  around,  and  incision 
into  lung  tissue  may  be  made  through  the  united  surfaces,  without  fear  of 
invading  the  general  pleural  cavity.  This  adhesion  is  made  more  certain 
and  firmer  by  also  suturing  the  pleura?  in  a  circular  manner  at  the  time  of 
the  exposure.  (6)  Incision  into  the  lung  is  usually  made  in  the  direction  of 
the  original  incision  by  which  it  has  been  approached — the  incision  extending 
through  the  full  thickness  of  the  variously  thick  layer  of  lung  tissue  overlying 
the  cavity.  (7)  Drainage  is  provided  for — the  drain  coming  out  through 
an  unsutured  lower  part  of  the  flap,  the  remainder  of  the  flap  being  sutured 
back  into  place — or  the  drain  may  come  out  through  a  convenient  opening 
in  the  flap,  the  circumference  of  the  flap  being  sutured  throughout. 

Comment. — (i)  Usually  the  removal  of  parts  of  one  or  two  ribs  suffices 
to  expose  the  site.  (2)  The  distance  of  the  cavity  from  the  surface  should 
be  determined  by  needle  before  incising.  (3)  The  following  methods  of 
incising  the  lung  tissue  are  used; — actual  cautery — best  for  soft  lung  tissue; 
incision  by  knife — safe  in  hardened  lung  tissue;  exploratory  needle  and  small 
grooved  director  introduced  simultaneously — the  needle  is  withdrawn  and 
director  left  in  situ — upon  which  dilators  of  increasing  size  are  slipped  into 
cavity,  which  is  then  dilated;  blunt  dissection;  trocar  and  cannula.  (4)  If 
hemorrhage  occurs  from  lung  tissue,  pack  with  gauze.  (5)  Collapse  of  lung 
is  very  apt  to  follow  going  through  the  opened  pleural  cavity  (where  the  two 
surfaces  are  not  united  by  adhesion) — requiring  the  use  of  a  Fell-O'Dwyer 
instrument.  (6)  Pneumotomy  may  be  performed  by  means  of  an  osteo- 
thoracoplastic  flap,  as  described  under  Pneumectomy — or  by  any  method 
which  satisfactorily  exposes  the  lung. 


PARTIAL   PNEUMECTOMY 

THROUGH     CUTANEOMUSCULO-OSSEOUS     THORACOPLASTIC     FLAP. 

Description. — The  excision  of  part  of  a  lung  involved  in  some  lesion — 
an  uncommon  though  possible  operation.  Access  may  be  obtained  by  the 
permanent  excision  of  parts  of  several  ribs,  after  raising  a  thoracoplasty  flap, 
as  described  under  Pneumotomy — or,  better  still,  by  the  turning  back  tem- 
porarily of  a  window  consisting  of  the  entire  thickness  of  the  soft  and  bony 
parts  of  the  chest- wall  (thoracoplasty).  The  operation  has  generally  been 
resorted  to  for  the  removal  of  malignant  and  hydatid  tumors  of  the  lungs — and 
also  for  localized  tuberculosis.  In  the  latter  cases  the  part  excised  has  usually 
been  the  apex.     The  trap-door  flap  may  hinge  in  any  direction. 

Preparation — Position — Landmarks. — As  in  Pneumotomy. 

Incision. — (1)  Supposing  the  tumor  to  be  of  the  middle  lobe  of  the  right 
lung — an  incision  is  to  be  planned  outlining  an  upper,  a  lower,  and  an  anterior 
side  of  a  square  or  rectangle,  the  fourth  or  posterior  side  forming  the  hinge 
—the  square  including  the  antero-lateral  aspect  of  the  fourth,  fifth,  and  sixth 
ribs.  The  upper  line  will  lie  in  the  middle  of  the  third  interspace,  in  its 
long  axis — the  lower  line  will  be  similarly  placed  in  the  center  of  the  sixth 
interspace — the  anterior  line  will  run  vertically  about  2.5  cm.  (1  inch)  outside 
of  the  costal  cartilages — and  the  posterior  side  will  be  parallel  with  the  anterior 
and  from  10  to  13  cm.  (about  4  to  5  inches)  behind  it.  (2)  Supposing  the 
case  to  be  one  of  localized  tuberculosis  of  the  apex  of  the  left  lung — a  U- 
shaped  flap  is  planned,  with  its  convexity  over  the  middle  of  the  sternum;  its 


PARTIAL    PXEU.MECTOMY. 


777 


base  reaching  nearly  to  the  anterior  axillary  line;  its  upper  horizontal  limb 
in  the  middle  of  the  first  intercostal  space;  its  lower  horizontal  limb  in  the 
middle  of  the  third  intercostal  space.  The  general  forms  of"  flap  are  shown  in 
Fig.  567,  A  and  C. 

Operation. — Carrying  out  the  steps  of  the  operation  indicated  in  the  first 
incision  given  above — (1)  Incise  through 
skin,  fascia,  and  overlying  thoracic 
muscles,  down  to  the  ribs  and  intercos- 
tal muscles,  along  the  upper,  lower,  and 
curved  sides  only  (Fig.  567,  C).  (2) 
Along  the  anterior  line,  where  the  ribs 
are  intersected  by  the  vertical  portion  of 
the  incision,  retract  the  soft  parts  a  lim- 
ited distance  on  each  side  over  the  ribs 
— and  make  a  short  incision  directly  1  wer 
the  center  of  their  long  axes,  passing 
through  the  periosteum  (not  through  the 
skin) — free  the  circumference  of  the  ribs 
here  subperiosteally  with  a  curved  peri- 
osteal elevator  over  the  least  width  of 
rib  possible  to  accomplish  its  freeing. 
Do  not  yet  divide  the  rib  (Fig.  569). 
(3)  A  short  incision  is  now  made 
directly  over  the  center  of  the  long  axis 
of  the  ribs  posteriorly,  through  all  the 
overlying  soft  parts  down  to  and  through 
the  periosteum — the  center  of  each  in- 
cision being  an  imaginary  line  connect- 
ing the  posterior  ends  of  the  upper  and 
lower  lines  (just  as  the  center  of  the 
transperiosteal  incisions  anteriorly  was 
the  real  line  connecting  the  anterior  ends 
of  the  horizontal  lines  of  incision). 
The  ribs  are  here  freed  subperiosteally 
as  in  front — their  circumference  being 
bared  over  the  smallest  space  practic- 
able (Fig.  569,  D,  D).  (4)  A  Gigli  saw 
is  now  carried  beneath  the  freed  por- 
tions of  the  ribs  in  front  and  behind — 
thus  entirely  freeing  the  bony  connec- 
tions of  the  flap.  (5)  The  upper,  lower, 
and  anterior  sides  of  the  square,  or 
rectangle,  are  now  carefully  incised 
through  their  soft  structures  not  already  muscular 
divided,  down  to  the  endothoracic  fascia, 
carefully  avoiding  penetration  of  the 
parietal  pleura.  (6)  This  large  cutaneo- 
musculo-osseous  flap  is  now  carefully 
elevated  and  turned  backward  upon  its 
posterior  hinge  (which  hinge,  as  far  as  the  soft  parts  and  the  integrity  of  their 
blood-supply  go,  has  been  very  little  injured  by  the  longitudinal  cuts 
over  the  ribs) — carefully  separating  it  from  the  parietal  pleura  as  it  is  turned 
backward.     (7)  If  it  be  found  that  the  two  surfaces  of  pleura?  are  not  ad- 


Fig.  567. — Incisions  for  Pxeumotomy 
or  Pneumectomy,  by  means  of  Cutaneo- 
or  cutaneomusculo-osseous 
Flaps: — A,  Trap-door  flap  involving  three 
ribs,  hinging  forward;  C,  One  involving  three 
ribs,  hinging  backward.  The  continuous  line 
represents  the  skin  incision — the  broken  lines, 
the  rib  sections.  If  base  of  flap  A  be  poste- 
rior, the  blood  supply  is  better. 


778  OPERATIONS    UPON    THE    THORAX. 

herent,  the  wound  is  rather  snugly  packed  with  gauze — the  flap  turned  as 
far  back  into  place  as  the  gauze  will  allow — and  adhesion  is  awaited  for  three 
or  four  days.  Or  the  vitality  of  the  flap  and  the  firmness  of  adhesion  would 
probably  be  more  safely  and  thoroughly  secured  if  the  parietal  and  visceral 
pleura?  were  sutured  around  the  extreme  margin  of  the  wound  with  catgut 
— allowing  the  flap  to  fall  fully  into  place,  where  it  could  either  rest,  or  be 
sutured,  the  necessary  time  for  adhesions  to  form — and  subsequently  raised 
for  the  excision  of  the  growth.  Or  the  pleura  may  be  incised  and  the  opera- 
tion completed  immediately,  after  the  suturing  together  of  the  pleural  sur- 
faces. (8)  At  the  time  of  the  removal  of  the  tumor,  the  method  of  the  removal 
will  be  somewhat  determined  by  the  character  of  the  tumor.  Whether  fluid 
(e.g.,  hydatid  cyst)  or  solid  (e.g.,  primary  malignant  tumor),  if  its  accessi- 
bility will  allow,  it  is  best  to  ligate  off  the  surrounding  lung  tissue  by  carrying 


Fig.  568. — Exposure  of  Pleura  and  Lung  by  means  of  a  Cutaneomusculo-osseous 
Flap: — A  flap  of  skin,  fascia,  muscles,  and  temporarily  excised  ribs  is  turned  back.  The 
parietal  pleura  has  been  incised  and  turned  back  separately  upon  the  composite  flap.  The 
lung,  with  an  interlobular  sulcus,  is  seen  in  the  field. 

chromic  gut  in  a  large,  fully-curved  needle  around  the  growth  in  segments — 
and  then  excise  by  actual  cautery,  knife,  or  blunt  dissection,  where  possible. 
(See  Pneumotomy,  page  774.)  Sometimes  previous  ligation  is  impossible — 
the  tumor  is  then  removed  without  it.  and  hemorrhage  controlled  by  packing 
the  cavity  with  gauze.  It  sometimes  happens  in  hydatid  cysts  that  the  tumors 
have  to  be  incised,  their  contents  evacuated  and  their  walls  curetted,  the 
remainder  being  allowed  to  slough  out — although  complete  removal  of  their 
walls  is  much  preferable.  (9)  The  cavity  left  by  the  removal  of  a  tumor 
should  be  temporarily  packed  with  gauze — which  is  brought  out  for  drainage 
through  a  convenient  opening  made  at  a  margin  of  the  flap — the  flap  being 
elsewhere  sutured  back  into  its  normal  position.  As  the  ribs  are  adherent 
to  the  soft  part  of  the  flap,  which  will  be  sutured  to  the  thorax  around  its 
margin,  the  ribs  will  thereby  be  held  in  place  and  prevented  from  being 
materially  displaced.     If,  when  the  section  of  the  ribs  is  made,  it  be  done  in 


PARTIAL    PXEUMECTOMY. 


779 


a  beveling  fashion  (at  the  expense  of  the  inner  aspect  of  the  parts  of  the  ribs 
in  the  flap),  when  the  flap  is  turned  back  into  place  this  beveling  will  addi- 
tionally steady  the  rib  ends  in  place.  If  desired,  the  contiguous  ends  of  the 
severed  ribs,  in  front  and  behind,  can  be  united  by  chromic  gut  or  silver  wire, 
after  having  been  previously  drilled. 

Comment. — (i)  In  carrying  out  the  steps  of  the  operation  indicated  in 
the  second  incision  given  above,  the  description  given  under  Pneumotomy 
by  a  Thoracoplasty  Flap  will  sufficiently  cover,  being  practically  similar. 
The  indurated  apex  of  the  lung,  when  exposed,  is  seized  with  forceps — de- 


D 


Fig.  569. — Manner  of  Raising  a  Cctaneomusculo-osseous  Thoracoplastic  "Trap- 
door" Flap: — A,  A,  A,  Line  of  incision  of  soft  parts  outlining  flap;  K,  K,  Retracting  convex 
portion  of  flap,  snowing  position  of  rib-sections  at  distal  end  of  flap;  C,  C,  Lines  of  incisions 
through  all  overlying  soft  parts,  including  periosteum,  down  to  ribs  at  base  of  flap;  D,  D,  Details 
of  wounds  made  through  incisions  C,  C,  showing  site  of  section  of  rib;  E,  E,  Position  of  rib- 
sections  at  base  of  flap. 

taching  it,  if  necessary,  from  its  adhesions — and  withdrawn  through  the 
thoracic  opening — a  chromic  gut  ligature  is  then  carried  below  the  involved 
portion — or  a  double  ligature  is  passed  through  upon  a  needle  and  each  side 
tied  separately — the  apex  is  now  excised — the  lung  replaced,  after  bringing 
together  the  raw  surfaces  of  the  lung  by  gut  suture,  if  possible — and  the  edges 
of  the  parietal  pleura?  sutured  with  catgut.  The  operation  is  completed  as  in 
Pneumotomy  by  Thoracoplastic  Flap.  (2)  Turner  has  removed  portions  of 
tubercular  lung  through  a  simple  intercostal  thoracotomy  in  the  second 
interspace — opening   the   pleura    and    delivering   and   excising   the    involved 


780  OPERATIONS    UPON    THE    THORAX. 

portion  of  lung.  (3)  Where  the  ligature  is  not  used,  the  actual  cautery  is 
the  safest  means  with  which  to  excise  lung  tissue.  (4)  The  operation  is 
simplified  if  the  neighboring  healthy  lung  is  adherent  to  the  parietal  pleura. 
Collapse  is  also  much  less  likely.  (5)  The  lower  two-thirds  of  the  first  rib 
are  sometimes  alone  excised. 


X.   THE  PERICARDIUM. 
SURGICAL  ANATOMY. 

Position. — Occupies  middle  mediastinum  of  thorax,  lying  Detween 
anterior  mediastinum,  in  front  (opposite  sternum  and  third,  fourth,  fifth, 
sixth,  and  seventh  costal  cartilages) — posterior  mediastinum,  behind — and 
pleura?,  laterally.  Consists  of  visceral  and  parietal  layers.  Has  general 
outline  of  heart,  except  where  reflected  on  to  great  vessels  at  base  of  heart. 

Attachments. — Apex;  covers  great  vessels  for  about  5  cm.  (2  inches) 
and  is  held  in  position  by  them.  Base;  attached  to  central  tendon  of  dia- 
phragm and  adjacent  surface.  Anterior  surface  of  pericardium;  attached 
to  posterior  surface  of  manubrium  and  ensiform  process  by  superior  and 
inferior  sterno-pericardial  ligaments. 

Relations. — Superiorly ;  great  vessels  of  heart.  Inferiorly ;  diaphragm. 
Anteriorly;  thymus  gland  (or  remains);  areolar  tissue;  margins  of  lungs 
(especially  left);  sterno-pericardial  ligaments;  triangularis  sterni  muscle; 
internal  mammary  vessels;  anterior  mediastinum;  sternum.  Posteriorly; 
bronchi;  esophagus;  descending  aorta;  pneumogastric  nerves;  posterior  medi- 
astinum. Laterally;  pleurae;  anterior  margins  of  lungs  (especially  left); 
phrenic  nerves;  accompanying  phrenic  vessels. 

Structures  Covered  by  Pericardium. — Aorta;  superior  vena  cava;  pul- 
monary artery  and  bifurcations;  ductus  arteriosus;  four  pulmonary  veins. 

Arteries. — Pericardiac  and  musculophrenic  from  internal  mammary; 
pericardiac,  esophageal,  and  bronchial  from  descending  aorta;  coronary  from 
ascending  aorta;  phrenic  from  abdominal  aorta. 

Veins. — Pass  to  azygos,  internal  mammary  and  phrenic  trunks,  cardiac 
veins  emptying  into  right  auricle. 

Nerves. — Branches  from  pneumogastric,  phrenic,  and  sympathetic. 

Lymphatics. — Empty  into  mediastinal  glands. 


SURFACE  FORM  AND  LANDMARKS. 

The  anterior  surface  of  the  upper  portion  of  the  pericardium  is  from  3 
to  5  cm.  (about  i\  to  2  inches)  posterior  to  the  sternum — and  the  anterior 
surface  of  the  lower  portion  is  about  1  cm.  (about  f  inch)  posterior  to  the 
sternum. 

Normally  there  is  a  collapsed  cul-de-sac  at  the  base  of  the  anterior  portion 
of  the  pericardium,  which  is  much  distended  in  effusion.  This  is  the  site 
sought  in  drainage. 

According  to  Yoinitch-Sianojentsky,  the  interpleural  pericardial  area 
extends  vertically  from  the  lower  border  of  the  left  fifth  chondro-sternal 
articulation  to  the  left  seventh  chondro-sternal  articulation — lying  mainly 
behind  the  sternum  but  also  corresponding  to  the  sternal  end  of  the  sixth 
intercostal  space — wherefore,  puncture  of  the  pericardium  in  the  sixth  space 


PERICARDIOCENTESIS.  781 

may  be  made  directly  inward — whereas  it  should  be  directed  very  obliquely 
downward  if  made  in  the  fifth  interspace,  to  avoid  the  heart  (that  is,  it  runs 
parallel  with  the  heart  after  entering  the  pericardium). 

A  cartilaginous  bridge  unites  the  sixth  and  seventh  costal  cartilages — 
and  sometimes  also  the  fifth  and  sixth — and  thereby  the  intercostal  area  for 
puncture,  between  the  inner  border  of  the  cartilaginous  bridge  and  the  left 
border  of  the  sternum,  may  be  considerably  encroached  upon. 

The  internal  mammary  artery  runs  down  at  an  average  distance  of  about 
1.2  cm.  (about  \  inch)  to  the  outer  side  of  the  sternal  border— to  the  sixth 
interspace,  where  it  divides  into  the  superior  epigastric  and  the  musculo- 
phrenic. 

For  outline  of  Pleura,  see  Anatomy  of  Pleura. 


PERICARDIOCENTESIS. 

Description. — -Pericardiocentesis,  or  paracentesis  pericardii,  consists  in 
the  penetration  of  the  pericardium  by  a  hollow  needle  attached  to  a  vacuum 
syringe  for  the  purpose  of  withdrawing  pericardial  contents.  It  is  chiefly  used 
for  diagnosis — sometimes  for  the  withdrawal,  in  bulk,  of  the  fluid  in  hemo- 
pericardium  and  hydropericardium.  In  pyopericardium  pericardiotomy 
should  be  performed,  rather  than  pericardiocentesis. 

Preparation. — Region  shaved,  if  necessary. 

Position. — Patient  supine,  preferably  resting  upon  some  object  which 
will  render  chest  prominent  and  increase  the  width  of  the  intercostal  spaces. 
Surgeon   on   left   of   patient. 

Sites  of  Puncture. — Puncture  may  be  made  in  either  the  fifth  or  sixth 
interspace — and  either  internal  to  or  external  to  the  internal  mammary  artery 
(Fig.  570) .  In  the  fifth  interspace,  the  width  is  greater  near  the  sternal  border, 
and  is  the  space  usually  chosen.  In  the  sixth  interspace,  the  internal  mammary 
artery  and  the  pleura  are  both  further  from  the  left  sternal  border,  and  puncture 
may  be  made  more  directly  inward.  Where  sufficient  width  of  space  exists, 
the  sixth  interspace  should  be  chosen.  Puncture  should,  by  preference,  be 
made  internal  to  the  internal  mammary  artery,  as  the  pleura  is  in  less  danger 
of  injury,  especially  in  the  fifth  space---and  even  in  the  sixth  space,  the  punc- 
ture would  have  to  be  about  2.5  cm.  (about  1  inch)  outside  of  the  border  of 
the  sternum  to  be  sure  of  being  external  to  the  internal  mammary  artery,  and 
then  it  is  apt  to  strike  the  pleura.     (See  Fig.  570.) 

Landmarks. — Fifth  left  intercostal  space  (or  sixth) ;  left  margin  of  sternum; 
course  of  internal  mammary  artery;  anterior  border  of  left  lung  and  pleura; 
right  border  of  heart.     See  the  Surgical  Anatomy  of  these  structures. 

Operation.— (1)  An  incision  should  be  made  in  the  long  axis  of  the  sternal 
end  of  the  fifth  intercostal  space,  through  skin,  fascia,  pectoralis  major,  down 
to  the  intercostal  membrane,  clamping  all  bleeding  vessels.  (2)  Expose  the  in- 
tercostal membrane  by  retraction  of  the  edges  of  the  wound.  Grasping  the 
needle  with  right  forefinger  and  thumb,  so  placed  as  to  prevent  its  suddenly 
entering  too  far,  pierce  the  fifth  intercostal  space  near  the  left  border  of  the 
sternum,  and  near  the  upper  border  of  the  sixth  costal  cartilage — penetrate 
straight  backward  about  0.8  cm.  (about  j\  inch),  which  is,  approximately,  the 
thickness  of  the  sternum — then  penetrate  inward  toward  the  posterior  surface 
of  the  sternum  for  1  to  2  cm.  (f  to  if  inch),  to  avoid  the  possible  forward 
extension  of  the  pleura — thence  penetrate  downward  and  inward  through  the 
pericardium — the  sensation  generally  indicating   when   the   pericardium   is 


782 


OPERATIONS    UPON    THE   THORAX. 


entered.  Briefly  stated — pass  backward,  inward,  and  downward  (Delorme 
and  Mignon).  Where  the  sixth  intercostal  space  is  used,  the  needle  is  passed 
directly  inward  and  backward,  close  to  the  sternum  and  in  the  middle  of  the 
interspace  (Voinitch-Sianojentsky) . 

Comment. — Puncture  may  be  made  without  previous  incision,  but  pre- 
liminary incision  is  better,  as  the  intercostal  space  and  border  of  the  sternum 
are  exposed,  and  the  course  and  depth  of  the  needle  and  entrance  into  the 
pericardium  are  better  appreciated.  Also  the  bridge  of  cartilage  across  the 
intercostal  space,  when  present,  may  be  avoided.  There  is  less  danger  of 
wounding   the   heart  in   the  sixth  interspace. 


Fig.  570. — Sites  for  Pericardiocentesis: — The  uncovered  area  of  the  heart  and  the 
course  of  the  internal  mammary  artery  are  shown.  Paracentesis  is  preferably  made  to  the  inner 
side  of  the  internal  mammary  artery,  in  the  sixth  (by  choice)  or  fifth  intercostal  space,  close  to 
the  margin  of  the  sternum, — or  to  the  outer  side  of  the  artery,  in  the  fifth  or  iourth  interspace, 
from  2.5  to  5  cm.  (1  to  2  inches)  outside  of  the  sternal  border.      (Thorax  modified  from  Deaver.) 


PERICARDIOTOMY 

THROUGH   AN   INTERCOSTAL  INCISION. 

Description. — Incision  of  the  pericardium  through  the  fifth  intercostal 
space — generally  resorted  to  for  purposes  of  drainage.  The  method  here 
described  will  be  the  simpler  one  of  exposing  and  incising  the  pericardium 
through  an  intercostal  incision.     The  more  extensive  exposures  involve  the 


PERICARDIOTOMY. 


783 


removal  of  part  of  the  cartilaginous  or  bony  wall  of  the  thorax.  The  inter- 
space where  the  operation  of  intercostal  pericardiotomy  is  usually  done  is 
so  narrow  that  the  operation  by  excision  of  the  fifth  costal  cartilage  is  much 
preferable. 

Preparation  and  Position. — As  for  Paracentesis  Pericardii. 

Landmarks. — Sternal  end  of  left  fifth  intercostal  space  (between  fifth 
and  sixth  rib-cartilages) ;  and  other  landmarks  mentioned  under  Paracentesis 
Pericardii. 

Incision. — Incision  in  center  of  fifth  intercostal  space,  parallel  with  its 
long  axis — beginning  at  the  left  sternal  border  and  extending  5  to  7.5  cm. 
(about  2  or  3  inches)  in  length.     (See  Fig.  571,  A.) 


Fi,c  571. — Sites  of.  Incisions  for  Pericardiotomy: — A,  Intercostal  incision  in  fifth 
left  interspace;  B,  Incision  for  excision  of  fifth  left  costal  cartilage:  C,  C,  Kocher"s  sternocostal 
incision  for  excision  of  sixth  and  sometimes  of  fifth  and  fourth  costal  cartilages.  (Thorax  modified 
from  Gray.) 

Operation. — (1)  Incise  skin,  fascia,  pectoralis  major,  external  intercostal 
membrane,  internal  intercostal  muscles — ligating  all  bleeding  vessels.  (2) 
Internal  mammary  artery  is  either  divided  between  two  ligatures,  or,  prefer- 
ablv,  drawn  outward.  (3)  Triangularis  sterni  muscle  is  divided,  or  its  fibers 
separated  by  blunt  dissection.  If  the  pleura  be  in  the  field,  it  will  lie  exposed 
after  passing  through  the  triangularis  sterni,  and  should  be  carefully  dis- 
placed outward.  (4)  The  pericardium  is  now  within  sight  and  touch — and 
is  carefully  seized  and  steadied  by  two  toothed  forceps  and  incised  for  1  to 
2.5  cm.  (about  ^  to  1  inch)  between  them,  in  a  direction  downward  and  out- 
ward from  the  border  of  the  sternum.  (5)  The  edges  of  the  pericardium 
are  sutured  into  the  deeper  plane  of  the  thoracic  wound — that  is,  at  the  opening 
through  the  internal  intercostal  muscle.  Drainage  is  established  from  the 
interior  of  the  pericardium  through  the  lowest  part  of  the  outer  wound,  the 
upper  portion  of  which  may  be  closed. 

Comment. — (a)  The  pericardium  should  be  opened  with  scissors,  and 
the  opening  increased  by  blunt-pointed  scissors  or  probe-pointed  knife, 
(b)  Pericardiotomy  may  also  be  performed,  but  less  safely,  through  the 
costo-xiphoid  angle  (Larrey's  space). 


784  OPERATIONS    UPON    THE   THORAX. 

EXPOSURE  OF  PERICARDIUM  AND  HEART 

FA'  EXCISION  OF  LEFT  FIFTH  COSTAL  CARTILAGE. 

Description. — Exposure  of  pericardium  and  heart  after  excision  of  the 
left  fifth  costal  cartilage — and,  where  more  room  is  required,  also  of  the 
fourth  and  sixth  costal  cartilages.  Generally  resorted  to  for  suturing  wounds 
of  the  heart  and  pericardium  and  for  drainage  of  the  latter — especially  in 
those  cases  where  more  space  is  required  than  attainable  by  the  intercostal 
operation. 

Preparation — Position. — As  for  Paracentesis  Pericardii. 

Landmarks. — Left  fifth  costal  cartilage;  and  other  landmarks  men- 
tioned under  Paracentesis  Pericardii. 

Incision. — Directlv  over  center  of  fifth  costal  cartilage — beginning  over 
center  of  sternum  and  ending  just  beyond  chondrocostal  articulations.  (See 
Fig.  571,  B.) 

Operation. — (1)  Incise  skin,  superficial  fascia,  pectoralis  major,  and 
deep  fascia  directly  down  upon  the  full  length  of  the  fifth  costal  cartilage, 
ligating  all  vessels  severed.  (2)  Isolate  the  fifth  costal  cartilage  from  its 
neighboring  structures  (external  intercostal  membrane,  internal  intercostal 
muscle,  and  triangularis  sterni,  if  any  of  the  last  be  attached)  as  completely 


I- if;.  5  72—  Exposlrk  of  Pkricardhm  and  Hkart  by  Partial  Excision  of  Left  Fifth 
Costal  Cartilage  :— A,  Pectoralis  major  muscle  retracted,  overlying  the  retracted  intercostal 
muscles  and  membrane;  B,  Internal  mammary  vessels;  C,  Intercostal  vessels;  D,  Sternum  and 
part  of  fifth  costal  cartilage;  E.  Pleura  and  lung  retracted;  F,  Pericardium,  incised  and  margins 
retracted  ;  G,  Heart,  showing  incised  wound  being  sutured. 

as  possible,  by  hugging  and  clearing  the  cartilage  closely.  Divide  its  sternal 
and  costal  ends  with  blunt-pointed  pliers — or,  preferably,  with  Gigli  saw. 
(3)  Ligate  the  intercostal  vessels  at  both  ends  of  the  wound  and  divide  them 
between  the  ligatures.  Divide  tissues  which  intervene  between  bed  of  carti- 
lage and  internal  mammary  artery.  Cut  the  internal  mammary  artery  be- 
tween two  ligatures,  or  draw  it  outward.  Incise  the  triangularis  sterni  if 
necessary,  or  separate  it  from  the  sternum  and  push  it  to  the  right.  Displace 
the  pleura  outward,  after  careful  separation  from  the  pericardium  and  sternal 
structures.  (4)  The  pericardium  is  now  in  the  field,  and  is  treated  as  indi- 
cated by  the  object  of  the  operation; — In  Pericardiotomy  (for  drainage)  the 


SURGICAL    ANATOMY    OF    THE    HEART.  785 

pericardium  is  steadied  between  two  toothed  forceps  and  carefully  incised 
obliquely  downward  and  outward  from  close  to  the  border  of  the  sternum; — 
In  Pericardiorrhaphy  (for  incised  wounds  of  the  pericardium)  the  lips  of  the 
pericardial  wound  are  approximated  and  so  sutured  with  catgut  as  to  bring 
the  serous  surfaces  together.  (5)  Where  the  pericardium  has  been  incised 
for  drainage,  it  is  sutured  into  the  lower  plane  of  the  outer  wound — that  is, 
the  triangularis  sterni  and  internal  intercostal  muscles.  The  external  wound 
is  closed  in  greater  part,  and  drainage  provided  from  the  interior  of  the  peri- 
cardium through  the  part  of  the  thoracic  wound  left  open.  Where  the  peri- 
cardium has  been  sutured,  temporary  drainage  of  the  external  wound  only 
is  instituted,  through  a  limited  opening — the  remainder  of  the  thoracic  wound 
being  closed.     (See  Fig.  572.) 

Comment. — (a)  This  may  be  considered  the  best  manner  of  exposing 
the  pericardium  and  heart — and  the  opening  of  the  pericardium  after  free 
exposure  may,  ordinarily,  be  considered  safer  than  puncture  or  aspiration 
through  an  unopened  thorax,  (b)  Having  excised  the  fifth  costal  cartilage 
by  the  above  incision,  if  more  room  be  required,  or  it  be  desired  also  to  remove 
the  fourth  and  sixth  costal  cartilages  in  addition,  the  object  may  be  accom- 
plished by  making  a  vertical  incision  at  the  inner  end  of  the  original  incision, 
down  the  center  of  the  sternum,  and  another  vertical  incision  at  the  outer  end 
of  the  original  incision.  Where  both  the  fourth  and  sixth  costal  cartilages 
are  to  be  removed,  these  two  vertical  incisions  will  extend  from  above  the 
fourth  to  just  below  the  sixth  cartilages,  thus  making  an  M-shaped  incision, 
and  enabling  two  flaps  of  soft  parts  down  to  the  cartilages  to  be  turned,  the 
one  upward,  and  the  other  downward.  If  it  be  desired  to  remove  only  the 
fourth  cartilage  in  addition,  then  only  the  upper  parts  of  the  vertical  incisions 
are  added.  If  only  the  sixth  cartilage  must  be  additionally  removed,  then 
only  the  lower  parts  of  the  vertical  incisions  are  used.  If  it  be  known  from 
the  start  that  two  or  more  costal  cartilages  must  be  removed,  an  oval  or  modi- 
fied horseshoe  flap  of  soft  parts  with  its  base  over  the  sternum  and  its  con- 
vexity extending  beyond  the  outer  limit  of  the  excision,  may  be  used, — or  an 
I-shaped  incision,  the  vertical  portion  being  from  1  to  2  cm.  (about  h  to  f  inch) 
from  the  sternum,  the  transverse  parts  corresponding  with  the  uppermost 
and  lowermost  ribs  to  be  removed,  may  be  used,  the  two  flaps  thus  outlined 
being  turned  inward  and  outward.  Additional  room  may  always  be  gotten 
by  resecting,  with  rongeur  forceps,  the  left  border  of  the  sternum. 

Comment. — Where  a  greater  exposure  is  necessary,  Kocher's  sternocostal 
incision  may  be  made — through  which  not  only  the  sixth,  but  the  fifth  and 
fourth,  costal  cartilages  may  be  excised  (Fig.  571,  C,  C). 

PERICARDIORRHAPHY. 

Consists  in  the  suturing  of  wounds  of  the  pericardium.  The  operation 
is  sufficiently  described  under  Exposure  of  the  Pericardium  and  Heart  by 
Excision  of  the  Left  Fifth  Costal  Cartilage  (page  784). 


XL  THE  HEART. 
SURGICAL  ANATOMY. 

Position  of  the  Heart  and  Its  Various  Parts. — Occupies  greater  por- 
tion of  middle  mediastinum — lying  obliquely  behind  lower  two-thirds  of 
sternum — and  projecting  about  7.5  cm.  (about  3  inches)  to  left  of  median  line, 

5° 


786  OPERATIONS    UPON    THE    THORAX. 

and  about  4  cm.  (about  1^  inches)  to  right  of  median  line — extending  from 
above  to  the  right,  to  below  and  to  the  left.  Base ;  directed  upward,  back- 
ward, and  to  the  right,  corresponding  to  interval  between  fifth  and  ninth  dorsal 
vertebra?.  Apex;  directed  downward,  forward,  and  to  left,  corresponding 
to  chest-wall  between  fifth  and  sixth  costal  cartilages — at  a  point  about  2  cm. 
(about  I  inch)  to  inner  side,  and  about  4  cm.  (about  ij  inches)  below  left 
male  nipple.  Inferior  border;  corresponds  to  right  ventricle  and  rests  on 
central  tendon  of  diaphragm.  Anterior  border ;  corresponds  to  right  auricle. 
Left  border;  corresponds  to  left  ventricle.  Anterior  surface;  formed 
mainly  by  right  ventricle  and  part  of  left.  Posterior  surface;  formed 
mainly  by  left  ventricle. 

Relations  of  Heart  to  Chest-wall. — Base;  corresponds  to  line  from 
point  on  lower  border  of  second  left  costal  cartilage  2.5  cm.  (1  inch)  from 
sternum,  to  upper  border  of  third  right  costal  cartilage  1.2  cm.  (about  J  inch) 
from  sternum.  Apex;  corresponds  to  point  3.8  cm.  (about  1^  inches)  below, 
and  2  cm.  (f  inch)  internal  to  left  male  nipple — which  is  about  9  cm.  (about 
3^  inches)  to  left  of  median  line,  and  between  fifth  and  sixth  costal  cartilages, 
and  just  internal  to  end  of  fifth  rib.  Lower  border ;  corresponds  to  line  from 
apex,  with  slight  downward  convexity,  to  seventh  right  chondro- sternal 
articulation.  Right  border;  represented  by  line  joining  right  extremity 
of  base-line  with  right  extremity  of  lower  border-line  (seventh  right  chondro- 
sternal  articulation),  with  a  slight  outward  convexity  projecting  about  3.8 
cm.  (about  1^  inches)  from  median  line.  Left  border;  represented  by  line 
joining  left  extremity  of  base-line  with  apex-point,  with  slight  convexity  to 
left — extending  about  7.6  cm.  (about  3  inches)  to  left  of  median  line  of  sternum. 

Relations  of  Parts  of  Heart  to  Chest-wall. — Right  auricle ;  behind 
sternal  ends  of  third,  fourth,  fifth,  and  sixth  costal  cartilages  of  right  side; 
corresponding  intervening  spaces;  right  border  of  sternum.  Right  auricular 
appendix;  behind  or  to  left  of  median  line,  on  level  with  third  costal 
cartilages.  Left  auricle ;  extends  vertically  from  level  of  lower  border  of 
second  left  costal  cartilage  to  upper  border  of  fourth — and  corresponds,  hori- 
zontally, with  body  of  seventh  dorsal  vertebra  and  heads  of  adjoining  left 
ribs.  Apex  of  left  auricular  appendix;  behind  third  costal  cartilage, 
about  3.2  cm.  (ij  inches)  to  left  of  sternum.  Right  ventricle;  extends 
from  third  costal  cartilage  above,  to  seventh  costal  cartilage  below,  on  left 
side.  Right  auriculo-ventricular  sulcus;  line  obliquely  upward,  from 
sternal  end  of  sixth  right  costal  cartilage,  to  third  left  costal  cartilage.  Left 
ventricle ;  not  in  contact  with  chest-wall,  except  small  part  of  apex  of  left 
ventricle  during  expiration. 

Relations  of  Orifices  of  Heart  to  Chest-wall. — Pulmonary  orifice 
(Pulmonary  Semilunar  Valves) ;  behind  junction  of  upper  border  of  left  third 
costal  cartilage  with  sternum.  Aortic  orifice  (Aortic  Semilunar  Valves); 
behind  left  half  of  sternum,  opposite  lower  border  of  third  costal  cartilage. 
Left  auriculo-ventricular  opening  (Mitral  Valves) ;  behind  sternum,  to 
left  of  median  line,  opposite  fourth  costal  cartilage.  Right  auriculo-ven- 
tricular opening  (Tricuspid  Valves);  behind  center  of  sternum,  opposite 
fourth  intercostal  space. 

Relations  of  Uncovered  Area  of  Heart  to  Chest-wall. — The  triangular 
area  of  the  heart  uncovered  by  pleura  is  represented  within  the  three  following 
lines; — (a)  Draw  line  downward  and  to  left  from  middle  of  sternum,  between 
fourth  costal  cartilages,  to  apex  of  heart;  (b)  Draw  line  from  starting-point 
of  first  line  down  the  lower  third  of  the  central  line  of  the  sternum; — (c)  Draw 
line  from  sternal  end  of  sixth  right  costal  cartilage  through  seventh  left  costal 
cartilage. 


PARACENTESIS    OF    RIGHT    VENTRICLE    OF    HEART.  787 

Arteries. — Anterior  and  posterior  coronary. 
Veins. — Correspond  with  arteries,  emptying  into  right  auricle. 
Lymphatics. — End  in  thoracic  and  right  lymphatic  ducts. 
Nerves. — From  cardiac  plexus. 


PARACENTESIS  OF  RIGHT  AURICLE  OF  HEART. 

Description. — Puncture  of  right  auricle  of  heart  by  needle  of  aspiratory 
syringe — for  the  purpose  of  withdrawing  a  portion  of  the  blood  in  cases  where 
the  right  side  of  the  heart  is  engorged  from  obstruction  to  the  circulation 
through  the  lungs. 

Preparation — Position. — As  for  Paracentesis  Pericardii. 

Landmarks. — Position  of  right  auricle. 

Operation. — An  aspiratory  needle,  so  held  as  to  control  the  depth  of 
puncture,  is  entered  in  the  right  third  intercostal  space,  close  to  the  margin 
of  the  sternum — and  thrust  directly  backward  through  skin,  fascia,  pectoralis 
major,  external  intercostal  membrane,  internal  intercostal  muscle,  probably 
through  fibers  of  triangularis  sterni,  through  areolar  tissue  of  anterior  medi- 
astinum, both  layers  of  pleura,  periphery  of  right  lung,  into  the  right  auricle — 
its  entrance  generally  being  recognized  by  the  sensation,  and  verified  by  the 
free  flow  of  blood  into  the  syringe.  The  requisite  amount  of  blood  is  with- 
drawn— and  the  wound  is  sealed  with  sterile  cotton  and  collodion.     (See 

Fig-  573,  D.) 

Comment. — (a)  A  preliminary  incision  may  be  made  in  the  intercostal 
space,  down  to  the  intercostal  membrane — whereby  the  entrance  of  the 
needle  into  the  auricle,  especially  in  thick  thoracic  walls,  is  more  readily 
recognized.  However,  in  using  a  vacuum  syringe,  this  is  not  generally  neces- 
sary, (b)  It  is  necessary  to  withdraw  blood  by  suction,  as  the  blood-pressure 
in  the  right  auricle  is  not  sufficient  to  cause  spontaneous  flow,  (c)  The  right 
auricle  is  preferable  to  the  right  ventricle  for  operation,  because  its  position 
is  not  apt  to  be  altered  and  its  internal  antero-posterior  diameter  is  greater 
than  that  of  the  richt  ventricle. 


PARACENTESIS  OF  RIGHT  VENTRICLE  OF  HEART. 

Description. — Puncture  of  right  ventricle  of  heart  by  needle  of  aspiratory 
syringe,  or  by  fine  trocar  and  cannula — in  the  same  cases  as  mentioned  under 
Paracentesis  of  Right  Auricle  (q.  v.). 

Preparation — Position. — As  in  Paracentesis  of  Right  Auricle. 

Landmarks. — Position  of  Right  Ventricle. 

Operation. — The  cannula  and  trocar,  or  needle,  are  entered  in  the  fourth 
right  intercostal  space,  2.5  cm.  (about  1  inch)  from  the  right  sternal  border. 
It  is  manipulated  as  in  Paracentesis  Auriculi — and  passes  through  practically 
the  same  structures — but  is  directed  inward  as  well  as  backward,  in  order  to 
strike  the  right  ventricle,  which,  normally,  might  not  be  certainly  reached, 
but  which  is  reached  with  greater  certainty  when  thus  engorged.  The 
requisite  amount  of  blood  is  allowed  to  flow  spontaneously — and  the  wound 
is  then  sealed  with  sterile  cotton  and  collodion.     (See  Fig.  573,  E.) 

Comment. — Blood-pressure  in  the  right  ventricle  is  sufficient  to  cause 
spontaneous  flow  through  the  cannula.  See  Comment  under  Paracentesis 
Auriculi. 


788  OPERATIONS    UPON    THE    THORAX 

EXPOSURE   OF  THE   HEART   AND  PERICARDIUM 

BY    A    THORACOPLASTIC    FLAP — ROTTER'S    OPERATION. 

Description. — The  heart  is  exposed  through  a  thoracoplasty  flap  con- 
sisting of  the  fourth  and  fifth  costal  cartilages  and  parts  of  the  corresponding 
ribs.  No  attempt  to  preserve  the  pleura  intact  is  made — as  that  membrane 
is  almost  always  involved  in  the  injury  and  it  is  generally  indicated  to  remove 
blood  from  its  cavity. 

Preparation. — As  pneumothorax  may  have  occurred  prior  to  operation, 


Fig-  573- — Sites  for  Paracenteses  and  Lines  for  Exposures  of  the  Heart: — D, 
Paracentesis  of  right  auricle;  E,  Paracentesis  of  right  ventricle;  A,  Rotter's  thoracoplastic  flap; 
B,  Fontan's  thoracoplastic  flap;  C,  Kocher's  thoracoplastic  flap.  (Thorax  modified  from 
Deaver.) 

or  may  take  place  in  the  course  of  the  operation,  the  operation  may  be  per- 
formed in  Sauerbruch's  chamber  (negative  atmospheric  pressure)  or  in  Bauer's 
apparatus  (increased  pressure).  In  this  way  the  collapse  of  the  lungs  and, 
therefore,  of  the  heart  is  avoided. 

Position. — Patient  supine,  preferably  resting  upon  some  object  which 
will  elevate  the  chest  and  render  it  prominent  and  thus  increase  the  width  of 
the  intercostal  spaces. 

Landmarks. — Left  border  of  sternum;  third,  fourth,  and  fifth  ribs  and 
their  cartilages;  mammary  line. 


EXPOSURE    OF    THE    HEART    AND    PERICARDIUM. 


789 


Incision. — A  flap  is  outlined  with  its  hinge  near  the  left  border  of  the 
sternum — beginning  about  2  cm.  (f  inch)  from  the  left  margin  of  the  sternum. 
These  incisions  are  continued  along  the  lower  borders  of  the  third  and  fifth 
ribs — and  may  extend  outward  in  the  interspaces  as  far  as  the  mammary  line. 
Their  outer  ends  are  connected  by  a  vertical  incision  (Fig.  573,  A). 

Operation. — (1)   In  the  horizontal  incisions  are  divided  the  skin,  fascia, 


Fig.  S74- — Rotter's  Osteoplastic  Exposure  of  Heart  and  Pericardium: — A,  Fifth  rib; 
B,  Fourth  rib;  C,  Intercostal  muscles;  D,  Pectoralis  major;  E,  Costochondral  junction  (frac- 
tured); F,  Internal  mammary  vessels;  G,  Parietal  pleura;  H,  Fatty  tissue  over  pericardium; 
I,  Visceral  pleura,  with  lung  showing  through;  J,  J,  Incised  pericardium  retracted;  K,  Traction- 
suture  in  apex  of  heart.     (Modified  from  Rockenheimer  and  Frohse.) 

pectoralis  major  and  minor,  intercostals,  and  generally  the  parietal  layer  of  the 
pleura  (Fig.  574).  The  vertical  incision  does  not  at  first  go  deeper  than  the 
pectoral  muscles.  The  intercostal  vessels  are  ligated  and  the  fourth  and  fifth 
ribs  divided — and  the  incision  is  then  carried  to  the  pleura.  (2)  The  entire 
cutaneomusculo-periosteo-osseous  flap  is  now  turned  upward  and  inward. 
Even  if  the  pleura  have  previously  escaped,  it  may  be  torn  in  the  process  of 


790  OPERATIONS    UPON    THE   THORAX. 

exposure  and  turning  back  of  the  flap.  Pneumothorax  should  be  prevented 
by  drawing  the  lung  forward  and  suturing  it  to  the  intercostal  muscles — or  the 
opening  in  the  pleura  may  be  covered  by  gauze  tampons,  the  lung  being  pushed 
backward  and  outward.  When  the  flap  is  turned  upward  and  inward,  the 
triangularis  sterni  muscle  is  torn.  The  costal  cartilages  are  apt  to  break  near 
their  articulations — disarticulation  should,  however,  be  carried  out.  The 
internal  mammary  artery  is  generally  left  intact.  (3)  The  fatty  areolar  tissue 
over  the  pericardium  is  retracted  and  the  pericardium  incised  in  its  longitudinal 
axis,  from  its  infero-external  aspect.  Fixation  sutures  are  introduced  into  the 
muscular  tissue  of  the  apex  of  the  heart  if  necessary  to  steady  it  in  the  indicated 
manipulations.  All  accumulated  blood  in  the  pericardium  is  removed.  (4) 
The  special  object  of  the  operation  is  now  accomplished.  Unless  specially 
indicated,  the  pericardium  is  sutured  without  drainage  (as  the  constant  impact 
of  the  heart  against  the  drain  is  apt  to  produce  pericarditis).  Drainage  may 
be  used  down  to  the  pericardium,  in  closing  the  wound. 


CARDIORRHAPHY. 

Description. — Suturing  of  wounds  of  the  heart-muscle — after  having 
freely  exposed  the  organ  by  the  operation  just  described  or  by  one  of  those 
mentioned  in  the  preceding  pages. 

Preparation — Position. — As  for   Paracentesis   Auriculi. 

Landmarks. — The  landmarks  will  be  those  of  the  operation  by  which  the 
heart  is  exposed.  For  the  fullest  exposure,  the  osteoplastic  resection  for 
exposure  of  the  anterior  and  middle  mediastina  is  probably  best — see  page 
750.  For  a  less  extensive  exposure,  the  resection  of  the  fifth  costal  cartilage 
may  be  used — see  page  784.  Additionally,  the  landmarks  of  the  parts  of  the 
heart  should  be  noted. 

Operation. — (1)  The  pericardium  having  been  exposed  and  the  wound 
in  it  enlarged,  if  necessary,  the  heart  is  brought  into  the  held.  (2)  Silk,  upon 
a  fully  curved  needle,  held  in  a  good  needle-holder,  is  used.  The  needle 
is  quickly,  but  gently  and  steadily,  inserted  during  diastole  only,  and 
no  attempt  is  made  to  proceed  with  the  operation  except  during  diastole. 
The  needle  enters  about  4  to  5  mm.  (about  f,;  to  yV,  inch)  from  one  edge — 
penetrates  moderately  deeply  only  (never  entering  the  endocardium)  — 
crosses  the  gap  between  the  walls  of  the  wound  (or  may  dip  beneath  the 
bottom  of  the  wound,  if  the  wound  does  not  entirely  penetrate  the  wall  of  the 
heart  and  there  is  room  beneath  it  for  suture  to  pass  without  entering  the 
endocardium) — and  makes  its  exit  at  a  corresponding  point  on  the  opposite 
side.  During  a  subsequent  diastole  the  thread  is  drawn  through  the  lips  of 
the  wound — and,  during  still  another,  knotted.  After  the  first  suture  has 
been  placed,  gentle  traction  upon  it  steadies  the  heart  while  placing  the  others. 
(3)  The  pericardial  wound  might  also  be  sutured  in  a  perfectly  clean  case — 
but,  practically,  it  is  better  to  temporarily  leave  it  open,  lightly  packing  the 
mouth  of  the  pericardial  wound  and  carrying  drainage  through  that  part  of 
the  external  wound  not  closed.     (See  Fig.  572.) 

Comment. — When  the  needle  enters  the  heart,  there  is  a  momentary 
stoppage,  followed  by  brief  tumultuous  action. 


BRONCHOTOMY.  79 1 

XII.  THE  THORACIC  TRACHEA. 
SURGICAL  ANATOMY. 
See  Trachea  under  Operations  upon  the  Xeck  (page  702). 

THORACIC  TRACHEOTOMY 

BY    POSTERIOR    MEDIASTINAL    THORACOPLASTIC    FLAP    OPERATION. 

See  Posterior  Mediastinal  Thoracotomy  (page  752).  The  exposure  and 
incision  of  the  trachea  in  the  posterior  mediastinum  is  resorted  to  for  the 
removal  of  foreign  bodies  situated  too  low  in  the  trachea  to  be  accessible  and 
removable  from  a  cervical  tracheotomv  wound. 


XIII.   THE  BRONCHI. 
SURGICAL  ANATOMY. 

Relations. — (1)  Right  bronchus;  vena  azygos  major  passes  above  bron- 
chus from  behind  forward,  on  its  way  to  superior  vena  cava ;  right  pulmonary 
arteryliesat  first  below  and  then  in  front  of  bronchus.  (2)  Left  bronchus; 
passes  beneath  arch  of  aorta,  resting  upon  esophagus,  thoracic  duct,  and  de- 
scending aorta;  left  pulmonary  artery  lies  at  first  above  and  then  in  front  of  it. 

Differences  in  the  Bronchi. — (1)  Right  bronchus;  about  2.5  cm. 
(about  1  inch)  long;  wider,  shorter,  and  more  horizontal  than  left;  enters 
right  lung  opposite  fifth  dorsal  vertebra.  About  2  cm.  (about  f  inch)  from 
origin,  the  upper  or  eparterial  branch  of  bronchus  is  given  off  above  right 
pulmonary  artery  to  upper  lobe  of  lung:  the  main  bronchus,  or  hyparterial 
branch,  passes  below  and  behind  right  pulmonary  artery  and  divides  into 
two  branches,  for  middle  and  lower  lobes.  2  Left  bronchus;  about  5 
cm.  (about  2  inches)  long;  smaller,  longer,  and  more  oblique  than  right: 
enters  left  lung  opposite  sixth  dorsal  vertebra  (about  2.5  cm.,  or  1  inch,  lower 
than  right).  Left  bronchus  is  entirely  below  left  pulmonary  artery  (hypar- 
terial), and  divides  into  two  branches,  for  upper  and  lower  lobes.  Note. — In 
majoritv  of  cases,  right  bronchus  seems  a  more  direct  continuation  of  trachea 
than  left  (that  is,  the  dividing  ridge  between  the  two  bronchi  lies  more  to  the 
left) — although  the  left  is  the  more  oblique  in  direction — wherefore,  foreign 
bodies  are  more  frequently  lodged  in  the  right  bronchus. 

Arteries. — Bronchial  branches  of  thoracic  aorta. 

Veins. — Bronchial — emptying  into  vena  azygos  major  on  right  side — and 
into  superior  intercostal  vein  on  left. 


BRONCHOTOMY. 

Description. — Exposure  and  incision  of  the  bronchial  tubes.  Generally 
resorted  to  for  the  removal  of  foreign  bodies — and  sometimes  for  the  drainage 
of  bronchiectatic  cavities.  The  manner  and  site  of  the  operation  will  depend 
upon  the  circumstances  of  the  individual  case — the  manner  of  approach  being 
by  one  of  the  procedures  already  described. 

Where  Bronchotomy  is  done  for  the  removal  of  foreign  bodies,  the  main 
bronchi  are  the  ones  usually  opened — and  are  exposed  through  a  Posterior 
Mediastinal  Thoracotomy,  by  means  of  the  osteoplastic  flap  operation  de- 
scribed at  page  752.  The  bronchi  are  opened  as  the  trachea  is  opened  in  that 
operation — either  directly  over  the  foreign  body — or  at  the  site  most  accessible 


792  OPERATIONS    UPON   THE    THORAX. 

to  the  object — the  object  being  sought,  in  the  latter  case,  by  slender,  curved 
forceps  introduced  through  the  opening  in  the  bronchus.  Both  the  bronchial 
wound  and  the  outer  wound  are  treated  as  in  the  operation  to  which  reference 
has  been  made. 

Where  Bronchotomy  is  performed  to  afford  drainage  in  a  case  of  dilated 
bronchial  tube,  in  Bronchiectasis,  the  operation  is  practically  the  same  as 
Pneumotomy  for  abscess,  etc.  The  operation  is  rarely  of  much  avail,  unless 
it  be  practically  a  single,  defined  cavity  in  an  accessible  site,  previously  well 
located.     (See  Fig.  559,  J.) 


XIV.   THE  THORACIC  ESOPHAGUS. 

SURGICAL  ANATOMY. 
See  Esophagus  under  Operations  upon  the  Neck  (page  711). 

THORACIC  ESOPHAGOTOMY 

BY  POSTERIOR  MEDIASTINAL  OSTEOPLASTIC  ELAP  OPERATION. 

See  Posterior  Mediastinal  Thoracotomy  (page  752). 

Exposure  and  incision  of  the  esophagus  in  the  posterior  mediastinum  are 
resorted  to  for  the  removal  of  foreign  bodies  situated  too  low  in  the  esophagus 
to  be  accessible  and  removable  from  a  cervical  esophagectomy. 

Having  isolated  the  esophagus,  as  described  in  the  operation  mentioned, 
and  having  located  the  foreign  body,  the  esophagus  is  steadied  with  toothed 
forecps,  if  necessary — an  incision  in  its  longitudinal  axis  is  made — the  lips 
of  the  wound  are  held  apart  by  two  pairs  of  toothed  forceps,  and  the  foreign 
body  removed  with  appropriate  forceps.  The  opening  into  the  esophagus 
should  be  made  upon  its  lateral  aspect  (generally  the  left  aspect).  The 
wound  in  the  esophagus,  in  favorable  cases,  may  be  sutured  with  catgut — 
for  drainage  may  take  place  into  the  stomach  (where  in  a  corresponding 
operation  upon  the  trachea,  or  bronchi,  drainage  is  by  means  of  the  external 
wound,  and  suturing  of  the  trachea  or  bronchus  is  not  indicated).  Drainage 
is  instituted  from  the  wall  of  the  esophagus  through  the  outer  wound.  (See 
Fig-  559,  K0 


CHAPTER  V. 

OPERATIONS  UPON  THE  ABDOMINO-PELVIC 

REGION. 

L  THE  ABDOMINO-PELVIC  WALL. 
SURGICAL  ANATOMY  OF  THE  ABDOMINO-PELVIC  WALL. 

Boundaries  of  the  Abdomino-pelvic  Cavity. — Above ;  concave  dome 
of  diaphragm.  Below;  levatores  ani  and  coccygei  muscles  ("diaphragm 
of  pelvis").     Laterally;  lower  thoracic,  and  abdominal  and  pelvic  walls. 

Boundaries  of  Abdominal  Cavity. — Superiorly;  central  tendon  of  dia- 
phragm (rising  to  about  inferior  end  of  sternum,  or  seventh  chondro-sternal 
joint);  right  half  of  diaphragm  (to  about  level  of  fifth  rib,  or  about  2.5  cm.,  or 
1  inch,  below  right  male  nipple) ;  left  half  of  diaphragm  (rising  not  quite  so 
high  as  right) ;  costal  arches  and  ensiform  process  of  sternum.  Inferiorly ; 
ileo-pectineal  lines,  laterally;  crest  of  pubic  bones,  anteriorly;  base  of  sacrum 
and  sacro-vertebral  angle,  posteriorly;  Poupart's  ligaments,  superficiallv. 

Boundaries  of  Pelvic  Cavity. — Superiorly;  ileo  pectineal  lines,  later- 
ally; crest  of  pubic  bones,  anteriorly;  base  of  sacrum  and  sacro-vertebral 
angle,  posteriorly.  Inferiorly;  Anteriorly;  pubic  arch  and  subpubic  liga- 
ment; rami  of  os  pubis  and  ischium; — Posteriorly;  great  sacro-sciatic  liga- 
ments and  tip  of  coccyx; — Laterally;  tuberosities  of  ischia. 

Regions  of  the  Abdomino-pelvic  Cavity  and  Their  Contents. — Basis  of 
divisions ;  Two  horizontal  lines  are  drawn — one  corresponding  with  the 
lowest  part  of  the  tenth  costal  arch — the  other  with  the  most  prominent  lateral 
points  of  the  iliac  crests; — and  two  vertical  lines  are  made  to  intersect  these 
passing  upward  from  the  center  of  Poupart's  ligaments — thus  forming  the 
nine  following  regions  (Quain) ; — Epigastric  ;  most  or  all  of  left  lobe  of  liver; 
part  of  right  lobe  of  liver;  gall-bladder;  part  of  body  and  cardiac  and  pyloric 
orifices  of  stomach;  first  and  second  parts  of  duodenum;  duodeno-jejunal 
flexure;  pancreas;  supero-internal  part  of  spleen;  parts  of  both  kidneys; 
suprarenal  bodies.  Right  hypochondriac;  most  of  right  lobe  of  liver; 
hepatic  flexure  of  colon;  part  of  right  kidney.  Left  hypochondriac;  por- 
tion of  stomach;  greater  part  of  spleen;  tail  of  pancreas;  splenic  flexure  of 
colon;  part  of  left  kidney;  part  of  left  lobe  of  liver  (sometimes).  Umbilical; 
most  of  transverse  colon;  third  part  of  duodenum;  some  convolutions  of 
jejunum  and  ileum;  part  of  mesentery;  part  of  great  omentum;  part  of 
right  kidney  (sometimes  parts  of  both).  Right  lumbar;  ascending  colon; 
portion  of  right  kidney;  part  of  ileum  (sometimes).  Left  lumbar;  de- 
scending colon;  part  of  jejunum;  small  part  of  left  kidney  (sometimes). 
Hypogastric  ;  convolutions  of  ileum;  bladder  in  children  (and  in  adults  when 
distended);  gravid  uterus;  sigmoid  loop;  upper  portion  of  rectum.  Right 
iliac;  caecum,  with  vermiform  appendix;  end  of  ileum.  Left  iliac;  sig 
moid  colon;  convolutions  of  jejunum  and  ileum. 

793 


794  OPERATION'S    UPON    THE    ABDOMINO-PELVIC    REGION. 

Apertures  in  the  Abdominal  Wall. — Above;  those  through  the  dia- 
phragm (see  that  structure,  page  756).  Below;  for  femoral  vessels ;  for  sper- 
matic curd.     Anteriorly;  umbilicus. 


Fig.  575- — Distribution  of  Nerves  to  Antero-lateral  Abdominal  Wall:— The 
Intercostal' (upper  six)  nerves  are  distributed  to  the  chest  proper; — The  lower  abdominal  inter- 
costal (lower  six)  nerves  pass  forward  from  the  intercostal  spaces,  between  the  internal  oblique 
and  transversalis  muscles,  to  the  sheath  of  the  rectus.     (Modified  from  an  unplaced  source.) 

Structures  of  Antero-lateral  Abdominal  Wall. — (From  without  in- 
ward)— skin;  superficial  fascia,  superficial  and  deep  layers;  general  areolar 
tissue  overlying  external  oblique  muscle,  and  special  intercolumnar  fascia 
of  external  abdominal  ring;  external  oblique  and  its  aponeurosis;  internal 
oblique  and  its  aponeurosis;  transversalis  and  its  aponeurosis;  rectus; 
pyramidalis;   fascia  transversalis;   subperitoneal   areolar  tissue;  peritoneum. 

Structures  of  Posterior  Abdominal  Wall.— (J)  Osseous  Portion — five 


SURGICAL    ANATOMY    OF    THE    ABDOMINO-PELVIC    WALL.  795 

lumbar  vertebrae  and  interarticular  fibro-cartilages;  posterolateral  portions 
of  ilia; — (2)  Soft  Portion  (from  without  inward) — skin;  subcutaneous  areolar 
tissue ;  lumbar  aponeurosis  (posterior  layer) ;  erector  spina? ;  lumbar  aponeu- 
rosis (middle  layer)  attached  to  transverse  processes  of  lumbar  vertebrae; 
quadratus  lumborum;  lumbar  aponeurosis  (anterior  layer);  psoas;  crura  of 
diaphragm;  kidney,  areolar  tissue,  and  colon;  subperitoneal  areolar  tissue; 
peritoneum. 

Arteries  of  Antero-lateral  Abdominal  Wall. — Superficial  epigastric, 
superficial  circumflex  iliac,  and  superficial  external  pudic  from  femoral; 
lowest  two  intercostals  from  thoracic  aorta;  abdominal  branches  of  lumbar 
arteries  from  abdominal  aorta;  ilio-lumbar  from  internal  iliac;  deep  circum- 
flex iliac  and  deep  epigastric  from  external  iliac;  superior  epigastric  and 
musculophrenic  from  internal  mammary. 

Arteries  of  Posterior  Abdominal  Wall. — Lumbar  branches  of  abdom- 
inal aorta. 

Veins  of  Antero-lateral  Abdominal  Wall. — Correspond,  chiefly,  with 
the  arteries. 

Veins  of  Posterior  Abdominal  Wall. — Correspond,  chiefly,  with  the 
arteries. 

Lymphatics  of  Antero-lateral  Abdominal  Wall. — Superficial  vessels 
above  umbilicus  empty  into  axillary  glands: — superficial  vessels  below  um- 
bilicus empty  into  inguinal  glands: — deep  vessels  above  umbilicus  empty  into 
sternal  glands  (probably) : — deep  vessels  below  umbilicus  empty  into  iliac 
glands. 

Lymphatics  of  Posterior  Abdominal  Wall. — Median  (aortic)  lumbar 
glands: — lateral  (psoas)  lumbar  glands. 

Distribution  of  Nerves  to  Antero-lateral  Abdominal  Wall  (Fig.  575). — 
Lower  intercostal  nerves;  emerging  from  intercostal  spaces  behind  costal 
cartilages  (except  twelfth,  which  is  subcostal),  they  pass  forward  between  inter- 
nal oblique  and  transversalis  (generally  intercommunicating  here) — penetrate 
outer  edge  of  sheath  of  rectus — supply  rectus — pass  through  its  substance — 
penetrate  anterior  layer  of  rectal  sheath — and  are  distributed  to  skin.  Lateral 
cutaneous  branches  of  lower  intercostal  nerves;  divide  into  Anterior 
Branches  (to  skin  up  to  outer  border  of  rectus,  and  superficial  part  of  external 
oblique)  and  Posterior  Branches  (to  skin  of  outer  part  of  back).  Sixth 
intercostal;  supplies  region  between  lower  end  of  sternum  and  tip  of  end- 
form  cartilage.  Seventh  intercostal;  distributed  to  region  near  lower  end 
of  ensiform  cartilage.  Eighth  intercostal;  runs  up  under  cover  of  costal 
arch  and  supplies  area  of  middle  linea  transversa,  between  tip  of  ensiform 
cartilage  and  umbilicus.  Ninth  intercostal;  runs  directly  forward  on  level 
with  ninth  costal  cartilage  and  supplies  region  just  above  umbilicus.  Tenth 
intercostal;  runs  directly  forward  on  level  with  tenth  costal  cartilage  and  sup- 
plies skin  about  umbilicus.  Eleventh  intercostal;  runs  forward  and  down- 
ward, supplying  the  region  a  little  below  the  umbilicus.  Twelfth  intercostal ; 
passes  in  front  of  quadratus  lumborum,  along  lower  border  of  twelfth  rib — 
pierces  transversalis  and  runs  forward  between  transversalis  and  internal 
oblique — (a)  Anterior  Branch  of  Twelfth  Intercostal,  penetrates  rectus  and 
is  distributed  below  a  point  midway  between  umbilicus  and  pubis — (b) 
Lateral  Cutaneous  Branch  of  Twelfth  Intercostal,  penetrates  internal  oblique, 
then  emerges  from  external  oblique  from  2.5  to  8  cm.  (about  1  to  3  inches) 
above  the  iliac  crest,  and  is  distributed  to  skin  over  front  of  hip.  Ilio-hypo- 
gastric  branch  of  first  lumbar ;  emerges  from  upper  outer  border  of  psoas 


796  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

— runs  in  front  of  quadratus  lumborum  to  iliac  crest — piercing  transversalis 
posteriorly,  and  divides  between  transversalis  and  internal  oblique,  about 
6.5  cm.  (about  2 \  inches)  posterior  to  anterior  superior  iliac  spine  into: — (a) 
Hypogastric  Branch,  passing  forward  between  transversalis  and  internal 
oblique,  pierces  internal  oblique,  then  pierces  aponeurosis  of  external  oblique 
about  2.5  cm.  (about  1  inch)  above  and  just  to  outer  side  of  external  abdominal 
•  ring,  and  supplies  skin  of  hypogastric  and  external  ring  region, — (b)  Iliac 
Branch,  piercing  internal  oblique  and  external  oblique  directly  above  crest  of 
ilium,  and  supplying  skin  of  gluteal  region  posterior  to  lateral  cutaneous 
branch  of  twelfth  dorsal  nerve.  Ilio-inguinal  branch  of  first  lumbar; 
passes  from  outer  border  of  psoas  just  inferior  to  ilio-hypogastric — runs 
obliquely  across  quadratus  lumborum  and  iliacus — penetrates  transversalis 
near  anterior  part  of  iliac  crest  (communicating  here  with  ilio-hypogastric) 
—runs  forward  between  internal  oblique  and  transversalis,  piercing  internal 
oblique  a  little  in  front  of  anterior  superior  iliac  spine — passes  forward  beneath 
aponeurosis  of  external  oblique,  accompanying  cord  through  inguinal  canal 
and  emerging  at  external  abdominal  ring — supplying  skin  of  upper  and  inner 
aspects  of  thigh — and  scrotum  in  male,  and  labium  in  female. 

Distribution  of  Nerves  to  Posterior  Abdominal  Wall. — Posterior 
divisions  of  lumbar  nerves;  dividing  into  internal  and  external  branches. 
Genitocrural  nerve ;  arising  from  first  and  second  lumbar  nerves,  passes 
obliquely  through  psoas,  emerging  from  its  inner  border  opposite  disc  between 
third  and  fourth  lumbar  vertebrae — passing  downward  upon  anterior  surface 
of  psoas  and  dividing,  at  outer  side  of  external  iliac  artery,  into — (a)  Genital 
Branch,  piercing  fascia  transversalis  and  descending  on  posterior  part  of 
spermatic  cord  through  inguinal  canal — emerging  at  external  abdominal  ring 
and  supplying  cremaster  muscle  in  male,  and  round  ligament  in  female. — (b) 
Crural  Branch,  descending  on  external  iliac  artery  and  piercing  femoral 
sheath  about  5  cm.  (about  2  inches)  below  Poupart's  ligament,  to  be  dis- 
tributed to  skin  of  upper  central  part  of  thigh.  External  cutaneous ;  arising 
from  second  and  third  lumbar  nerves,  emerges  from  center  of  outer  border 
of  psoas  and  runs  obliquely  over  iliacus  muscle  to  notch  just  below  anterior 
superior  iliac  spine,  where  it  escapes  beneath  Poupart's  ligament  on  to  thigh. 
Anterior  crural ;  obturator ;  accessory  obturator  nerves — descend  to 
their  distributions  through  the  postero-lateral  aspect  of  the  abdomino-pelvic 
wall. 

Summary  of  Distribution  of  Anterior  Abdominal  Nerves. — Seventh 
and  eighth  run  upward  and  inward  and  supply  upper  third  of  abdominal 
wall; — ninth  and  tenth  run  nearly  transversely  inward  and  supply  middle 
third; — eleventh  and  twelfth,  and  Ilio-hypogastric  and  Ilio-inguinal,  run 
downward  and  inward  and  supply  lower  third  of  abdominal  wall. 

Anterior  Sheath  of  Rectus. — Formed,  above,  by  blending  of  aponeu- 
roses of  external  oblique  and  outer  lamella  of  internal  oblique — below,  by 
blending  of  aponeuroses  of  external  oblique,  internal  oblique,  and  trans- 
versalis. 

Posterior  Sheath  of  Rectus. — Formed,  above,  by  blending  of  aponeu- 
roses of  inner  lamella  of  internal  oblique  and  transversalis;  next  to  which 
come,  in  order,  transversalis  fascia,  subperitoneal  areolar  tissue,  and  parietal 
peritoneum, — below  semilunar  fold  of  Douglas,  by  transversalis  fascia  alone; 
next  to  which  come,  in  order,  subperitoneal  areolar  tissue  and  parietal  peri- 
toneum. 

Linea  Alba. — A  tendinous  raphe,  extending  from  ensiform  cartilage  to 


SURFACE    FORM    AND    LANDMARKS    OF    ABDOMINO-PELVIC    WALL.     797 

symphysis  pubis,  down  median  line  of  abdominal  wall,  and  formed  by  the 
union  of  the  aponeuroses  of  the  obliquus  externus  and  interims  and  the  trans- 
versalis,  between  the  inner  margins  of  the  rectus  muscles.  Most  distinct 
just  above  the  umbilicus.  Practically  absent  below  semilunar  fold  of  Douglas 
— because  from  that  line  downward  the  aponeuroses  of  external  oblique, 
internal  oblique,  and  transversalis  all  pass  in  front  of  rectus  (the  linea  alba 
being  formed  by  the  junction  of  the  anterior  and  posterior  aponeuroses  which 
form  the  sheath  of  the  rectus). 

SURFACE  FORM  AND  LANDMARKS  OF  THE  ABDOMINO-PELVIC 

WALL. 

Linea  alba — extending  from  apex  of  ensiform  cartilage  to  symphysis  pubis 
— broader  above,  narrower  below  the  umbilicus — incomplete  posteriorly 
(only)  in  its  lower  fourth,  where  the  transversalis  fascia  replaces  it.  One  or 
both  borders  of  the  recti  are  apt  to  be  incised  in  operating  below  the  umbilicus. 
Represents  junction  of  inner  borders  of  aponeuroses  of  the  flat  abdominal 
muscles. 

Linear  semilunares — represent  the  line  of  division  of  the  aponeuroses  of 
the  abdomen — correspond  with  the  outer  borders  of  the  recti  muscles — extend 
from  lowest  part  of  seventh  costal  cartilages  to  spines  of  os  pubis,  so  curved 
that  opposite  the  umbilicus  they  are  6  to  7.5  cm.  (2^  to  3  inches)  from  the 
median  line. 

Linea?  transversa? — three  tendinous  intersections  in  the  substance  of  the 
recti  muscles,  forming  transverse  furrows  upon  their  surface — the  upper  one, 
opposite,  or  just  below,  the  tip  of  the  ensiform  cartilage, — the  middle  one, 
between  the  tip  of  the  ensiform  cartilage  and  the  umbilicus  (about  opposite 
the  tenth  costal  cartilage), — the  lower  one,  opposite  the  umbilicus, — (and 
sometimes  a  fourth  one,  below  the  umbilicus). 

Semilunar  fold  of  Douglas — below  which  the  posterior  sheath  of  the  recti 
is  formed  by  transversalis  fascia  alone — about  opposite  the  junction  of  the 
upper  three-fourths  and  the  lower  fourth  of  the  recti  muscles — about  3  cm. 
(1  j  inches)  below  the  umbilicus. 

Abdominal  furrow — extends  from  infrasternal  fossa  to,  or  a  little  below, 
the  umbilicus,  where  it  becomes  lost.     Its  bottom  is  formed  by  the  linea  alba. 

Umbilicus — situated  in  the  linea  alba — always  above  the  level  of  the  highest 
points  of  the  crests  of  the  ilia  (generally  from  2  to  2.5  cm.,  f  to  1  inch,  above) 
— from  2  to  2.5  cm.  (f  to  1  inch)  above  and  to  the  inner  side  of  the  bifurcation 
of  the  abdominal  aorta — opposite  the  tip  of  the  third  lumbar  spine,  or  the 
intervertebral  disc  between  the  third  and  fourth  lumbar  vertebrae. 

Spine  of  the  os  pubis — found  by  following  up  the  tendon  of  the  abductor 
longus — nearly  on  the  same  horizontal  line  as  the  upper  edge  of  the  great 
trochanter — gives  attachment  to  the  outer  pillar  of  the  external  abdominal 
ring. 

Anterior  superior  iliac  spine — the  most  prominent  landmark  of  the  lower 
antero-lateral  abdominal  wall. 

Crests  of  the  iliac  bones — continuations  backward  of  the  anterior  superior 
iliac  spines — found  at  the  bottom  of  the  iliac  furrows,  in  the  fleshy. 

Poupart's  ligament — represented  by  a  line  curved  slightly  downward,  be- 
tween the  anterior  superior  iliac  spine  and  the  pubic  spine. 

Iliac  furrow — corresponds  to  the  iliac  crests — and  formed  by  the  attach- 
ment of  the  external  oblique  muscles  to  these  crests. 


798  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

Sacral  promontory — represented  by  a  transverse  line  between  the  two  an- 
terior superior  iliac  spines. 

Internal  abdominal  ring — situated  about  1.3  cm.  (\  inch)  above  the  center 
of  Poupart's  ligament. 

External  abdominal  ring — situated  just  superior  and  external  to  the  crest 
of  the  os  pubis. 

Aponeuro-muscular  limits  of  external  oblique — the  line  representing  the 
junction  of  the  aponeurotic  and  muscular  portions  anteriorly,  is  one  passing 
from  the  anterior  superior  iliac  spine  to  the  ninth  costal  cartilage  (or  one 
slightly  anterior  to  these  points) ; — The  lower  limit  of  the  fleshy  part  of  the 
external  oblique  is  represented  by  a  transverse  line  from  a  point  on  the  iliac 
crest  2.5  to  5  cm.  (1  to  2  inches)  posterior  to  the  anterior  superior  iliac  spine, 
to  a  corresponding  point  on  the  opposite  side.  The  fibers  of  the  muscle  and 
aponeurosis  run  about  at  a  right  angle  with  a  line  from  the  anterior  superior 
iliac  spine  to  the  umbilicus. 

Aponeuro-muscular  limit  of  the  internal  oblique — Above,  by  an  oblique 
line  from  a  point  below  the  anterior  end  of  the  twelfth  rib  extending  upward 
parallel  with  the  costal  arch, — Internally,  by  a  line  extending  from  the  middle 
of  Poupart's  ligament  upward  and  slightly  outward.  The  upper  line  marks 
the  upper  limit  of  the  muscular  part. 

Aponeuro-muscular  limit  of  the  transversalis — the  median  limit  of  the 
fleshy  part  of  the  transversalis  is  nearer  the  middle  line  of  the  body  above 
and  below  than  at  the  center. 

Deep  epigastric  artery — runs  from  a  point  just  internal  to  the  middle  of 
Poupart's  ligament  upward  and  inward  to  the  inner  aspect  of  the  internal 
abdominal  ring — thence  still  upward  and  inward  to  about  midway  between 
the  pubes  and  umbilicus — and,  passing  beneath  the  semilunar  fold  of  Douglas, 
runs  between  the  sheath  of  the  rectus  and  the  muscle,  finally  piercing  the 
muscle. 

Abdominal  aorta — bifurcates  about  2  cm.  (f  inch)  below  and  to  left  of 
the  umbilicus. 

Cceliac  axis — situated  from  10  to  12.5  cm.  (about  4  to  5  inches)  above 
the  umbilicus. 

Superior  mesenteric  and  suprarenal  arteries — arise  just  below  the  cceliac 
axis. 

Renal  arteries — arise  about  1.2  cm.  (J  inch)  below  the  superior  mesenteric. 

Inferior  mesenteric — arises  about  2.5  cm.  (1  inch)  above  the  umbilicus. 

Peritoneal  reflection  from  bladder  on  to  lower  abdominal  wall — see  under 
the  Bladder,  page  1093. 

Posterior  superior  spinous  process  of  ilium — generally  marked  by  a  de- 
pression on  a  level  with,  and  on  either  side  of,  the  spinous  process  of  second 
sacral  vertebra. 

Spinous  process  of  third  sacral  vertebra — generally  to  be  felt  below  the 
second  sacral  vertebra,  which  last  is  nearly  always  detectable. 

Outer  border  of  erector  spinae — generally  felt  by  deep  palpation  made  to 
the  outer  side  of  and  parallel  with  the  vertebral  column.  See  Surgical  Land- 
marks of  the  Kidney,  page  105 1. 


GENERAL  SURGICAL  CONSIDERATIONS.  799 


GENERAL  SURGICAL  CONSIDERATIONS  IN  OPERATIONS  UPON  THE 
ABDOMINO-PELVIC  CAVITY. 

Guide  to  the  choice  of  special  abdominal  incisions — that  incision  should 
be  chosen  which  most  satisfactorily  accomplishes  the  following  (in  order  of 
importance) : — free  access — avoidance  of  nerves — separation  of  muscular 
and  aponeurotic  fibers  rather  than  their  division — avoidance   of  vessels. 

Separation  of  the  fibers  of  muscles  and  aponeuroses  in  their  cleavage  line 
should  always  be  done  in  preference  to  a  division  of  those  fibers  transversely 
or  even  obliquely. 

Blood-vessels,  as  compared  with  nerves,  are  of  secondary  importance — 
though  the  deep  epigastric  artery  (the  most  important  of  the  abdominal 
wall),  and  its  anastomosis  with  the  superior  epigastric  of  the  internal  mam- 
mary, should  be  spared  when  possible.      (See  Fig.  575.) 

Better  to  cut  through  muscle  than  through  aponeurosis  (where  cleavage 
separation  is  not  possible) — as  the  former  is  more  resistant  to  hernia  (Hyrtl). 

Median  Incisions — available  for  parts  most  accessible  thereby.  Through 
a  median  incision  above  the  umbilicus;  the  stomach,  liver,  pancreas,  and 
intestines  may  be  reached.  Through  a  median  incision  below  the  umbilicus; 
the  intestines,  bladder,  ureters,  uterus,  and  ovaries  may  be  reached. 

Lateral  Vertical  Incisions — (along  the  outer  border  of  the  rectus) — not  ad- 
visable ordinarily,  as  they  divide  the  motor  nerves  to  the  rectus  muscle,  and 
thereby  predispose  to  hernia.  When  done,  generally  done  for  the  gall-bladder 
and  ducts,  duodenum,  ascending  and  descending  colons,  spleen,  and  kidneys. 

Transverse  or  slightly  Oblique  Incisions — preferable  for  reaching  those 
sites  laterally  placed.  The  incisions  are  more  or  less  parallel  with  the  nerves — 
the  muscles  are  separated  in  their  cleavage  lines,  where  possible,  and  re- 
tracted— the  nerves  are  recognized  in  the  intermuscular  planes  (especially 
between  internal  oblique  and  transversalis)  and  held  to  one  side.  This 
incision  may  be  used  for  the  appendix,  ascending  and  descending  colons, 
kidneys,  stomach,  liver,  gall-ducts,  intestines,  and  ureters. 

Special  Abdominal  Incisions — see  the  different  methods  of  abdominal 
section  following. 

In  the  above  summary  of  abdominal  incisions  no  hard-and-fast  rule  exists 
as  to  their  application — it  merely  being  meant  to  mention  some  cases  in 
which  each  category  of  incisions  may  be  used — more  specific  data  being  given 
under  the  different  viscera. 

All  abdominal  incisions  should  avoid,  where  possible,  the  anterior  branches 
of  the  dorsal  and  lumbar  nerves — which  run  obliquely  from  behind  downward 
and  forward  between  the  muscular  abdominal  planes.  The  lower  abdominal 
nerves  run  inwardly  somewhat  more  transversely  than  do  the  fibers  of  the 
external  oblique  muscle  and  aponeurosis — so  that  in  an  oblique  incision 
parallel  with  the  fibers,  one  or  more  nerves  may  be  encountered — but  should 
be  recognized,  and  can  generally  be  spared. 

All  vertical  incisions  of  the  abdominal  wall,  of  any  length,  except  those 
in  the  median  line,  cut  one  or  more  nerves. 

Vertical  incisions  over  the  center  of  the  rectus  divide  the  motor  nerves 
to  the  inner  half  of  the  rectus  muscle. 

Long  cutaneous  and  fascial  incisions  are  harmless — and  are  desirable  if 
thereby  free  access  to  the  site  be  gained. 

Longer  incisions  are  necessary  in  the  intramuscular  separation  than  where 
the  muscle-fibers  are  cut. 

Longer  incisions  are  necessary  in  verv  fat  and  thick  abdominal  walls. 


800  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Hernia  is  more  apt  to  follow  incisions  in  the  lower  than  in  the  upper 
part  of  the  abdomen — and  in  the  anterior  rather  than  in  the  lateral  and 
posterior  portions. 

Linea  alba  is  broader  above  than  below  the  umbilicus,  hence  both  inner 
rectal  borders  are  more  likely  to  be  exposed  by  a  median  incision  below 
than  above  the  navel.  If  it  be  desired  to  identify  the  linea  alba,  after  cutting 
through  the  superficial  fascia,  make  a  slightly  oblique  superficial  incision  over 
the  median  line — until  the  linea  alba  is  recognized  as  a  white  fascial  line 
or  as  a  cord  extending  between  the  inner  borders  of  the  recti. 

Pyramidales  (one  or  both)  may  overlap  the  median  line  and  their  fibers 
may  be  divided  in  a  median  abdominal  section  performed  low  down. 

Linea?  transversa.1  do  not  extend  all  the  way  through  the  rectus  to  its 
posterior  aspect. 

Avoid  cutting  through  the  umbilicus,  ordinarily.  Also  pass  slightly  to  its 
left  to  avoid  the  round  ligament.  Incision  may  be  made  directly  through 
the  center  of  the  umbilicus  itself — inclining  slightly  to  the  left  just  above  it, 
to  avoid  the  round  ligament.  Kelly  mentions,  after  cutting  through  the  um- 
bilicus, that  it  is  well,  in  closing  the  wound,  to  "  split  it  on  each  side  before 
putting  in  sutures,  to  convert  the  naturally  thin  surface  between  skin  and 
peritoneum  into  a  broader  area  for  better  approximation.  " 

If  the  round  ligament  of  the  liver  be  cut  during  operation,  no  harm  of 
consequence  is  done.     It  should  be  repaired  with  chromic  gut  suture. 

Peritoneum  is  more  loosely  connected  with  the  linea  alba  above  and  below 
the  umbilicus — and  more  closely  in  the  neighborhood  of  the  umbilicus. 

A  transverse  vessel  in  the  subcutaneous  fat,  about  2  cm.  (f  inch)  above 
the  symphysis  pubis,  is  mentioned  by  Kelly,  which  spouts  arterial  blood  from 
one  side  and  venous  blood  from  the  other  when  cut.  He  also  mentions  one 
or  more  veins  ("celiotomy  veins")  lying  just  over  the  peritoneum  in  the  lower 
third  of  the  linea  alba,  running  very  nearly  parallel  with  the  linea  alba  and 
ending  in  the  vesical  plexus  at  the  neck  of  the  bladder. 

Empty  the  bladder  before  operating — and,  if  necessary,  outline  the  bladder 
with  a  sound  during  operation. 

In  all  operations  involving  the  pelvic  and  lower  abdominal  regions,  the 
Trendelenburg  position  is  desirable — causing  a  displacement  of  the  intestines 
and  viscera  above  away  from  the  field  of  operation.  It  should  be  assumed 
just  before  the  operation  and  continued  during  it — at  an  angle  of  from  18 
to  45  degrees,  the  average  being  about  30  degrees. 

Intestines  and  viscera  are  best  held  out  of  the  way  by  means  of  flat  pads 
of  sterilized  non-absorbable  cotton  covered  with  non-absorbable  gauze. 

As  soon  as  the  peritoneum  is  incised,  and  in  order  to  make  less  likely 
the  stripping  of  the  peritoneum  from  the  muscular  wall,  a  silk  ligature  may 
be  passed  into  either  lip  of  the  peritoneum,  including  the  muscular  wall, 
and  used  as  a  retractor,  after  being  knotted. 

In  incising  the  abdominal  wall  the  peritoneum  is  at  first  only  opened  to 
a  limited  extent — the  opening  being  increased  after  intra-abdominal  examina- 
tion by  means  of  a  finger  introduced. 

Avoid  mistaking  the  transversalis  fascia  for  subserous  areolar  tissue — and 
subserous  areolar  tissue  for  omentum — and  especially  intestine  for  peritoneum. 

In  cleansing  the  abdomino-pelvic  cavity,  the  natural  fossae  should  receive 
especial  attention — especially  Douglas's  cul-de-sac,  rectal,  duodenal,  jejunal, 
renal,  and  caecal. 

Part  or  all  of  the  omentum  may  be  ligated  off  and  removed. 

Suture-materials — For  peritoneum;  fine,   plain   catgut.     For  fascial    and 


MEDIAN  ABDOMINAL  SECTION.  801 

aponeurotic  planes;  chromic  gut,  kangaroo  tendon,  silk,  silver  wire.  For 
muscles;  chromic  gut,  plain  gut,  silk,  kangaroo  tendon.  For  subcutaneous 
tissue;  plain  or  chromic  gut,  silk.     For  skin;  silkworm-gut,  silk  (gut). 

Avoid  including  omentum  and  intestinal  walls  in  the  tightening  of  sutures. 

Just  before  tightening  the  last  suture  or  two,  press  upon  the  abdominal 
wall  to  expel  air  or  fluids. 

Quilt  sutures  may  be  used  for  the  fascial  planes  of  suturing. 

Relaxation  sutures  may  be  used — about  2.5  cm.  (1  inch)  apart,  and  from 
about  1.2  to  2  cm.  (J  to  f  inch)  from  the  edges  of  the  wound. 

In  all  kinds  of  suturing  the  process  is  aided  by  the  use  of  wound -hooks, 
which  render  the  edges  straight,  parallel,  and  tense,  and  lift  away  the  abdomi- 
nal wall  from  the  underlying  intestines  and  viscera. 

Sutures  are  removed  from  the  tenth  to  the  fifteenth  day. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  THE  ABDOMINO-PELVIC 

WALL. 

Scalpels;  probe-pointed  bistoury;  scissors,  pointed  and  blunt,  straight  and 
curved;  forceps,  dissecting  and  toothed;  artery-clamp  forceps;  retractors, 
various;  probe;  grooved  director;  tenaculum;  wound-hooks;  sponge-holders; 
aneurism-needle  ;  needles,  curved  and  straight  ;  needle-holder;  ligature-car- 
riers; ligatures  and  sutures,  plain  and  chromic  gut,  silk,  silkworm-gut;  gauze 
pads;  drainage-tubes. 


MEDIAN  ABDOMINAL  SECTION. 

Description. — The  opening  of  the  abdominal  or  abdomino-pelvic  cavity 
through  an  incision  in  the  median  line  of  the  abdomino-pelvic  wall.  The 
site  of  this  incision  may  be  anywhere  between  the  tip  of  the  ensiform  cartilage 
and  the  svmphysis  pubis — dependent  upon  the  object  of  the  operation.  Ab- 
dominal section,  except  in  cases  where  done  for  exploration,  is  generally  but 
the  preliminary  step  preceding  some  special  operation. 

Preparation. — Anterior  abdominal  wall  shaved,  especially  along  site  of 
linea  alba.  Recesses  of  navel  thoroughly  cleansed.  Bladder  is  emptied, 
especially  if  incision  is  to  extend  very  low. 

Position. — Patient  supine,  at  edge  of  table,  with  arm  beneath  back. 
Operation-site  is  walled  off  with  sterilized  towels.  Surgeon  on  right,  cutting 
from  above  downward.     Assistant  opposite. 

Landmarks. — Median  line  (linea  alba).  The  center  of  the  lower  portion 
of  the  sternum,  the  umbilicus,  and  the  suprapubic  notch  all  are  in  the  median 
straight  line  of  the  body  in  the  normal  abdomen. 

Incision. — Is  placed  directly  in  the  median  line — above,  below,  or  in- 
cluding the  umbilicus,  as  indicated.  If  more  room  be  needed  than  planned 
in  the  original  incision,  it  may  be  gotten  by  continuing  the  incision  upward 
or  downward.  After  incising  to  within  5  cm.  (2  inches)  of  the  bladder,  great 
care  should  be  exercised  and  the  bladder  protruded  away  from  the  line  of 
incision  by  the  fingers  of  the  left  hand — for,  although  empty,  if  adherent 
unusually  high,  it  may  be  wounded.  In  passing  the  site  of  the  umbilicus 
the  incision  may  be  carried  directly  through  its  center,  with  a  slight  tendency 
to  the  left  just  above  the  umbilicus,  to  avoid  the  suspensory  ligament  of  the 
liver — or  may  pass,  when  quite  near  the  upper  or  lower  aspects  of  the  um- 
bilicus, in  a  curved  direction  around  it — the  curve  passing  to  the  left,  thereby 
51 


802 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


avoiding  the  round  or  suspensory  ligament  (the  remains  of  the  fetal  umbilical 
vein)  between  the  umbilical  fissure  of  the  liver  and  the  umbilicus — which  is, 
in  consequence,  left  adherent  to  the  right  lip  of  the  wound.  (See  Fig.  576 
A  and  B.) 


I 

Fig- 5 76-— Incisions  for  Abdominal  Sections: — A,  Median  Abdominal  Section,  supra-umbil- 
ical; B,  Median  Abdominal  Section,  infra-umbilical;  C,  Imaginary  line  from  umbilicus  to  anterior 
superior  iliac  spine;  D,  Anterior  superior  iliac  spine;  E,  Incision  for  McBurney's  Intramuscular 
Abdominal  Section  ;  F,  Incision  (skin  portion)  for  Weir's  prolongation  of  the  antero-lateral  Intra- 
muscular Abdominal  Section;  G,  The  Battle-Jalaguier-Kammerer  Incision;  H,  Superficial  trans- 
versely curved  incision  of  Pfannenstiel's  Median  Inferior  Abdominal  Section  ;  I,  Deep  vertical  inci- 
sion of  Pfannenstiel's  Median  Inferior  Abdominal  Section  ;  J,  Meyer's  "  Hockey-stick  "  Incision  ;  K, 
Fowler's  Angular  Incision;  L,  Oblique  Subcostal  Incision;  M,  Vischer's  Lumbo-iliac  Incision;  N, 
Position  of  deep  epigastric  vessels. 


Operation. — (1)  Having  steadied  and  rendered  tense  the  abdominal  wall 
by  left  thumb  and  forefinger  (or  middle  finger)  on  either  side  of  the  median 
line,  the  incision  is  made  the  full  length  of  the  predetermined  distance,  at 
one  clean  sweep  of  the  knife,  passing  through  skin  and  connective  tissue. 


MEDIAN  ABDOMINAL  SECTION. 


803 


In  very  fat  subjects  the  skin  and  thick  fatty  areolar  tissue  may  be  divided 
by  two  or  three  successive  sweeps  of  the  knife.  Throughout  the  passage 
through  the  abdominal  wall,  all  incisions  should  be  made  the  full  length  of 
the  original  skin  incision.  (See  Fig.  577.)  (2)  Clamp  all  bleeding  vessels 
upon  the  lips  of  the  wound,  and  subsequently  tie  with  gut  those  likely  to 
bleed.     (3)   Continuing  to  retract  the  lips  of  the  wound  with  left  thumb  and 


Fig.  577- — Median  Abdominal  Section: — A,  Skin;  B,  Fascia;  C,  C,  Inner  borders  of  the 
recti  and  pyramidales  muscles;  D,  Transversalis  fascia  and  subperitoneal  areolar  tissue;  E, 
Peritoneum;  F,  F,  Forceps  grasping  and  lifting  up  the  peritoneum;  G,  Knife  cutting  through  the 
fold  of  peritoneum  made  prominent  by  traction. 

forefinger,  incise  the  aponeurosis  of  the  recti  directly  to  the  median  line. 
While  aiming  to  cut  between  the  inner  margins  of  the  recti  muscles,  along 
their  line  of  junction,  without  dividing  their  muscular  fibers,  it  is  found, 
especially  when  operating  below  the  umbilicus,  that  frequently  one  or  both 
recti,  together  with  their  sheaths,  are  cut,  or  the  pyramidales,  where  the 
latter  overlap  inwardly.  The  linea  alba  is  not  as  distinct  below  the  umbilicus 
as  above  it.     In  the  upper  three-fourths  of  the  anterior    abdominal  wall, 


804  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

directly  in  the  median  line,  after  passing  through  the  skin  and  fascia,  one 
divides  the  aponeurosis  between  the  inner  borders  of  the  recti;  and  just  to 
one  side  of  the  median  line,  one  divides  the  outer  layer  of  the  rectal  sheath, 
the  rectus  muscle,  the  inner  layer  of  the  rectal  sheath  (which  inner  layer  is 
formed  by  the  aponeurosis  of  the  transversalis  and  inner  lamella  of  the  internal 
oblique).  In  the  lower  one-fourth  of  the  anterior  abdominal  wall,  directly 
in  the  median  line,  after  passing  through  skin  and  fascia,  one  divides  the 
aponeurosis  between  the  inner  borders  of  the  recti;  and  just  to  one  side  of 
the  median  line,  one  divides  the  outer  layer  of  the  rectal  sheath,  the  pyrami- 
dalis,  the  rectus  muscle,  and  comes  directly  down  upon  the  transversalis  fascia, 
which  here  alone  forms  the  posterior  layer  of  the  rectal  sheath.  All  bleeding 
vessels  encountered  in  passing  through  the  aponeurotic  and  muscular  planes 
of  the  abdominal  wall  are  clamped  or  tied.  (4)  The  fascia  transversalis  is 
now  exposed  in  the  whole  length  of  the  wound,  lying  beneath  the  posterior 
layer  of  the  rectal  sheath  in  the  upper  three-fourths  of  the  linea  alba — and 
forming  the  posterior  layer  in  the  lower  fourth — and  is  similarly  incised.  (5) 
The  subperitoneal  areolar  tissue  lies  between  the  transversalis  fascia  and  the 
peritoneum,  and  is  generally  divided  together  with  the  transversalis  fascia. 
It  may  be  quite  thick  in  the  very  fatty.  All  clamped  vessels  are  now  tied 
before  opening  the  peritoneum.  (6)  The  peritoneum  is  now  encountered 
lying  directly  beneath  the  subperitoneal  areolar  tissue — its  position  being 
anticipated  by  a  recognition  of  the  structures  and  layers  through  which  the 
incisions  have  passed — and  its  actual  presence  is  further  recognized  by  its 
commoner  characteristics,  available  in  the  majority  of  cases — its  glistening, 
bluish,  arborescent  surface,  and  tough  nature  (which  are  less  available  iii 
adhesions  and  other  abnormalities).  Having  controlled  all  bleeding,  the  peri- 
toneum, the  final  barrier  to  the  peritoneal  cavity,  is  now  to  be  opened.  L 
is  important  that  the  peritoneum  should  be  isolated  from  all  underlying 
structures,  and  especially  the  intestines,  before  being  incised.  This  is  best 
done  by  picking  it  up  lightly  with  a  pair  of  toothed  forceps,  in  the  form  of 
a  small  fold.  Thus  grasping  the  peritoneum,  the  forceps  should  be  shifted 
laterally  and  vertically  to  determine  that  they  hold  nothing  in  their  teeth 
but  peritoneum  alone.  Should  intestines,  omentum,  or  other  structures  have 
been  grasped,  in  addition  to  the  peritoneum,  a  new  and  lighter  hold  should 
be  taken.  While  thus  held  in  the  grasp  of  the  forceps — or,  better  still,  between 
the  grasps  of  two  pairs  of  forceps,  one  held  by  the  surgeon  and  the  other 
by  the  assistant — the  peritoneum  is  at  first  opened  to  a  very  limited  extent, 
by  making  a  carefully  guarded  scissors-cut  or  knife-incision,  in  the  median 
line,  near  the  tip  of  the  single  pair  of  forceps — or  between  the  tips  of  the 
double  pair.  One  limb  of  a  pair  of  straight,  blunt  scissors,  or  a  probe-pointed 
bistoury,  is  now  introduced  into  this  small  opening,  and  the  incision  enlarged 
by  cutting  in  the  median  line — introducing  the  left  first  and  second  fingers 
as  a  guide  (formed  by  their  palmar  surface)  as  soon  as  sufficient  opening 
has  been  made — after  which  the  peritoneal  opening  is  enlarged  to  correspond 
with  the  length  of  the  rest  of  the  wound,  which  should  nowhere  be  funnel- 
shaped,  but  of  equal  depth  throughout.  (7)  Having  opened  the  peritoneum 
and  widely  retracted  the  lips  of  the  abdominal  wound,  the  special  object 
for  which  the  abdominal  section  was  made  is  now  carried  out.  (8)  Having 
completed  the  object  of  the  operation,  and  prior  to  closing  the  abdominal 
wound,  the  abdominal  cavity  should  be  cleansed  of  all  fluid,  by  means  of 
gauze  mops  or  sponges — especially  in  the  regions  of  Douglas's  pouch,  in  the 
female,  the  iliac  fossae,  the  renal  and  hepatic  regions,  and  among  the  intestinal 
coils  and  recesses.     Where  the  abdominal  cavity  has  been  extensivelv  soiled, 


MEDIAN  ABDOMINAL  SECTION. 


8o5 


especially  bv  tenacious  fluids,  a  general  flushing  of  the  cavity  may  be  indicated, 
until  the  irrigating  fluid  comes  away  clear,  followed  by  light  sponging  with 
gauze  mops.  Having  cleansed  the  cavity,  stopped  all  bleeding  by  ligature, 
and  counted  all  instruments  and 
sponges,  or  pads,  used  in  the  oper- 
ation, the  abdomen  is  ready  for 
closure.  (9)  Several  methods  of  su- 
turing the  lips  of  the  wound  are  in 
use.  Preceding  the  adoption  of  any 
particular  method,  the  underlying  in- 
testines and  viscera  are  protected  and 
held  out  of  the  way  by  a  broad  pad 
of  absorbable  gauze.  This  pad  also 
absorbs  any  suture-bleeding  which 
may  occur,  and  remains  in  situ  until 
nearly  the  entire  length  of  the  deepest 
layer  (or  nearly  all  of  the  single  layer, 
where  but  one  layer  of  sutures  is  used) 
is  placed  and  tied  (if  interrupted),  or 
tightened  (if  continuous) — and  is  then 
withdrawn  through  one  end.  (a)  In- 
terrupted sutures  of  all  layers  in  a 
single  tier: — Having  armed  a  fully 
curved  needle,  held  in  a  needle- 
holder,  with  fairly  stout  silk,  the  su- 
tures are  passed  from  without  into  the 
abdominal  cavity  through  one  wound- 
lip,  and  thence  outward  through  the 
opposite,  passing  through  all  of  the 
constituents  of  each  lip,  in  the  follow- 
ing manner:  While  the  lips  of  the 
wound  are  held  under  slight  tension 
by  wound-hooks  at  either  end,  the  sur- 
geon grasps  the  entire  thickness  of  one 
lip  between  his  left  thumb  and  finger 
and  sees  that  all  of  the  component 
structures  of  that  lip  are  brought  into 
line  at  the  margin  of  the  wound,  so 
as  to  be  within  bite  of  the  point  of 
the  needle.  This  is  particularly  neces- 
sary in  the  case  of  the  peritoneum, 
which  is  often  partially  separated 
from  the  rest  of  the  abdominal  wall 
in  the  subperitoneal  areolar  plane 
and  is  thus  apt  not  to  be  included 
in  the  suture.  While  thus  holding 
the  lip  of  one  side,  the  needle  is 
passed  from  without  inward,  passing 
through  all  the  structures  of  the  lip  at 
the  same  distance  from  their  free  edge 
and  entering  the  abdominal  cavity.  The  opposite  lip  is  similarly  grasped 
and  the  needle  similarly  passed — but  from  within  outward,  emerging  at  a 
corresponding  point  on  the  side  opposite  to  that  entered.     Each  of  the  in- 


Fig.  578. — Tier-suturing  of  the 
Wound  following  Median  Abdominal 
Section: — Continuous  suture  approxima- 
ting edges  of  peritoneum; — Interrupted 
sutures  bringing  together  subserous  areolar 
tissue,  transversalis  fascia,  borders  of 
recti  muscles,  and  aponeuroses  of  the 
recti; — Continuous  suture  of  superficial 
fascia,  especially  where  this  is  thick; — 
Interrupted  sutures   of  the  skin. 


806  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

terrupted  sutures  will  penetrate  the  lips  of  the  wound  at  about  0.5  cm.  (T\ 
inch)  from  their  edge,  and  will  be  about  1  cm.  (f  inch)  apart.  When  all 
are  placed,  the  free  ends  of  the  sutures  on  either  side  should  be  grasped 
and  drawn  upon,  to  see  if  the  lips  come  well  and  evenly  together.  While  the 
lips  are  still  under  tension  the  sutures  are  tied,  generally  beginning  at  one 
or  the  other  end.  Just  prior  to  completing  the  tying,  the  gauze  pad  over 
the  intestines  must  be  withdrawn.  Superficial  sutures  may  be  put  through 
the  skin  and  connective  tissue  between  the  others,  if  necessary.  Where  much 
tension  exists,  deep  relaxation  sutures,  placed  about  1.2  cm.  (^  inch)  from 
the  lips  of  the  wound,  and  about  2  cm.  (f  inch)  apart,  may  be  placed.  Chro- 
mic gut  may  be  similarly  used.  Silkworm-gut  may  be  used,  but  requires 
especial  care  in  tying  the  knot,  (b)  Tier-suturing: — First  Tier — peritoneum. 
(To  shut  off  the  abdominal  cavity.)  A  buried,  continuous  (may  be  inter- 
rupted), fine,  chromic  catgut  suture,  passed  upon  a  straight  needle,  at  a 
distance  of  about  0.3  cm.  (£  inch)  from  the  edge.  Second  Tier — aponeuroses 
of  rectal  sheath,  including  transversalis  fascia  and  subperitoneal  areolar 
tissue,  and  margins  of  recti  where  they  have  been  cut.  (Chief  suture  of 
strength.)  Interrupted,  buried,  chromic  catgut  suture,  introduced  upon  a 
curved  needle,  about  0.5  cm.  (f^-  inch)  from  the  edge  and  about  1  cm.  (f 
inch)  apart.  Third  Tier — subcutaneous  areolar  tissue,  that  is,  all  tissues 
between  the  outer  layer  of  the  rectal  sheath  and  the  skin.  (To  obliterate 
dead  spaces.)  A  continuous,  buried,  chromic  catgut  suture,  introduced  upon 
a  straight  needle.  Fourth  Tier — skin.  (To  shut  off  outside  contamination.) 
A  continuous,  subcuticular  silk  suture  passing  through  the  tough  corion,  intro- 
duced upon  Keith's  long,  straight  abdominal  needle.  (See  Fig.  578.)  Inter- 
rupted silkworm-gut  maybe  used  for  the  fourth  tier  (though  stitch-abscesses  are 
more  frequent) .  Or  strong,  fine  catgut  may  be  used — and  need  not  be  removed. 
Interrupted  silk  sutures  are  often  used.  The  tier  method  of  suturing  is  prefer- 
able to  the  single- layer  suture.  Often  but  three  tiers  are  used — Continuous 
chromic  suture  of  peritoneum; — Interrupted  chromic  gut  suture  of  subperi- 
toneal and  transversalis  fascial,  rectal  aponeuroses  (or  recti  themselves)  en 
masse; — Interrupted  silkworm-gut,  or  silk  suture,  of  skin  and  subcutaneous 
fascia.  Sometimes  only  two  tiers  are  used — Continuous  chromic  gut  of  peri- 
toneum;— and  Interrupted  silk  or  chromic  gut  of  the  remaining  tissues.  (10) 
No  drainage  is  ordinarily  used.  Several  layers  of  gauze  and  cotton  are 
placed  over  the  wound — and  one  of  the  various  forms  of  abdominal  binders 
applied. 

Complications  Occurring  during  Abdominal  Section. — (a)  Adhe- 
sions;— (1)  Adhesions  of  the  intestines,  viscera,  or  omentum  with  each 
other,  or  with  the  parietal  wall,  may  be  encountered.  (2)  When,  in  the 
presence  of  adhesions,  there  is  doubt  as  to  whether  the  peritoneal  cavity  has 
been  reached,  pick  up  and  roll  the  tissues  between  the  finger-tips,  thus  judging 
of  their  nature.  (3)  The  general  principle  to  be  adopted  in  the  management 
of  adhesions  is  to  find  the  plane  of  cleavage  in  the  abnormal  union — and, 
following  it  up,  separate  it  as  carefully  as  possible  by  fingers  or  blunt  dissection. 
Where  this  is  impossible,  areas,  dependent  upon  their  nature,  have  to  be 
ligated  or  clamped  and  cut,  with  the  sacrifice  of  some  portion  of  the  least 
important  structure.  Ligatures  are  best  made  with  plain  gut  for  small  adhe- 
sions, and  chromic  gut  for  large  adhesions.  While  slighter  adhesions  may  be 
mechanically  separated,  denser  ones  are  to  be  clamped  or  ligated,  en  masse 
or  piecemeal,  and  cut.  (4)  Intestinal  Adhesions.  Thin  membranous  adhe- 
sions may  be  stripped  apart.  Dense,  organized  adhesions  must  be  separated 
by  careful  dissection,  requiring  especial  care,  as  no  part  of  the  entire  thickness 


ANTEROLATERAL  ABDOMINAL  SECTION.  807 

of  the  adhesion  can  be  taken  from  the  one  and  left  as  a  patch  on  the  other, 
as  may  be  done  in  some  adhesions  in  other  localities.  (5)  Omental  Adhesions. 
These  must  be  stripped  off,  or  ligated  and  excised.  The  entire  omentum 
may  be  ligated  and  excised,  if  necessary.  Omental  adhesions  are  ligated 
on  their  proximal  side — by  pushing  forceps  through  the  free  spaces  and 
drawing  back  the  gut  ligature  and  tying — and  repeating  the  step,  always 
tying  over  the  free  edge  left  by  the  preceding  ligature.  See  Omentum,  page 
830.  (6)  Visceral  Adhesions: — Where  separation  cannot  be  accomplished — - 
and  where  the  step  is  possible,  a  layer,  or  the  entire  thickness,  of  the  less 
important  structure  is  left  attached  to  the  more  important  one — after  ligaturing 
and  blunt  dissection  or  incision.  The  serous  covering  of  the  viscera  should 
be  preserved  wherever  possible — thereby  aiding  in  the  preservation  of  nutrition 
and  the  avoidance  of  adhesions  and  sloughing.  Such  denuded  surfaces  may 
have  omental  grafts  applied.  See  Omentum,  page  830.  In  the  median  ab- 
dominal section  it  is  to  be  remembered  that  an  adherent  bladder,  though 
empty,  may  not  be  able  to  descend  out  of  the  way  of  the  incision, — and  thereby 
may  not  escape  injury  unless  specially  guarded.  For  further  consideration 
of  adhesions,  see  the  Peritoneum,  page  820.  Also  see  Fig.  586.  (B)  Hemor- 
rhage : — Tie,  where  possible,  all  vessels  prior  to  their  division,  or  immediately 
afterward — as  encountered  in  the  steps  of  the  operation  after  entering  the 
abdominal  cavity.  Vessels  which  have  been  cut  without  recognition,  should  be 
immediately  clamped  and  then  tied.  In  the  abdominal  incision,  prior  to  enter- 
ing the  cavity,  the  vessels  are  clamped  as  cut  and  tied  before  opening  the  peri- 
toneal cavity.  Gauze  pressure  and  hot  douching  often  control  bleeding  from 
indefinite  sources.  (C)  Irrigation  : — Unless  the  abdominal  cavity  be  contami- 
nated or  soiled,  or  unless  much  hemorrhage  have  occurred,  irrigation  is  gen- 
erally not  indicated.  If  indicated,  hot  normal  salt  solution  is  used.  Localized 
infection  can  often  be  treated  by  localized  flushing  and  wiping — general 
infection  by  general  flushing  and  drying  with  gauze  mops.  (D)  Drainage  : — 
Not  indicated  in  uncomplicated  cases.  Indicated  in  (a)  Localized  and 
general  infection  (in  the  former,  generally — in  the  latter  always), — (b)  After 
intestinal  or  hollow-visceral  suturing,  where  there  is  uncertainty  of  efficiency 
of  the  suturing  or  integrity  of  the  intestine  or  viscus, — (c)  In  persistent  hemor- 
rhage. Nature  of  drainage  materials, — gauze,  rubber  tubing,  glass  tubing, 
strands  of  gut,  silk,  or  horsehair.  Where  drainage  is  used,  the  wound  should 
have  the  suturing  placed  throughout,  and  just  as  though  the  entire  wound 
were  to  be  closed — and  those  at  first  left  untied  for  the  passage  of  the  drain, 
should  be  tightened  and  tied  when  all  occasion  for  drainage  has  ceased. 
Comment. — See  under  General  Surgical  Considerations,  page  799. 


ANTERO-LATERAL  ABDOMINAL  SECTION 

BY  McBURNEY'S    INTRAMUSCULAR  ("GRIDIRON")  INCISION. 

Description. — Having  divided  skin  and  fascia,  the  various  musculo- 
aponeurotic  planes  of  the  abdominal  wall  are  divided  in  the  order  encountered 
and  in  a  line  with  the  muscular  and  tendinous  fibers  composing  those  planes — ■ 
thus  avoiding  the  division  of  any  important  nerves;  the  transverse  division  of 
any  of  the  component  muscular  fibers;  the  retraction  of  transversely  cut  mus- 
cular and  tendinous  fibers — and,  therefore,  avoiding  the  consequent  paralysis 
of  parts  supplied  by  severed  nerves,  and  weakening  of  cut  muscles. 

While  McBurney's  operation  is  chiefly  applicable  to  the  antero-lateral 
abdominal  region  (where  the  external  and  internal  oblique  and  the  transver- 


8o8 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


salis  muscles  are  all  present),  the  principle  of  intramuscular  separation  should 
be  applied  to  all  sites  of  the  abdominal  wall  where  it  is  possible  to  do  so. 
The  operation  is  principally  resorted  to  for  the  removal  of  the  appendix 
vermiformis,  especially  in  the  quiescent  stage  of  appendicitis 

Preparation.— Site  of  incision  to  be  shaved. 

Position.— As  in  Median  Abdominal  Section. 

Landmarks. — Where  the  operation  is  done  in  connection  with  Appendic- 


i 

Fig.  579. — Anterolateral  Abdominal  Section  by  McBurney's  Intramuscular 
("Gridiron")  Incision: — A,  A,  Retracting  external  oblique,  the  fibers  of  which  have  been 
separated  in  the  line  of  their  cleavage;  B,  B,  Retracting  internal  oblique  and  transversalis, 
split  in  the  lines  of  their  cleavage.  Beneath  these  an  incised  wound  in  the  peritoneum  is  seen, 
through  which  appear  coils  of  intestine. 

ectomy,  McBurney's  point  is  located,  which  is  a  point  on  an  imaginary 
line  extending  from  the  anterior  superior  iliac  spine  to  the  umbilicus,  at  a 
distance  of  3.8  cm.  (ij  inches)  internal  to  the  anterior  superior  iliac  spine. 

Incision. — In  cases  of  Appendicectomy,  the  incision  commences  about 
2.5  cm.  (1  inch)  above  the  imaginary  line  just  mentioned,  and  passes  obliquelv 
downward  and  inward  in  the  direction  of  the  fibers  of  the  external  oblique 
muscle  and  aponeurosis — crossing  the  above  line  at  McBurney's  point — and 
ending  about  the  same  distance  below  as  above  it.     The  length  of  the  incision 


AXTERO-LATERAL    ABDOMINAL    SECTION.  809 

may  be  greater  or  less  than  the  above,  according  to  the  space  required.  A 
free  skin  incision  greatly  aids  the  muscular  retraction.     (See  Fig.  576,  E.) 

Operation. — (I)  Having  incised  the  skin  and  fascia  in  the  above  line 
(which  will  correspond  with  the  cleavage  line  of  the  skin),  and  having  con- 
trolled hemorrhage  and  retracted  the  lips  of  the  wound,  the  muscular  and 
tendinous  fibers  of  the  external  oblique  will  be  exposed.  (See  Fig.  579.)  (2) 
Incise  the  external  oblique,  with  a  sharp  scalpel,  directly  in  a  line  with  its 
muscular  fibers  above,  and  their  tendinous  continuation  in  the  aponeurosis 
below — continuing  the  separation  with  scalpel  or  scissors,  incising  between 
the  fibers  without  severing  them.  The  two  lips  of  the  incised  external  oblique 
are  drawn  respectively  upward  and  inward,  and  downward  and  outward — 
thus  exposing  the  intermuscular  fascia  between  external  and  internal  oblique. 
(3)  The  sheath  and  fibers  of  the  internal  oblique  (the  muscle  being  here  quite 
thick)  are  now  similarly  separated  by  scalpel,  scissors,  or  blunt  dissection, 
in  the  line  of  their  cleavage  (which  is  nearly  at  a  right  angle  to  the  cleavage 
line  of  the  fibers  of  the  external  oblique),  the  center  of  the  separation  of  the 
fibers  being  about  opposite  the  anterior  superior  iliac  spine.  The  lips  of  the 
internal  oblique  are  now  retracted  respectively  upward  and  outward,  and 
downward  and  inward — thus  exposing  the  intermuscular  fascia  between  in- 
ternal oblique  and  transversalis.  Guard  with  especial  care  all  nerves  lying 
in  this  intermuscular  plane.  (4)  The  fibers  of  the  transversalis,  which,  for 
practical  purposes,  run  very  nearly  in  the  same  direction  as  those  of  the 
internal  oblique,  are  now  similarly  separated  in  their  cleavage  line.  The  lips 
of  the  transversalis  may  be  separately  retracted  upward  and  downward, 
but  are  generally  included  in  the  grasp  of  the  same  retractors  which  retract 
the  internal  oblique.  The  transversalis  fascia  at  the  bottom  of  the  wound 
is  thus  exposed  for  an  inch  or  more.  (5)  The  transversalis  fascia  is  grasped 
with  forceps  and  divided  in  the  line  of  the  transversalis  muscle  (transversely) — 
when  the  subserous  areolar  tissue  and  peritoneum  will  be  exposed.  (6)  The 
peritoneum  is  grasped  with  two  delicate-toothed  forceps,  manipulated  as  in 
the  median  abdominal  section,  and  divided  with  scissors  to  a  limited  and 
guarded  extent.  One  blade  of  the  scissors  is  then  carefully  introduced  within 
the  abdominal  cavity  and  the  opening  enlarged  toward  the  median  line  and 
the  anterior  superior  iliac  spine.  The  subperitoneal  areolar'  tissue,  trans- 
versalis fascia,  and  peritoneum  may  be  simultaneously  incised — but  it  is  better 
to  incise  down  to  and  recognize  the  peritoneum,  and  then  incise  the  peritoneum 
separately  and  alone.  (7)  The  special  object  of  the  operation  is  now  accom- 
plished. The  wound  is  then  ready  for  closure.  (8)  Separate  continuous 
suturing  of  the  following  layers  with  catgut  is  made ; — (a)  peritoneum,  sub- 
serous areolar  tissue,  and  transversalis  fascia — (b)  transversalis — (c)  internal 
oblique — (d)  external  oblique — (e)  subcutaneous  fascia,  especially  where 
thick — (f)  and  the  skin  is  closed  by  subcuticular  silk  suture,  or  interrupted 
silkworm-gut.  The  subcutaneous  areolar  tissue  and  skin  are  often  included 
in  one  tier,  where  interrupted  suturing  of  these  two  structures  is  done.  All 
parts  are  thus  brought  together  along  their  original  cleavage  lines  and  accu- 
rately approximated. 

Comment. — (I)  But  small  part  of  the  muscular  portion  of  the  external 
oblique  is  exposed.  (2)  The  twelfth  intercostal  nerve,  and,  when  the  incision 
is  long,  the  iliohypogastric  nerve  are  in  danger  (as  they  run  somewhat  more 
transversely  than  the  fibers  of  the  external  oblique)  and  should  be  retracted 
out  of  danger.  (3)  This  is  the  best  method  of  entering  the  abdominal  cavity, 
where  applicable. 


8io 


OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 


ANTERO-LATERAL  ABDOMINAL  SECTION 

BY  THE  HARRINGTON-WEIR    PROLONGATION  OF  THE  ANTERO-LATERAL    INTRA- 
MUSCULAR INCISION  THROUGH  THE  RECTAL  SHEATH,  WITH  TEMPORARY 
DISPLACEMENT  OF  THE  RECTUS. 

Description. — Having  entered  the  abdominal  cavity  by  the  intramuscular 
operation  just  described,  an  extension  or  enlargement  of  that  incision,  with 
a  fuller  exposure  of  the  abdominal,  pelvic  and  iliac  cavities,  may  be  obtained 
by  continuing  that  incision  to  the  outer  border  of  the  rectal  sheath,  tearing 
off  the  "  denuded  fascia  of  the  external  oblique  muscle,"  incising  transversely 
the  remaining  structures  forming  the  anterior  layer  of  the  rectal  sheath  and 
displacing  the  rectus  muscle  toward  the  median  line,  followed  by  the  transverse 
division  of  the  posterior  rectal  sheath.  While  the  operation  is  chiefly  appli- 
cable to  the  region  of  the  appendix,  it  may  be  used  on  either  side  of  the 
abdomino-pelvic  region,  and  also  in  the  region  of  the  liver  and  gall  -bladder 
where  additional  room  is  necessary.  It  will  be  here  described  in  connection 
with  appendicectomy. 

Preparation — Position. — As  in  McBurney's  Intramuscular  Operation 
(page  808). 

Landmarks. — McBurney's  point  (see  McBurney's  Operation,  Landmarks, 
page  808) ;  linea  alba;  semilunar  line. 

Incision. — Begins  as  an  ordinary  McBurney  intramuscular  incision — and, 
after  prolonging  the  incision  to  the  outer  border  of  the  rectus,   and    after 


Fig.580.— Antero-lateral  Abdominal  Section  by  Weir's  Method  :— A,  External  oblique 
muscle;  B,  External  oblique  being  separated  from  the  anterior  layer  of  the  rectal  sheath  ;  C,  Internal 
oblique  muscle  ;  D,  Transversalis  muscle;  E,  Transversalis  fascia,  subperitoneal  areolar  tissue,  and 
peritoneum;  F,  Anterior  layer  of  rectal  sheath;  G,  Posterior  layer  of  rectal  sheath;  H,  Rectus 
muscle  ;  I,  Deep  epigastric  vessels  ;  J,  Branch  of  deep  circumflex  iliac,  or  of  one  of  lumbar  arteries; 
K,  Twelfth  intercostal,  or  iliohypogastric  nerve  ;  L,  A  superficial  vessel ;  M,  Coils  of  small  intestine. 


tearing  off  and  retracting  inward  the  fascia  of  the  external  oblique  from  the 
sheath  of  the  rectus,  the  incision  is  continued  across  the  anterior  layer  of 
the  sheath  of  the   rectus  in  a  prolongation  of  the  same  line  with  the  intra- 


ANTERIOR    ABDOMINAL    SECTION    THROUGH    RECTAL    SHEATH.       8ll 

muscular  opening  into  the  peritoneum  (or  may  be  continued  transversely 
across) — followed  by  the  inward  retraction  of  the  rectus  muscle  and  trans- 
verse division  of  the  posterior  rectal  sheath.     (See  Fig.  576,  F.) 

Operation. — (1)  Proceed  exactly  as  in  the  McBurney  operation,  up  to 
the  point  of  entering  the  abdominal  cavity — whether  operating  upon  the  right 
or  left  side.  (2)  Continue  the  separation  of  the  fibers  of  the  external  oblique 
muscle  and  aponeurosis,  in  the  line  of  their  cleavage,  right  up  to  the  linea 
semilunaris  (outer  border  of  the  rectal  sheath).  Also  continue  the  separation 
of  the  fibers  of  the  internal  oblique  and  transversalis  until  the  inner  aspect 
of  the  common  opening  is  brought  up  to  the  outer  margin  of  the  rectal  sheath. 
(See  Fig.  580.)  (3)  The  already  denuded  fascia  of  the  external  oblique  is 
now  separated  by  blunt  dissection  from  the  anterior  layer  of  the  sheath  of 
the  rectus,  from  the  linea  semilunaris  inward  to  the  median  line — retracting 
or  dividing  the  overlying  structures  where  necessary.  (4)  While  the  denuded 
and  displaced  fascia  of  the  external  oblique  is  held  retracted,  the  remaining 
structures  forming  the  anterior  layer  of  the  rectal  sheath  (aponeuroses  of  in- 
ternal oblique  and  transversalis)  are  divided  transversely,  or  slightly  obliquelv, 
inward,  in  a  line  continuing  the  external  oblique  intramuscular  incision — or,  if 
the  abdominal  cavity  have  been  already  opened  and  more  room  be  needed,  in  a 
line  with  the  intramuscular  opening  into  the  peritoneum.  (5)  Separate  the 
outer  border  of  the  rectus  from  its  sheath  and  retract  the  muscle  inward  as  far 
as  necessary,  lifting  it  away  from  the  posterior  layer  of  the  sheath.  (6)  Doublv 
ligate  and  divide  the  deep  epigastric  artery  and  veins  lying  upon  the  transver- 
salis fascia — unless  they  may  be  temporarily  displaced  by  retraction.  (7) 
Incise  transversely  the  posterior  layer  of  the  sheath  of  the  rectus  (which,  in 
the  lower  part  of  the  abdomen,  consists  of  transversalis  fascia  alone)  and 
peritoneum,  both  in  the  same  line  as  the  incision  through  the  anterior  laver — 
thus  opening  up  the  abdomino-pelvic  cavity  toward  the  median  line.  (8) 
The  abdominal,  pelvic,  and  iliac  cavities  are  thus  exposed  and  the  object 
of  the  operation  accomplished.  (9)  The  suturing  of  the  general  wound  is 
done  as  in  the  McBurney  operation  (page  809,  paragraph  8).  In  closing  the 
portion  involving  the  rectal  sheath,  the  posterior  layer  of  the  sheath  is  sutured 
with  continued  catgut — the  rectus  muscle  is  then  allowed  to  fall  back  into 
place — and  the  anterior  layer  of  the  sheath  is  similarly  closed. 

Comment. — Additional  exposure  is  secured  by  the  Trendelenburg  posi- 
tion, or  by  sand-bags  under  the  hips.  This  is  the  best  one  of  the  modifications 
of  the  intramuscular  operation,  for  giving  increased  room. 


ANTERIOR  ABDOMINAL  SECTION  THROUGH  THE  RECTAL  SHEATH, 
WITH  TEMPORARY  DISPLACEMENT  OF  THE  RECTUS, 

BV  THE    BATTLE-JALAGUIER-KAMMERER   METHOD. 

Description  . — Consists,  after  a  vertical  incision  of  skin  and  fascia,  in 
the  vertical  division  of  the  anterior  layer  of  the  sheath  of  the  rectus,  with 
the  retraction  of  the  entire  rectus  inward — followed  by  the  vertical  division 
of  the  posterior  layer  of  the  rectal  sheath,  somewhat  nearer  the  median  line, 
together  with  the  subserous  areolar  tissue  and  peritoneum.  At  the  end  of 
the  operation  the  rectus  is  allowed  to  resume  its  normal  position,  and  the 
divided  rectal  sheath  is  repaired.  Chiefly  used  in  the  quiescent  stage  of  appen- 
dicitis— and  also  applicable  in  some  operations  upon  the  stomach,  liver,  and 
gall-bladder. 

Preparation— Position.— As  in  Median  Abdominal  Section. 


8l2 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


Landmarks. — Linea  alba  and  linea  semilunaris,  forming,  respectively, 
the  inner  and  outer  boundaries  of  the  rectal  sheath. 

Incision. — Vertical  incision  about  7.5  cm.  (3  inches)  long,  and  calculated, 
as  nearly  as  possible,  to  fall  from  1  to  2.5  cm.  (f  to  1  inch)  internal  to  the 
outer  border  of  the  rectus.     (See  Fig.  576,  G.) 

Operation. — (1)  Incise  skin  and  fascia  in  the  above  line — clamp  vessels — 
retract  overlying  tissues — and  expose  the  rectal  sheath.  (2)  Incise  the  ante- 
rior layer  of  the  sheath  of  the  rectus  vertically,  at  a  distance  of  from  1  to  2.5 
cm.  (f  to  1  inch)  internal  to  its  outer  border.  (See  Fig.  581.)  (3)  Retract 
outward  the  outer  portion  of  the  divided  rectal  sheath,  so  as  to  expose  the 


Fig.  5S1. — Abdominal  Section  by  the  Battle-Jalaguier-Kammerer  Incision: — A,  A, 
Anterior  layer  of  rectal  sheath;  B,  Posterior  layer  of  rectal  sheath;  C,  Incision  through  anterior 
layer  of  rectal  sheath;  D,  Left  rectus  muscle  displaced  toward  median  line;  E,  Incision  through 
posterior  layer  of  rectal  sheath  (further  toward  median  line  than  incision  through  outer  rectal 
sheath)  exposing  coils  of  intestine;  F,  Transverse  fascia,  subperitoneal  areolar  tissue,  and  peri- 
toneum; G,  A  superficial  vessel.     The  operation  is  here  shown  on  the  left  side. 


outer  border  of  the  rectus  muscle — and  then  retract  the  intact  rectus  muscle  in- 
ward (Fig.  582).  (4)  Incise  the  posterior  layer  of  the  rectal  sheath  somewhat 
nearer  the  median  line  than  in  the  case  of  the  anterior  layer.  Or,  in  operating  in 
the  neighborhood  of  the  deep  epigastric  artery,  in  order  to  avoid  this  vessel, 
the  incision  in  the  posterior  layer  may  be  made  somewhat  further  outward 
than  the  incision  through  the  anterior  layer.  The  artery  may,  however,  be 
readily  ligated  if  in  the  way.  (5)  In  the  same  line  as  the  division  of  the 
posterior  layer  of  the  rectal  sheath,  incise  vertically  the  subjacent  tissues — 
which  will  consist  of  transversalis  fascia,  subperitoneal  areolar  tissue,  and 
peritoneum,  except  below  the  semilunar  fold  of  Douglas,  below  which  line 


ANTERIOR   ABDOMINAL    SECTION   THROUGH   RECTAL    SHEATH.       813 

the  posterior  layer  of  the  sheath  itself  consists  of  transversalis  fascia  alone, 
and  the  subjacent  tissues  consist  of  subperitoneal  areolar  tissue  and  perito- 
neum. (6)  Having  accomplished  the  object  of  the  operation,  the  structures 
are  to  be  sutured  in  the  following  layers, — peritoneum,  subserous  areolar 
tissue,  and  posterior  layer  of  the  rectal  sheath,  with  interrupted  or  continuous 
catgut  suture; — anterior  layer  of  rectal  sheath  with  interrupted  gut  sutures, 
which  also  pass  partly  through  the  rectus  muscle  (the  displaced  border  of  the 
rectus  should  also  be  sutured  to  the  outer  margin  of  the  rectal  sheath) ; — 
the  fascia,  with  gut — and  the  skin  with  subcuticular  silk,  or  interrupted  silk- 
worm-gut sutures  (or  skin  and  fascia  may  be  sutured  together). 


Fig.  582. — " Overlapping "  Closure  of  Exposltre  of  Abdominal  Cavity  through 
the  Rectal  Sheath: — Line  of  continuous  sutures  through  peritoneum,  subserous  areolar 
tissue,  and  transversalis  fascia;  Interrupted  mattress  sutures  passing  through  posterior  layer  of 
outer  portion  of  rectal  sheath,  on  the  left,  and  posterior  layer  of  rectal  sheath  and  outer  aspect  of 
rectus,  on  the  right;  Mattress  suture  passing  through  inner  aspect  of  anterior  layer  of  rectal 
sheath,  on  the  right,  and  the  outer  aspect  of  the  anterior  layer,  on  the  left;  Interrupted  skin 
sutures. 


Comment. — The  chief  objection  to  the  operation  is  the  division  of  the 
nerves  corresponding  with  the  incision,  and  consequent  atrophy  and  paresis 
of  the  rectus.     The  nerves  severed  in  the  site  where  the  operation  is  usually 


814 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


performed  (for  appendicitis)  being  generally  the  tenth,  eleventh,  and  twelfth 
dorsal,  with  or  without  the  iliohypogastric.  The  deep  epigastric  artery  is 
usually  divided,  although  this  is  of  no  great  consequence. 

A  lateral  exposure  of  the  abdominal  contents  may  be  secured  by  adding  to 
the  regular  Battle-Jalaguier-Kammerer  form  of  exposure  the  features  common 
to  the  Fowler  operation  and  to  the  Weir  modification  of  the  McBurney  oper- 
ation.    The  sheath  of  the  rectus  is  exposed  in  the  usual  manner  (Fig.  583). 


Fig.  583. — Fowler's  Method  of  Intramuscular  Transverse  Exposure  of  the 
Abdominal  Cavity: — A,  Retracting  skin  and  fatty  areolar  tissue  from  external  oblique;  B, 
Retracting  inner  lip  of  incision  through  outer  aspect  of  rectal  sheath.     (Modified  from  Fowler.) 


The  rectus  is  then  retracted  inward  (Fig.  584) — after  which  the  fibers  of  the 
external  oblique  are  separated  in  their  cleavage  line  (Fig.  584) — the  internal 
oblique  is  retracted  or  divided — the  transversalis  fibers  are  separated  in  the 
line  of  their  cleavage — and  the  transversalis  fascia,  subserous  areolar  tissue,  and 
peritoneum  are  incised  at  a  right  angle  to  the  line  of  the  rectus — and  the  poste- 
rior layer  of  the  rectal  sheath  is  incised  transversely,  after  careful  retraction  of 
the  rectus  muscle  and  epigastric  vessels.  At  the  close  of  the  operation  the 
aponeurotic  lines  of  division  are  closed  in  the  lines  of  their  separation. 


MEDIAN    INFERIOR    ABDOMINAL    SECTION. 


>I5 


Fig.  584. — Same  as  Above: — A,  Inward  retraction  of  rectal  sheath;  B,  Inward  retraction 
of  rectus;  C,  Separation  of  fibers  of  external  oblique  in  cleavage  line.  The  internal  oblique  is 
shown  beneath  the  fibers  of  the  external  oblique — as  is  also  the  transverse  incision  through  the 
peritoneum  and  posterior  layer  of  the  rectal  sheath.     (Modified  from  Fowler.) 


MEDIAN  INFERIOR  ABDOMINAL  SECTION 

BY  PFANNENSTIEL'S  SUPERFICIAL  TRANSVERSELY  CURVED  AND  DEEP  VERTICAL 

INCISIONS. 

Description . — A  method  of  entering  the  peritoneal  cavity  in  the  lower 
median  abdominal  region — by  means  of  a  superficial  curved  incision,  with 
downward  convexity,  just  above  the  inner  halves  of  Poupart's  ligaments  and 
the  symphysis.,  with  an  upward  retraction  of  the  outlined  flap  of  skin,  fascia, 
and  anterior  rectal  sheath — followed  by  a  deep  vertical  division  in  the  median 
line.  A  median  scar  is  avoided,  and  the  transverse  scar  lies  partly  hidden 
by  the  hair-line.  Hernia  is  supposed  to  be  less  apt  to  follow.  Chiefly  used 
for  limited  operations  upon  the  tubes,  ovaries,  uterus,  bladder,  and  pelvic 
cavity. 

Preparation — Position. — As  for  Median  Abdominal  Section. 

Landmarks. — Linea  alba;  position  of  deep  epigastric  arteries;  Poupart's 
ligaments;  symphysis  pubis. 

Incision. — (1)  Superficial  transversely  curved  incision,  with  downward 
convexity,  beginning  and  ending  over  the  deep  epigastric  arteries,  passing 
just  above  the  inner  halves  of  Poupart's  ligaments  and  the  symphysis  pubis, 


8i6 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


in  the  hair-line; — (2)  Deep  vertical  incision,  after  the  anterior  layer  of  the 
rectal  sheath  has  been  retracted,  passes  between  the  inner  borders  of  the 
recti  muscles,  in  the  median  line,  from  just  above  the  symphysis  pubis  upward. 
(See  Fig.  576,  I  and  H.) 

Operation. — (1)  Incise  skin,  fascia,  and  anterior  layer  of  rectal  sheath 
in  the  superficial  transversely  curved  incision.  Clamp  vessels.  Dissect  and 
retract  the  curved  flap  thus  formed  upward,  including  the  anterior  rectal 


Fig.jS^. — Abdominal  Section  by  Pfannenstiel's  Superficial  Transversely  Curved  and 
Deep  Vertical  Incisions  : — A,  Flap,  with  anterior  layer  of  rectal  sheath  adherent,  turned  upward  ; 
B,  Linea  semilunaris;  C,  Rectus  muscle;  D,  Pyramidalis  muscle;  E,  Transversalis  fascia,  subperi- 
toneal areolar  tissue,  and  peritoneum;  F,  Coils  of  small  intestine;  G,  Uterus;  H,  Bladder;  I,  A 
superficial  vessel. 

sheath,  thereby  exposing  the  bared  recti  muscles.  (See  Fig.  585.)  (2)  Incise 
between  the  inner  borders  of  the  recti  and  pyramidales  muscles,  just  as  in 
median  abdominal  section,  until  the  peritoneal  cavity  is  reached,  which  is 
entered  just  as  in  that  operation.  (3)  Having  accomplished  the  object  of 
the  operation,  the  wound  is  sutured  in  the  following  manner; — the  posterior 
laver  of  the  rectal  sheath  is  closed  with  continued  catsrut  suture,  including 


INFERIOR    ANTEROLATERAL    ABDOMINAL    SECTION.  817 

the  edges  of  the  peritoneum  and  subserous  areolar  tissue — the  inner  margins 
of  the  recti  are  next  sutured  with  gut — the  cut  edge  of  the  transversely  divided 
anterior  rectal  sheath  is  similarly  sutured  with  gut — and  the  skin  wound  is 
closed  with  silk,  or  silkworm-gut. 

Comment. — Care  is  necessary  to  avoid  wounding  the  bladder,   which 
should  be  empty  at  the  time  of  operation. 


INFERIOR  ANTERO-LATERAL  ABDOMINAL  SECTION 

BY  MEYER'S   "  HOCKEV-STICK  "  IN'CISION. 

Description. — A  method  of  entering  the  lower  antero -lateral  abdominal 
cavity,  partly  by  intramuscular  separation,  partly  by  transverse  division  of 
muscle,  by  means  of  an  incision  shaped  somewhat  like  a  "hockey-stick." 
Resorted  to  for  the  purpose  of  gaining  a  greater  degree  of  exposure  of  the 
abdomino  pelvic  cavity  than  afforded  by  the  simple  McBurney  incision. 
Used  by  its  originator  for  some  complicated  cases  of  appendicitis. 

Preparation — Position. — As  in  McBurney's  Operation. 

Landmarks. — Imaginary  line  from  umbilicus  to  anterior  superior  iliac 
spine,  with  the  location  of  McBurney's  point  (see  McBurney's  operation. 
Landmarks,  page  808);  Poupart's  ligament;  outer  border  of  the  rectus;  deep 
epigastric  artery. 

Incision. — (1)  Primary  Incision, — begins  about  1.3  cm.  (\  inch)  above 
an  imaginary  line  from  the  umbilicus  to  the  anterior  spine  of  the  ilium,  at 
a  point  2  cm.  (J  inch)  to  the  inner  side  of  the  anterior  superior  iliac  spine 
(that  is,  midway  between  McBurney's  point  and  the  anterior  superior  iliac 
spine),  and  passes  thence  in  a  direct  line  toward  the  point  where  the  femoral 
artery  runs  under  Poupart's  ligament,  ending  about  1.3  to  2  cm.  (h  to  f  inch) 
above  Poupart's  ligament.  (2)  Secondary  incision,  which  is  only  made  sub- 
sequently, for  the  purpose  of  gaining  more  room,  passes  upward  and  inward, 
or  curves  directly  inward,  from  the  lower  end  of  the  primary  incision  toward 
the  outer  border  of  the  rectus.     (See  Fig.  576,  J.) 

Operation. — (1)  Incise  skin  and  fascia  in  the  line  of  the  primary  inci- 
sion— clamp  vessels — and  retract  margins  of  wound.  (2)  Split  the  fibers  of 
the  external  oblique  muscle  and  its  aponeurosis  in  their  cleavage  line.  (3) 
Divide  the  internal  oblique  and  transversalis  in  the  same  line  as  made  by 
the  separation  of  the  fibers  of  the  external  oblique — which  will  cut  the  fibers 
of  the  internal  oblique  transversely  and  those  of  the  transversalis  obliquely. 
(4)  Incise  the  transversalis  fascia,  subserous  areolar  tissue,  and  peritoneum 
transversely.  (5)  If  more  room  be  now  necessary,  the  left  index  is  passed 
into  the  abdominal  cavity  to  the  deep  epigastric  artery,  as  a  guide  and  pro- 
tector, and  the  lower  end  of  the  incision  is  extended  upward  and  inward, 
or  directly  inward,  to  the  outer  border  of  the  rectus  muscle.  (6)  If  still  more 
room  be  needed,  the  rectus  muscle  itself  can  be  displaced  inward  and  the 
peritoneum  incised  beneath  it.  (7)  The  object  of  the  operation  is  now  accom- 
plished.    The  wound  is  then  closed  by  tier-suturing. 

Comment. — The  deep  epigastric  vessels  are  doubly  ligated  and  divided, 
if  necessary. 
52 


OPERATIONS    UPON    THE    ABDOMINO-PELVTC    REGION. 


INFERIOR  ANTERO-LATERAL  ABDOMINAL  SECTION 

PA'  FOWLER'S  ANGULAR   INCISION. 

Description. — Founded,  in  part  of  its  application,  upon  the  same  principle 
as  McBurney's  intramuscular  operation — and  planned  to  give  freer  access  to 
the  contents  of  the  ileo-caecal  region,  and  especially  to  the  base  of  the  appendix. 
Especially  intended  by  its  author  for  cases  of  appendicitis  in  which  the  process 
is  still  limited  to  the  appendix. 

Preparation — Position. — As  in  McBurney's  operation. 

Landmarks. — Anterior  superior  iliac  spine;  outer  border  of  the  rectus. 

Incision. — Begins  at  the  upper  border  of  the  anterior  superior  iliac 
spine — runs  horizontally  inward  to  the  outer  border  of  the  rectus  muscle — 
curves  thence  downward  and  runs  parallel  with  the  outer  border  of  the  rectus 
for  5  to  7.5  cm.  (2  to  3I  inches).     (See  Fig.  576,  K.) 

Operation. — (1)  Incise  skin  and  fascia  in  the  above  line — clamp  vessels — 
and  turn  downward  and  outward  this  triangular  flap  of  skin  and  fascia, 
exposing  the  aponeurosis  of  the  external  oblique  beneath.  Place  retractors  at 
the  center  of  the  transverse  incision  and  at  the  lower  angle  of  the  wound, 
and  retract  in  the  cleavage  line  of  the  external  oblique.  (2)  Incise  the  ex- 
ternal oblique  muscle  and  aponeurosis  in  the  cleavage  line  of  their  fibers, 
and  retract  in  the  direction  opposite  to  their  cleavage  line.  (3)  Expose  and 
open  the  sheath  of  the  rectus  and  retract  the  rectus  muscle,  with  the  deep 
epigastric  vessels,  strongly  toward  the  linea  alba — while  retracting  the  aponeu- 
rosis to  the  outer  side.  (4)  Incise  transversely,  in  line  with  the  horizontal 
part  of  the  skin  incision,  the  internal  oblique  and  transversalis  muscles, 
transversalis  fascia,  subserous  areolar  tissue  and  peritoneum,  all  as  one 
structure — beginning  at  the  outer  margin  of  the  retracted  rectus.  And  retract 
the  deep  lips  of  the  wound,  exposing  the  abdominal  cavity.  (5)  The  special 
object  of  the  operation  is  now  accomplished.  (6)  At  the  completion  of  the 
operation,  the  structures  are  sutured  in  the  following  order; — peritoneum, 
subserous  areolar  tissue,  transversalis  fascia,  transversalis  and  internal  oblique 
muscles  are  all  sutured  in  one  layer,  with  continuous  chromic  gut; — the  rectus 
is  allowed  to  fall  back  into  place; — the  external  oblique  aponeurosis  and 
muscle  are  sutured  with  continuous  kangaroo  tendon,  in  which  layer  the 
rectal  sheath  is  also  included ; — and  the  skin  is  closed  by  a  subcuticular  silk 
suture  (and  the  fascia  separately  with  gut,  if  it  be  very  thick). 

Comment. — In  applying  the  above  operation  to  cases  of  appendicitis, 
Fowler  considers  the  base  of  the  appendix  to  be  most  generally  found  at 
the  intersection  of  a  transverse  line  between  the  anterior  superior  iliac  spines 
with  a  vertical  line  running  midway  between  the  median  line  of  the  body 
and  the  anterior  superior  iliac  spine. 

This  operation  gives  no  more  room  than  Weir's — and  the  latter  operation 
does  not  divide  muscle-fibers  transversely. 


SUPERIOR  ANTERO-LATERAL  ABDOMINAL  SECTION 

BY  OBLIQUE   SUBCOSTAL   IN'CISION. 

Description. — A  method  of  entering  the  abdominal  cavity  parallel  with 
and  a  short  distance  below  the  costo-chondral  arches.  Generally  resorted 
to  for  the  exposure  of  the  subhepatic,  gastric,  and  splenic  regions. 


LATERAL    ABDOMINAL    SECTION.  819 

Preparation — Position. — As  in  Median  Abdominal  Section. 

Landmarks. — Costo-chondral  arches. 

Incision. — Generally  parallel  with  and  about  2.5  cm.  (1  inch)  below  the 
costo-chondral  arch  of  one  or  the  other  side — with  the  center  of  the  incision 
over  the  object  sought.     (See  Fig.  576,  L.) 

Operation. — (I)  Incise  skin,  and  fascia — clamp  vessels — retract  lips  of 
wound.  (2)  Incise  external  oblique,  which  will  be  aponeurotic  above  and 
muscular  below — the  incision  crossing  its  fibers  about  at  a  right  angle.  (3) 
Separate  the  fibers  of  the  internal  oblique  in  their  cleavage  line — which  may 
be  done  external  to  the  outer  border  of  the  rectal  sheath.  (4)  Incise  the 
transversalis  parallel  with  the  costo-chondral  border,  which  will  be  perpen- 
dicular to  their  fibers.  (5)  Incise  the  transversalis  fascia,  subserous  areolar 
tissue,  and  peritoneum  in  the  same  line  with  the  preceding  incision — and  thus 
enter  the  peritoneal  cavity.  (6)  Having  completed  the  object  of  the  opera- 
tion— suture  the  structures  in  the  following  layers,  with  buried  catgut; — peri- 
toneum, subserous  areolar  tissue,  transversalis  fascia; — transversalis  and  in- 
ternal oblique  muscles; — external  oblique  ; — and  fascia  and  skin  with  silk 
or  silkworm-gut. 

Comment. — This  incision  corresponds  with  the  cleavage  line  of  the  skin — 
and  especially  corresponds  with  the  course  of  the  seventh  and  eighth  inter- 
costal nerves,  which  run  upward  and  are  thereby  uninjured.  The  incision 
can  be  prolonged  up  to  the  rectus  muscle  followed  by  a  transverse  incision 
of  its  anterior  sheath,  with  inward  retraction  of  the  intact  muscle — and  a 
similar  transverse  division  of  its  posterior  sheath — the  sheath  being  sutured 
at  the  end  of  the  operation.  For  the  application  of  this  incision,  see  operations 
upon    the    stomach. 


EXPOSURE  OF  HYPOCHONDRIAC  REGIONS  BY  CHONDROPLASTIC 
RESECTION  OF  CHEST-WALL 

BY    SUBCOSTAL    INCISION    AXD    TEMPORARY    DIVISION    OF    SEVENTH,    EIGHTH, 
NINTH,    AND    TENTH    COSTAL    CARTILAGES. 

Owing  to  the  rigidity  of  the  chest-wall  it  is  difficult  to  satisfactorily  expose 
the  dome  of  the  diaphragm,  the  upper  surface  of  the  liver,  the  lower  end  of  the 
esophagus,  and  the  cardiac  end  of  the  stomach  and  the  spleen.  By  the  tem- 
porary resection  of  the  costal  arch  of  either  the  right  or  left  side,  as  indicated, 
these  structures  are  much  more  readily  brought  into  the  operative  field. 

The  details  of  this  operation  have  been  given  under  Thoracic  Operations, 
page  734- 

LATERAL  ABDOMINAL  SECTION 

BY  YISCHER/S   LLMBO-ILIAC    INCISION. 

Description. — Consists  in  the  separation  of  the  muscular  and  tendinous 
fibers  of  the  abdominal  muscles  of  the  lumbo-iliac  region,  just  above  the 
center  of  the  iliac  crest,  in  their  cleavage  lines,  without  transverse  division 
of  muscle-fibers,  or  harm  to  abdominal  nerves — and  exposing  the  operation- 
site  by  retraction  of  the  separated  muscles.  Applicable  to  exposure  of  struc- 
tures in  the  above  region,  and  especially  for  suppurating  cases  of  appendi- 
citis— being  advantageous  because  of  the  ability  to  extend  the  opening  from 
either  end  of  the  original  incision. 


820  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

Preparation. — As  in  McBurney's  operation. 

Position. — Patient  partly  turned  toward  opposite  side,  with  pad  placed 
beneath  involved  side,  to  render  site  of  operation  prominent.  Surgeon  on 
side  of  operation.     Assistant  opposite  to  surgeon. 

Landmarks. — Crest  of  ilium;  anterior  superior  iliac  spine;  Poupart's 
ligament. 

Incision. — Runs  2.5  cm.  (1  inch)  above  and  parallel  with  the  crest  of 
the  ilium,  beginning  at  the  outer  border  of  the  external  oblique  (which  corre- 
sponds with  about  the  center  of  the  iliac  crest)  and  ending  opposite  the  anterior 
superior  iliac  spine — or  may  extend  forward  parallel  with  the  outer  part  of 
Poupart's  ligament.     (See  Fig.  576,  M.) 

Operation. — (1)  Incise  skin  and  fascia  in  the  above  line — clamp  vessels — 
retract  lips  of  wound,  exposing  the  external  oblique.  (2)  The  fibers  of  the 
external  oblique  are  now  separated  in  their  cleavage  line.  As  the  fibers  of 
the  muscular  portion  run  somewhat  more  vertically  here  than  the  line  of 
the  skin  incision,  a  good,  free  length  of  separation  is  necessary,  with  firm 
retraction  inward  and  upward,  and  outward  and  downward,  respectively,  in 
order  to  expose  the  internal  oblique.  (3)  The  fibers  of  the  internal  oblique, 
which  run  upward  and  inward,  are  similarly  separated  in  their  cleavage 
line,  and  retracted  upward  and  backward,  and  downward  and  forward; — care- 
fully guarding  all  important  nerve  structures  between  the  internal  oblique 
and  transversalis,  which  latter  muscle  is  now  exposed.  (4)  The  fibers  of  the 
transversalis,  running  transversely  inward,  practically  in  the  same  line  with 
the  internal  oblique,  are  now  separated  in  like  manner  in  their  cleavage  line, 
and  retracted  upward  and  downward,  exposing  the  transversalis  fascia.  (5) 
The  transversalis  fascia,  subserous  areolar  tissue,  and  peritoneum  are  divided 
vertically — and  the  peritoneal  cavity  entered.  (6)  Upon  completion  of  the 
operation,  the  structures  are  sutured  as  in  McBurney's  operation  (page  809). 

Comment. — More  room  may  be  gotten  anteriorly,  by  continuing  the 
separation  of  the  aponeurotic  fibers  of  the  external  oblique  parallel  with 
Poupart's  ligament,  in  the  line  of  the  original  incision, — and  posteriorly  and 
superiorly,  by  continuing  the  separation  of  the  muscular  fibers  and  lumbar 
aponeurosis.  A  branch  of  the  deep  circumflex  iliac  artery,  between  trans- 
versalis and  internal  oblique,  is  clamped  and  divided. 

Note. — Other  incisions  are  given  under  the  different  abdomino-peivic 
viscera.  Closure  of  the  abdominal  wall  by  "  overlapping  "  methods  is  espe- 
cially shown  under  Operations  for  Hernia,  pages  1163  to  1183. 


II.   THE  PERITONEUM. 

SURGICAL  ANATOMY. 

Course  of  the  Peritoneum  Forming  the  Greater  Sac — In  Longitudinal 
Section. — Passing  down  from  the  umbilicus,  the  peritoneum  lines  the  anterior 
abdominal  wall — covers  the  urachus  and  obliterated  hypogastric  arteries — 
passes  onto  the  bladder,  from  its  upper  aspect  to  the  trigone — is  reflected 
onto  the  anterior  and  upper  part  of  the  lateral  aspects  of  the  rectum,  in  the 
male,  forming  the  recto-vesical  pouch.  In  the  female,  the  reflection  is  from 
the  bladder  onto  the  uterus  (utero-vesical  fold) — extending  thence  over  the 
upper  portion  of  the  posterior  vaginal  wall — and  thence  to  the  rectum  (recto- 
vaginal pouch).  From  the  rectum,  the  sigmoid  flexure  of  the  colon  is  entirely 
covered  (sigmoid  mesocolon) — the  ascending  and  descending  colons  being 


SURGICAL    ANATOMY    OF    THE    PERITONEUM.  821 

covered,  generally,  only  anteriorly  and  laterally — and  passing  from  the  spine 
downward,  the  peritoneum  covers  the  small  intestines,  forming  the  lower 
leaf  of  the  mesentery — and  thence  back  again,  completing  the  investment 
of  the  small  bowel,  forming  the  upper  leaf  of  the  mesentery — and  passes 
backward  over  the  transverse  portion  of  the  duodenum  to  the  pancreas — 
thence  forward  to  form  the  inferior  layer  of  the  transverse  mesocolon — covers 
the  inferior  and  part  of  the  anterior  aspect  of  the  transverse  colon — thence 
runs  downward  to  form  the  posterior  layer  of  the  great  omentum — returning 
to  form  the  anterior  layer  of  the  great  omentum — thence  to  the  stomach, 
covering  its  antero-superior  aspect — thence  to  the  under  surface  of  the  liver, 
forming  the  anterior  layer  of  the  lesser  or  gastro-hepatic  omentum — thence 
covers  the  inferior  surface  of  the  liver,  from  the  transverse  fissure  to  its  anterior 
border — whence  it  is  reflected  over  the  anterior  border  to  cover  the  superior 
surface  of  the  liver  to  the  posterior  peritoneal  limit — thence  it  passes  to  the 
inferior  concave  surface  of  the  diaphragm  (superior  layer  of  the  coronary 
ligament) — thence  over  the  anterior  portion  of  the  concavity  of  the  diaphragm 
to  the  anterior  abdominal  wall — whence  it  passes  down  the  anterior  abdominal 
parietes  to  the  umbilicus,  to  the  place  of  beginning. 

Course  of  the  Peritoneum  Forming  the  Lesser  Sac — In  Longitudinal 
Section. — Beginning  at  the  posterior  aspect  of  the  stomach,  which  it  covers, 
the  peritoneum  of  the  lesser  sac  passes  upward  to  the  inferior  surface  of  the 
liver,  behind  the  transverse  fissure,  forming  the  posterior  layer  of  the  lesser 
or  gastro-hepatic  omentum — and  having  covered  the  postero-inferior  aspect  of 
the  liver,  it  passes  on  to  the  under  surface  of  the  diaphragm  (inferior  layer 
of  the  coronary  ligament) — thence  passes  downward  over  the  posterior  portion 
of  the  concavity  of  the  diaphragm  to  the  spine,  covering  the  great  vessels — 
thence  to  the  pancreas — thence  forward,  forming  the  upper  layer  of  the 
transverse  mesocolon — covers  the  supero-anterior  aspect  of  the  transverse 
colon — descends,  forming  the  innermost  layer  of  the  great  omentum — then 
ascends  to  the  greater  curvature  of  the  stomach — and  covers  its  posterior  wall, 
to  the  place  of  beginning.  The  lesser  sac  is  in  relation  with  the  inner  aspect 
of  the  spleen,  forming  the  inner  layer  of  the  gastro-splenic  omentum — and 
also  in  relation  with  the  superior  portion  of  the  left  kidnev. 

Layers  and  Folds  of  Peritoneum. — (i)  Parietal  Layer — connected  by 
subperitoneal  areolar  tissue  with  the  walls  of  the  abdomino-pelvic  cavity. 
(2)  Visceral  Layer — covers  some  part,  or  the  entire  surface,  of  all  the  viscera 
of  the  abdomino-pelvic  cavity.  (3)  Mesenteries — folds  of  peritoneum  con- 
necting parts  of  the  intestinal  tract  with  the  posterior  abdomino-pelvic  wall. 
See  page  833.  (4)  Omenta — folds  of  peritoneum  connecting  the  stomach 
with  other  viscera.  See  page  830.  (5)  Ligaments — reflections  of  peritoneum 
from  parts  of  the  abdomino-pelvic  walls  and  diaphragm  to  the  various 
abdomino-pelvic  viscera  other  than  the  intestines — for  example,  those  of  the 
liver,  spleen,  uterus,  etc.  For  these  ligaments,  see  the  various  viscera  of  the 
abdomino-pelvic  region. 

Foramen  of  Winslow. — Communication  between  the  greater  and  lesser 
peritoneal  sacs — revealed  by  lifting  the  liver  upward  and  to  the  right,  and 
depressing  the  first  part  of  the  duodenum  and  intestines  downward  and  to 
the  left.  Bounded: — Superiorly;  by  caudate  lobule  of  liver; — Inferiorly;  by 
first  part  of  duodenum  and  first  part  of  hepatic  artery; — Anteriorly;  by  liga- 
mentum  hepato-duodenale  (right  free  edge  of  lesser  omentum),  with  its  con- 
tained ductus  communis  choledochus,  vena  portae,  and  hepatic  artery,  in  order 
from  right  to  left — the  vena  porta?  lying  somewhat  posterior  to  artery  and  duct. 

Viscera  Almost  Entirely  Covered  by  Peritoneum. — Liver;  stomach; 


822  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

spleen;  first  portion  of  duodenum;  jejunum;  ileum;  transverse  colon;  caecum; 
sigmoid  flexure  of  colon;  upper  half  of  rectum;  uterus;  ovaries. 

Viscera  Partly  Covered  by  Peritoneum. — Descending  and  transverse 
parts  of  duodenum;  ascending  and  descending  colons;  mid-portion  of  rec- 
tum; upper  part  of  vagina;  posterior  wall  of  bladder. 

Viscera  in  Contact  with  Peritoneum  without  Being  Especially  Cov- 
ered by  It. — Kidneys;  suprarenal  capsules;  pancreas. 

Viscera  Uncovered  by  Peritoneum. — Lower  end  of  rectum;  neck,  base 
and  anterior  aspect  of  bladder;  anterior  and  inferior  portion  of  posterior 
wall  of  vagina. 


GENERAL  SURGICAL  CONSIDERATIONS  IN  OPERATIONS  UPON  THE 

PERITONEUM. 

Where  the  peritoneum  is  attacked  surgically  it  is  generally  dealt  with 
incidentally,  as  a  part  of  some  special  operation.  The  technic,  therefore, 
of  dealing  with  the  peritoneum  is  described  in  those  special  operations.  In 
some  cases,  however,  the  peritoneum  is  the  structure  primarily  dealt  with — 
and  will  be  so  considered  in  the  present  section. 

The  surface  form  and  landmarks  of  the  peritoneum,  as  well  as  the  instru- 
ments used,  are  sufficiently  given  under  the  operations  upon  the  viscera  of 
the  abdomino-pelvic  cavity. 


OPERATIONS    FOR    THE    SEPARATION,    DIVISION,    OR    LIGATION    OF 
PERITONEAL  ADHESIONS. 

Description. — Adhesions,  resulting  from  the  union  of  the  serous  surfaces 
of  the  peritoneum,  may  occur  in  the  form  of  thin,  thick,  narrow  or  broad 
sheets  or  membranes; — in  the  form  of  fragile,  dense,  short  or  long  bands; — 
or  as  limited  or  extensive  surfaces  loosely  or  intimately  united.  Adhesions 
may  be  vascular  or  comparatively  non-vascular.  Adhesions  may  be  en- 
countered in  any  operation  involving  any  serous  cavity — therefore,  the  special 
features,  anatomical  relations,  and  all  steps  preliminary  to  the  discovery  of 
the  adhesions,  will  depend  upon  the  operation  in  question. 

Two  general  methods  of  dealing  with  adhesions  are  available;  (i)  By 
blunt  dissection,  with  or  without  ligature, — more  applicable  in  non-vascular, 
loose  and  limited  adhesions; — (2)  By  division  between  ligatures, — more  appli- 
cable to  vascular,  firmer  and  more  extensive  adhesions. 

Separation  of  Adhesions  by  Blunt  Dissection,  with  or  without  Liga- 
tion.— The  underlying  principle  in  this  method  of  dealing  with  adhesions 
is  to  find  the  plane  of  cleavage  in  the  abnormal  union  and  follow  it  up,  sepa- 
rating the  adherent  surfaces  as  carefully  as  possible.  This  separation  is  best 
accomplished  by  means  of  a  blunt  dissector,  the  handle  of  a  knife,  the  closed 
ends  of  a  pair  of  blunt  scissors,  or  the  tip  of  the  finger.  If  the  last  be  used, 
a  better  hold  may  be  gotten  upon  the  parts  by  stretching  a  single  thickness 
of  gauze  over  the  finger-tip.  The  adhesions  are  gently  torn  apart,  always 
endeavoring  to  adhere  strictly  to  the  cleavage  line,  especially  where  important 
structures  are  involved,  as  in  the  serous  coverings  of  viscera.  If  the  adhesions 
be  limited  and  but  little  vascular,  ligation  is  generally  unnecessary.  If  they 
be  vascular,  and  especially  if  somewhat  extensive  and  dense,  they  should  be 
ligated  in  two  places  from  1.3  to  2.5  cm.  (J  to  1  inch)  apart,  according  to 
circumstances,  and  then  divided  between  the  ligatures.     The  preferable  liga- 


OPERATIONS    FOR    PERITONEAL    ADHESIONS. 


^3 


ture  is  plain  gut  for  small  adhesions — and  chromic  gut  for  larger  ones.     Ad- 
hesions are  often  first  divided  and  then  ligated.     (See  Fig.  586,  D.) 

Division  of  Adhesions  between  Ligatures. — The  adhesions  are  first 
carefully  isolated — and  then  treated  according  to  their  nature.  If  they  be  in 
the  form  of  bands,  double  ligatures  of  chromic  gut  are  thrown  around  them 


Fig.586.— OPERATIONS  FOR  THE    SEPARATION    OF    PERITONEAL    ADHESIONS    AND  THE    LIGATION 

ok  Omentum  : — A,  A,  Dividing-,  in  sections,  thick  layers  of  intestino-abdominal  adhesions  between 
double  ligatures  ;  B,  Incising  thin  layers  of  inter-intestinal  adhesions  ;  C,  Ligating  isolated  bands  of 
intestino-abdominal  adhesions  ;  D,  Separation  of  membranous  inter-intestinal  adhesions  by  blunt  dis- 
section ;  E,  F,  F,  Tying  off.  in  sections,  adherent  omentum,  preparatory  to  excision  of  distal  portion 
— E,  by  means  of  individual  ligature  carried  by  aneurism-needle — F,  F,  by  means  of  continuous  liga- 
ture applied  to  the  posterior  and  drawn  through  the  anterior  aspect  of  the  omentum  in  sections,  by 
catch-forceps. 


and  tied,  and  the  bands  are  then  divided  between  them.  If  the  adhesions 
be  in  the  form  of  broad  surfaces,  they  are  ligated  in  sections  and  divided 
upon  the  distal  side  of  the  ligatures — or  between  two  ligatures,  if  indicated. 
(See  Fig.  586,  A.) 

Visceral  Adhesions  to  the  Abdomino-pelvic  Wall. — \\  hen  entering 
the  abdominal  cavity  where  adhesions  may  be  suspected,  or  where,  in  the 


824  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

neighborhood  of  known  adhesions,  it  is  uncertain  as  to  whether  the  peritoneal 
cavity  have  been  entered,  the  underlying  tissues  should  be  picked  up  and 
rolled  between  the  fingers,  to  enable  a  judgment  to  be  formed  by  the  sensation 
imparted.  If  the  peritoneal  cavity  be  entered  in  the  immediate  vicinity  of 
an  adhesion,  this  should  be  at  once  recognized  by  sweeping  the  finger  around 
the  vicinity  of  the  opening — and  the  adhesion  separated  by  blunt  dissection, 
or  divided  between  double  ligatures  if  necessary.  Where  the  opening  made 
comes  directly  down  upon  adhesions,  these  should  be  recognized  as  soon 
as  possible,  that  the  progress  toward  the  peritoneal  cavity  may  be  known — 
and  then  an  endeavor  be  made  to  reach  a  free  margin  of  the  adhesion,  from 
which  the  remainder  of  the  separation,  or  division,  may  be  made  on  the 
general  principles  mentioned.     (See  Fig.  586,  A,  C.) 

Intestinal  Adhesions. — The  thin,  membranous  or  velamentous  adhesions 
may  generally  be  separated  by  blunt  dissection  with  the  fingers — by  putting 
the  parts  gently  upon  the  stretch  and  keeping  the  adhesion  in  a  broad,  thin 
layer,  rather  than  in  a  thick,  twisted  cord.  Dense,  organized  adhesions 
require  careful  dissection — that  no  part  of  either  wall  raav  be  dangerouslv 
thinned.     (See  Fig.  586,  B,  D.) 

Inter-visceral  Adhesions. — Or  adhesions  between  growths  and  viscera — 
should  be  dealt  with  by  putting  the  adhesion  upon  moderate  stretch — by 
traction  upon  one  or  both  viscera,  until  the  bond  of  adhesion  is  demonstrated — 
then  first  ligate  or  clamp  on  each  side,  safely  to  the  outer  side  of  the  viscus, 
and  divide  the  adhesion  between  the  ligatures  or  clamps. 

Omental  Adhesions. — Adherent  omentum  may  often  be  stripped  off 
with  the  fingers.  If  too  dense,  or  too  firmly  united  for  this,  it  should  be 
ligated  with  a  single  ligature,  or  in  sections,  and  divided.  Large  portions 
of  the  omentum — and  even  the  entire  omentum — may  be  amputated.  The 
omentum  may  require  onlv  a  proximal,  or  mav  require  double  ligaturing. 
(See  Fig.  586,  E,  F,  F.) 

Comment. — (1)  While  the  separation  in  the  plane  of  the  abnormal  adhe- 
sion should  always  be  the  course  attempted,  where  this  is  impossible  it  often 
happens  that  areas,  dependent  upon  their  nature,  have  to  be  ligated,  or 
clamped,  and  cut,  with  the  sacrifice  of  some  portion  of  the  least  important 
structure.  (2)  Where  the  separation  of  an  adhesion  between  viscera  and 
neighboring  structures  (visceral  or  otherwise)  is  impossible,  and  where  the 
step  is  permissible,  one  or  more  layers,  or  even  the  entire  thickness,  of  the 
less  important  structure  is  left  attached  to  the  more  important  one — after 
ligating  and  blunt  dissection,  or  incision,  of  the  adhesion — thus  leaving  a 
limited  area  of  adherent  tissue  attached  to  an  organ,  rather  than  risk  injuring 
the  organ  by  further  attempt  at  removal.  In  such  cases  the  portion  left  is 
reduced  to  its  smallest  and  thinnest  size.  (3)  It  is  always  desirable  to  preserve 
the  serous  covering  of  a  viscus  (to  aid  nutrition  and  avoid  adhesions  and 
sloughing) — and  sometimes  surfaces  left  raw  by  separating  adhesions  may  be 
covered,  and  hemorrhage  also  controlled,  by  suturing  adjacent  serous  surfaces 
over  them — or  by  attaching  omental  grafts.     (See  page  832.) 

Xote. — For  further  consideration  of  this  subject,  see  Complications  of 
Median  Abdominal  Section,  page  806. 


PARACENTESIS  ABDOMINIS. 

Description. — Puncture  of  the  peritoneal  cavity  for  diagnostic  purposes, 
or  for  evacuation  of  fluid. 


OPERATIVE    TREATMENT    OF    DIFFUSE    SEPTIC    PERITONITIS.       825 

Preparation. — Shave  abdominal  wall.  Empty  bladder  and  bowels. 
Area  of  dulness  verified  by  percussion  immediately  before  paracentesis. 
Cocainization  of  the  area  of  puncture. 

Position. — Patient,  where  possible,  sits  upright  in  chair — where  impossi- 
ble, lies  upon  edge  of  bed.  A  many-tailed,  sterilized  bandage,  or  ordinary 
towel,  with  a  central  opening  corresponding  to  the  site  of  paracentesis,  is 
placed  around  the  patient,  and  tightened  posteriorly  by  an  assistant  as  the 
abdominal  enlargement  decreases  with  the  evacuation  of  fluid.  Surgeon  sits 
immediately  in  front  of  patient. 

Landmarks. — Linea  alba;  umbilicus;  limit  of  upper  aspect  of  bladder 
(see  that  structure,  page  796). 

Special  Instruments. — For  exploratory  punctures,  aspiratorv  svringes 
with  needles  of  small  caliber.  For  evacuation  of  considerable  quantity  of 
fluid,  a  straight  cannula  and  trocar  of  fairly  large  size  is  used.  Aspirators 
of  the  Dieulafoy  and  Potain  type  may  be  employed.  Where  the  skin  is  to 
be  preliminarily  incised,  a  knife  is  necessary — and  a  needle  and  thread, 
where  the  incision,  or  trocar-wound,  is  to  be  closed  bv  suture. 

Site  of  Paracentesis. — Generally  in  the  linea  alba,  midway  between 
umbilicus  and  symphysis  pubis.  Sometimes  the  puncture  is  made  in  the 
lower  half  of  either  semilunar  line. 

Operation. — (1)  Having  so  placed  the  broad  bandage  that  the  opening  is 
opposite  the  site  of  paracentesis,  and  having  grasped  the  exploratorv  or  aspira- 
torv needle,  or  trocar,  in  such  a  way  as  to  predetermine,  by  means  of  the  right 
index,  the  depth  to  which  it  is  to  enter,  which  will  be  decided  bv  the  estimated 
thickness  of  the  abdominal  wall,  the  instrument  is  quickly  but  guardedly 
thrust  through  the  abdominal  wall  into  the  free  peritoneal  cavity,  in  a  single 
movement.  In  the  case  of  the  exploratory  syringe,  sufficient  fluid  is  with- 
drawn for  examination — the  needle  withdrawn,  and  the  wound  closed  with 
collodion  and  cotton.  (2)  In  the  case  of  the  evacuation  of  large  amounts 
of  fluids  by  means  of  cannula  and  trocar  (or  aspirator)  the  trocar  is  with- 
drawn and  the  cannula  left  in  situ — the  fluid  is  then  allowed  to  flow,  the 
bandage  being  tightened  pari  passu.  At  the  end  of  the  operation,  the  can- 
nula is  withdrawn — and,  if  it  have  been  of  large  size,  an  interrupted  gut 
suture  is  made  to  close  the  opening  by  being  passed  on  a  curved  needle, 
from  side  to  side,  through  a  part  of  the  thickness  of  the  abdominal  wall. 
The  outer  aspect  of  the  opening  is  then  closed  with  collodion  and  gauze,  or 
cotton. 

Comment. — (i)  Where  a  large  size  instrument  is  used,  it  is  best  to  make 
a  small  preliminary  incision  through  the  tough  skin.  (2)  A  cannula  should 
preferably  be  used  the  end  of  which  is  not  pointed  or  sharp.  (3)  If  the 
cannula  be  obstructed  during  the  flow,  it  may  generally  be  freed  by  the 
passage  of  a  sterile  probe  down  its  length.  (4)  As  the  fluid  escapes,  the 
inner  end  of  the  cannula  (especially  if  dull)  may  be  shifted  so  as  to  furnish 
the  best  evacuation.  (5)  The  fluid  should  be  made  to  escape  slowly — and 
may  be  retarded  by  a  compress  over  the  outer  end  of  the  cannula — tc  avoid 
syncope. 


OPERATIVE  TREATMENT  OF  DIFFUSE  SEPTIC  PERITONITIS. 
murphy's  method. 

A  great  variety  of  methods  of  operating  for  diffuse  septic  peritonitis, 
variously  combined,  have  been  resorted  to  by  various  surgeons — the  chief 
among  which  have  been:     Local  dry  sponging  of  the  involved  area,  with  or 


826  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

without  evisceration;  Extensive  saline  irrigation  of  the  entire  peritoneal  cavity 
during  the  operation;  Local  irrigation  of  the  involved  area;  Simple  evacu- 
ation of  septic  fluid,  with  no  other  procedure;  Cigarette,  cigar  and  Mikulicz 
drains;  Glass-tube  drainage,  with  or  without  gauze;  Rubber-tube  drainage, 
with  or  without  gauze;  Drainage  through  unsutured  wound,  or  through 
wound  but  partly  sutured,  with  or  without  gauze  or  other  drains;  Drainage 
through  counter-openings  (as  through  the  pelvis,  loin,  perineum,  or  vagina) ; 
Closure  without  irrigation;  Irrigation  followed  by  closure;  Elevation  of 
head  of  bed  (Fowler's  position),  with  one  or  more  of  the  above  measures. 

Two  methods  will  be  here  described;  Murphy's  method,  illustrating 
drainage; — and  Blake's  method,  illustrating  irrigation  with  closure. 

It  can  not  be  said  that  any  radically  new  ideas  are  used  in  either  method — 
but  each,  by  grouping  various  measures,  has  evolved  a  technic. 

The  features  of  the  Murphy  method  are  the  following: 

(1)  The  rapid  removal  of  the  cause  of  infection,  as  far  as  possible,  and  with 
the  minimum  handling  of  the  intestines.  No  attempt  is  made  to  sponge  the 
peritoneal  surfaces,  or  to  remove  lymph  exudate,  which  would  tend  to  open 
up  channels  for  toxic  absorption. 

(2)  The  drainage  of  the  floor  of  the  pelvis  through  a  suprapubic  incision 
as  well  as  through  the  operative  incision.  The  combined  post-operative  pos- 
ture and  the  action  of  the  diaphragm  thereby  aid  in  the  expulsion  Of  accumu- 
lated fluid. 

(3)  The  foregoing  of  all  lengthy  procedure  and  secondary  objects  accom- 
plishing satisfactory  drainage  and  minimizing  manipulation  and  length  of 
anesthesia. 

(4)  The  semi-sitting  post-operative  posture  (Fowler's  position), — for  the 
purpose  of  causing  the  fluids  to  gravitate  toward  the  drains  and  away  from 
the  channels  of  greatest  absorption  into  the  system. 

(5)  The  post-operative  absorption  of  large  quantities  of  saline  solution 
through  the  rectum,  thus  reversing  the  lymphatic  current  and  converting  the 
peritoneal  surface  into  a  secreting  rather  than  an  absorbing  membrane — and 
also  largely  increasing  the  urine.  This  is  accomplished  in  the  following  way; — 
a  nozzle  with  several  openings  is  inserted  into  the  rectum — to  which  is  attached 
a  rubber  tubing  leading  to  a  reservoir  bag — the  bag  hanging  only  a  few  inches 
above  the  level  of  the  rectum — so  that  the  fluid  simply  trickles  into  the  rectum 
at  but  slightly  faster  rate  than  absorption  occurs.  From  one  to  two  quarts  flows 
in  continuously  in  about  an  hour.  Through  the  extra  holes  in  the  nozzle 
flatus  is  expelled  and  the  intestine  thus  kept  deflated,  especially  as  the  nozzle 
may  remain  in  situ  after  the  tube  is  disconnected.  The  peritoneum  thus 
discharges  fluid  freely — whicn,  by  diaphragmatic  action  and  the  special  pos- 
ture, is  carried  downward  toward  the  dependent  drains — thereby  washing 
the  peritoneum  in  its  passage  over  its  surface  and  escaping  through  the  exits 
provided.  The  heart's  action  is  increased  and  larger  quantities  of  urine  are 
voided,  thus  increasing  the  elimination  of  septic  material. 

(6)  Intestinal  peristalsis  is  prevented  by  abstinence  from  mouth-feeding 
and  drinking — thereby  lessening  the  chance  of  disseminating  septic  matter. 
Opium  may  possibly  be  given  to  aid  to  this  end. 

OPERATIVE  TREATMENT  OF  DIFFUSE  SEPTIC  PERITONITIS. 

blake's  method. 

The  features  of  this  technic  are,  in  the  words  of  its  author, — "Early  oper- 
ation— lavage  of  the  peritoneum  with  large  quantities  of  saline  solution — 


OPERATIVE    TREATMENT    OF    DIFFUSE    SEPTIC    PERITONITIS.       827 

closure  of  the  peritoneal  cavity  without  drainage,  unless  the  latter  is  absolutely 
indicated  by  the  presence  of  non-absorbable  amounts  of  necrotic  material." 

Three  categories  of  cases  are  recognized — Localized  collections  of  pus, 
with  limiting  adhesions — cases  of  spreading  peritonitis  with  no  limitations  of 


Fig.  587. — Sites  and  Forms  of  Intra-abdominal  Drainage  and  Irrigation: — (1) 
Cigarette  drainage  in  the  appendical  region;  (2)  Mikulicz  bag  and  pack  in  the  left  hypochondriac 
region;  (3)  Gauze  drain  from  the  pelvic  peritoneum  through  the  posterior  vaginal  pouch  and 
vagina;  (4)  Intra-peritoneal  irrigation  by  Blake's  irrigator  through  median  incision  (the  filling 
funnel  and  exit  tube  are  not  attached);  (5)  Drainage  of  the  pelvic  peritoneum  may  also  be 
accomplished  through  this  wound,  especially  if  made  somewhat  lower;  (6)  Intra-peritoneal 
irrigation  by  Kelly's  irrigator  (the  water  returning  through  open  wound,  along  tube,  after  dis- 
tending abdomen);  (7)  Drainage  of  the  right  hypochondrium  may  also  be  secured  through  this 
wound. 

the  process  by  adhesions  or  gravitation,  but  in  which  the  limits,  nevertheless, 
are  ascertainable — and  cases  of  general  peritonitis  in  which  apparently  the 
entire  peritoneal  cavity,  with  possibly  the  exception  of  the  lesser  cavity,  is 
involved.     The  last  two  categories  constitute  general  diffuse  peritonitis. 


828 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


The  two  essential  features  of  the  technic  are — The  removal,  as  early  as 
possible,  of  the  cause  of  infection,  or  the  limitation  of  the  results  of  infection, 
thereby  minimizing  additional  peritoneal  and  general  infection;  the  placing 
of  the  peritoneum  in  the  best  condition  to  combat  and  eliminate  generalized 
infection. 

The  peritoneum  is  cleansed  by  abundant  irrigation  with  decinormal  saline 
solution  of  no°  F.  This  solution  may  be  delivered  into  the  cavity  of  the 
peritoneum  from  the  mouth  of  a  pitcher — or,  more  recently,  is  carried 
throughout  the  indicated  portions  of  the  peritoneal  cavity  by  means  of  a 
special  irrigator  (Fig.  587).     As  much  of  the  fluid  as  does  not  readily  flow 


Fig.  588. — Approaching  an  Appendical  Abscess  by  an  Extra-peritoneal  Route: — 
A,  A,  Retracting  abdominal  wound;  B,  Reflection  of  peritoneum  detached  from  iliac  fossa  and 
pushed  inward;  C,  Cecum;  D,  Ileum;  E,  Appendix;  F,  Iliac  muscle;  G,  Psoas  muscle;  H,  Iliac 
vessels;  I,  Appendical  abscess;  J,  Course  of  approach  and  drainage  of  abscess.  (Modified 
from  Kelly  and  Hurdon.) 

out  is  left  in  the  cavity — and  handling  of  the  intestines,  other  than  done  by 
the  irrigator  and  fluid,  is  avoided.  The  peritoneal  endothelium  is  thus  less 
damaged  and  the  detachable  products  of  infection  are  diluted  and  removed. 

In  those  cases  in  which  the  focal  cause  of  infection  can  be  removed,  drainage 
may  or  may  not  be  used.  In  other  cases  drainage  has  been  generally  used  by 
the  majority  of  operators.  More  latterly  the  author  of  the  technic  has  omitted 
drainage  almost  entirely — only  using  it  in  cases  where  the  existence  of  necrotic 
tissue  or  hemorrhage  necessitated  it. 

When  indicated,  the  parietal  wound  can  be  drained  down  to  the  peritoneum. 
Other  forms  of  intra-abdominal  irrigation  and  drainage  are  shown  in  Fig.  587. 


OPERATIVE    TREATMENT    OF    DIFFUSE    SEPTIC    PERITONITIS.       829 
OPERATIVE  TREATMENT  OF  INTRA-ABDOMINAL  ABSCESSES. 

Only  generalizations  of  technic  can  be  here  mentioned — the  indications 
differing  in  abscesses  of  different  origins  and  sites.  In  the  present  instance  an 
abscess  of  appendical  origin  will  be  taken  as  a  type. 

The  site  of  evacuation  of  such  an  abscess,  as  of  any  other,  will  often  be 
determined  by  the  local  phenomena  of  tenderness  and  swelling — and  the 
incision  to  the  focus  of  suppuration  should  generally  be  over  these.      As  a 


Fig.  589. — Localization  of  an  Adherent  Appendicular  Abscess  through  a  Primary 
Incision  in  the  Outer  part  of  the  Right  Rectus,  opening  up  the  General  Peritoneal 
Cavity — and  its  Evacuation  and  Drainage  through  a  Secondary  Incision  near  the 
Iliac  Crest,  through  Adhesions  Walling  it  off  from  the  General  Cavity — the  Main 
Wound  being  Closed.     (Modified  from  Kelly  and  Hurdon.) 


usual  thing,  the  incision  will  lie  rather  to  the  outer  side,  between  the  position 
of  the  appendix  and  the  iliac  crest,  or  Poupart's  ligament.  Where  it  is  possible, 
the  fibers  of  the  external  oblique  should  be  separated  rather  than  cut.  The 
internal  oblique  and  transversalis  should  be  injured  as  little  as  possible,  but 
the  fibers  of  one  or  both  must  generally  be  divided — or  may  be  penetrated  by 


830  OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

blunt  dissection.  Sometimes  it  is  necessary  to  make  a  free  incision,  largely 
dividing  the  muscles  from  the  last  rib  to  the  iliac  crest. 

When  it  is  possible  to  do  so,  the  abscess  should  be  opened  retroperitoneally 
— which  is  usually  accomplished  by  following  down  closely  to  the  iliac  fossa, 
detaching  and  pushing  the  peritoneum  inward — until  the  abscess  can  be  reached 
behind   the   peritoneum    (Fig.  588). 

If,  on  approaching  the  abscess,  the  peritoneum  be  found  free  and  movable 
over  the  abscess,  one  of  several  courses  may  be  pursued — By  displacement  of 
the  peritoneum,  or  the  mass,  an  attempt  may  be  made  to  reach  the  site  of  pus 
outside  of  the  peritoneum,  as  just  described — The  general  relations  and  extent 
of  the  abscess  may  be  discovered  by  one  hand  introduced  into  the  general 
peritoneal  cavity  through  a  median,  or  other,  incision,  and,  while  this  is  open, 
or  after  its  closure,  the  abscess  may  be  approached  and  evacuated  through  a 
second  incision  extraperitoneally  (Fig.  589) — Or  the  abscess  may  be  deliber- 
ately incised  transversely,  after  packing  off  the  field  with  gauze  and  guarding 
the  general  cavity  from  infection. 

Whether  the  pus-sac  be  reached  retroperitoneally,  or  through  adherent  peri- 
toneum, or  be  free  in  the  peritoneal  cavity,  it  is  best  opened  by  carrying  a  pair 
of  closed  artery  or  dressing  forceps  into  its  cavity — and  opening  its  blades  in 
the  act  of  withdrawal  (Fig.  589).  The  neighboring  structures  should  be 
protected  from  soiling  by  gauze  packing  and  the  abscess  be  brought  as  near 
to  the  surface  before  emptying  as  possible,  that  its  contents  may  be  poured 
directly  outward.  Part  of  its  fluid,  especially  if  the  cavity  be  distended,  may 
be  first  aspirated,  that  the  remainder  may  be  more  fully  controllable  during 
evacuation.  Following  penetration  of  its  wall,  a  finger  should  be  introduced 
for  exploration. 

After  evacuation  and  cleansing  of  the  abscess  cavity  free  drainage  should 
be  established  by  means  of  cigarette  drains,  Mikulicz  pack,  or  rubber  tubes. 

III.   THE  OMENTUM. 
SURGICAL  ANATOMY. 

Description. — The  omenta  are  folds  of  peritoneum  connecting  the  stom- 
ach with  other  viscera.  They  consist  of  the  great  or  gastro-colic,  small  or 
gastro-hepatic,  and  gastro-splenic  omenta. 

Great  or  Gastro-colic  Omentum. — Passes  down  from  the  greater  curva- 
ture of  the  stomach  as  an  apron  in  front  of  the  small  intestine,  thence  upward 
to  be  fused  with  the  transverse  colon,  being  connected  with  the  gastro-splenic 
omentum  on  the  left,  and  with  the  hepatic  flexure  of  the  colon  and  descend- 
ing colon  on  the  right; — consisting  of  four  layers,  two  descending  and  two 
ascending;  the  two  middle  layers  belonging  to  the  lesser  sac  and  the  two 
superficial  layers  to  the  greater  sac; — its  vessels  coming  chiefly  from  the 
gastro-epiploica  sinistra  of  the  splenic  artery,  and  to  a  less  extent  from  the 
gastro-epiploica  dextra  of  the  gastro-duodenal  branch  of  the  hepatic  artery. 

Small  or  Gastro-hepatic  Omentum. — Extends  from  transverse  fis>ure 
of  liver  to  lesser  curvature  of  stomach,  being  continuous  on  the  right  with 
the  first  part  of  the  duodenum  (there  forming  the  ligamentum  hepato-duo- 
denale),  and,  on  the  left,  with  the  gastro-splenic  omentum; — formed  of  two 
la  vers,  one  from  the  lesser  and  one  from  the  greater  sac; — and  having  the 
following  relation  of  vessels  between  the  layers  of  the  hepato-duodenal  portion 
of  the  gastro-hepatic  omentum:  ductus  communis  choledochus,  on  the  right: 
hepatic  arterv,  on  the  left:  vena  porta\  between  the  two  and  somewhat  pos- 
terior to  them. 


LIGATION    OF    THE    OMENTUM. 


831 


Gastro-splenic  Omentum. — Extends  from  the  fundus  of  the  stomach 
to  the  gastric  surface  of  the  spleen; — and  transmits  the  vasa  brevia  of  the 
splenic  artery  to  the  stomach. 

GENERAL  SURGICAL  CONSIDERATIONS  IN  OPERATIONS  UPON  THE 

OMENTUM. 

The  remarks  made  under  this  head  in  connection  with  the  Peritoneum 
are  applicable  to  this  section.     See  page  649. 


Fig.    590. — LlGATIXG    THE    OMENTUM   THROUGH    AREAS    PREVIOUSLY    CRUSHED    BY    AN   ANGIO- 

TRIBE. 

LIGATION  OF  THE  OMENTUM. 

Description. — In  the  course  of  intra-abdominal  operations,  it  is  often 
necessary  to  ligate  portions  of  the  omentum,  either  for  the  purpose  of  freeing 
adhesions,  or  as  a  preliminary  step  to  the  removal  of  a  part,  or  even  the 
whole,  of  the  great  omentum. 

Ligation  of  Omental  Adhesions. — The  general  principle  of  dealing 
with  adhesions  by  separation  by  blunt  dissection,  or  by  ligature  and  division, 
described  under  the  operations  for  peritoneal  adhesions  (see  page  649), 
applies  equally  to  those  of  the  omentum.  \Yhere  the  separation  can  be 
accomplished  by  blunt  dissection,  this  should  be  done.  Where  division  by 
knife  or  scissors  is  necessary,  this  should  generally  be  preceded  by  ligation 
with  chromic  gut.  The  ligature  may  be  conveniently  passed  by  means  of 
an  aneurism-needle — either  around  a  single  band  of  adhesion,  or  in  sections 
through  broader  extents  of  adhesion.  The  omentum  is  then  divided  distally 
to  the  ligature — or,  where  indicated,  as  is  generally  the  case  in  dense  adhe- 
sions, between  double  ligatures.     (See  Fig.  586,  E,  F,  F.) 

Ligation  of  the  Omentum  Preparatory  to  Removal  of  Larger  Por- 
tions.— The  omentum  may  be  so  irregularly  and  completely  bound  down 
as  to  require  ligature  and  division  in  piecemeal,  as  in  tying  off  adhesions, 


832 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


as  just  described.  Where,  however,  it  is  largely  or  entirely  free,  a  tier  of 
ligatures  may  be  quickly  run  across  the  free  portion  just  above  the  line  of 
subsequent  division.  This  tier  may  be  applied  in  sections  by  means  of  an 
aneurism-needle.  (See  Fig.  586,  E.)  Or  it  may  be  more  quickly  placed  by 
holding  the  ligature  in  contact  with  the  back  or  opposite  side  of  the  omen- 
tum, and  then,  at  proper  intervals,  piercing  the  omentum  from  the  front  with 
a  pair  of  catch-forceps,  or  a  Cleveland  ligature-carrier,  grasping  the  ligature 
and  drawing  it  through — it  is  then  cut  at  each  opening  through  which  drawn, 
interlocked  with  its  neighbor  by  a  half-turn,  and  tied — as  shown  in  Fig.  586, 
F,  F.  Heavy,  thick  portions  of  omentum  are  best  crushed  with  an  angiotribe 
and  ligated  through  the  crushed  area  (Fig.  590). 

OMENTAL  GRAFTING. 

Description. — Consists  in  the  using  of  isolated  pieces  of  omentum  to 
repair  peritoneal  defects.  These  pieces  of  omentum  are  excised  from  the 
great  omentum  and  sutured  to  wounded  or  denuded  surfaces,  or  suture- 
lines,  of  the  abdomino-pelvic  viscera  normally  covered  by  peritoneum.  They 
are  especially  used  to  reinforce  suspicious  intestinal  sites — but  may  be  applied 
to  any  of  the  serous  surfaces  of  other  viscera.  They  become  adherent  within 
a  few  hours — and  thus  strengthen  weakened  sites. 

Operation. — The  application  of  omental  grafts  is  called  for  during  the 
course  of  intra-abdominal  operations — and  the  technic  of  the  operation  is 
simple.     A  small  piece  of  the  great   omentum,   preferably  its  free  aspect, 


Fig-.  591.— Omental  Grafting  :— Graft  of  omentum  reinforcing  circular  enterorrhaphy,  sutured  to 
the  mesentery  and  partly  sutured  to  the  intestine. 


calculated  in  shape  and  size  to  cover  the  defect  by  a  good  margin,  is  cut 
away  with  scissors,  distally  to  previously  placed  ligatures  of  gut — and  this 
graft  is  placed  in  contact  with  the  area  to  be  reinforced,  preceded  or  not 
by  slight  scarification  of  the  site  with  a  needle-point — and  is  held  in  contact 
by  means  of  a  few  loosely  applied,  interrupted,  fine  gut-sutures.  If  the 
grafts  cannot  be  used  immediately  after  being  cut,  they  are  placed  in  warm 
normal  salt  solution  until  required,  when  they  are  partially  dried  between 
gauze.  The  grafts  used  to  reinforce  circular  enterorrhaphy  generally  average 
from  4  to  5  cm.  (1^  to  2  inches)  in  width,  and  should  be  long  enough  to 
completely  surround  the  site  in  question.     (See  Fig.  591.) 


SURGICAL    ANATOMY    OF    THE    SMALL    INTESTINES.  833 

IV.  THE  MESENTERY. 

SURGICAL  ANATOMY. 

Description. — The  mesenteries  are  peritoneal  folds  connecting  any  por- 
tion of  the  gastro-intestinal  tract  to  the  posterior  abdomino-pelvic  wall. 

Divisions. — Mesogastrium;  mesoduodenum;  mesentery  proper;  mesen- 
teriolum  (mesentery  of  the  vermiform  appendix) ;  ascending  mesocolon  (some- 
times present);  transverse  mesocolon;  descending  mesocolon  (sometimes 
present);  sigmoid  mesocolon;  mesorectum. 

Mesentery  (proper). — A  fan-shaped  fold  of  peritoneum  beginning  at 
the  spinal  column  and  following  and  covering  the  anterior  aspect  of  the 
superior  mesenteric  vessels  to  the  loops  of  the  small  intestine,  enveloping 
all  the  coils  of  the  jejunum  and  ileum  (but  not  those  of  the  duodenum)  — 
returning  thence  along  the  posterior  aspect  of  the  superior  mesenteric  vessels 
to  the  vertebral  column.  The  root  of  the  mesentery  extends  from  the  left 
lateral  aspect  of  the  body  of  the  second  lumbar  vertebra  downward — crossing 
obliquely  the  spinal  column,  aorta,- vena  cava  inferior,  and  third  portion 
of  the  duodenum,  ending  at  the  right  sacro-iliac  synchondrosis,  or  in  the 
right  iliac  fossa.  It  contains,  between  its  right  upper  and  left  lower  layers, 
the  mesenteric  arteries  and  veins,  lacteals,  lymphatics  and  nerves,  all  held 
together  by  fatty  areolar  tissue.  The  right  upper  layer  of  the  mesentery 
passes  from  the  root  of  the  mesentery  to  the  lower  layer  of  the  transverse 
mesocolon.  Laterally  the  layers  are  continuous  with  the  inner  lamellae  of 
the  right  and  left  colons.  Below,  the  left  layer  is  continuous  with  the  peri- 
toneum covering  the  lumbar  vertebra?,  and  passing  thence  over  the  pelvic 
organs.  In  dimensions,  its  length  (convex  intestinal  border)  is  about  6.45 
m.  (21  feet) — its  width  averages  20.5  to  23  cm.  (8  to  9  inches),  its  greatest 
width  (opposite  the  central  and  lower  loops  of  the  intestine)  being  from  20 
to  25  cm.  (8  to  10  inches). 

GENERAL  SURGICAL  CONSIDERATIONS  IN  OPERATIONS  UPON  THE 

MESENTERY. 

The  mesentery  is  involved  surgically  chiefly  in  the  operation  of  partial 
enterectomy. 

PARTIAL  EXCISION  OF  THE  MESENTERY. 
See  under  Partial  Enterectomy,  page  850. 

SUTURING  OF  THE  MESENTERY. 

See  under  Partial  Enterectomy,  page  850. 

V.  THE  INTESTINES. 
SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINES. 

Description. — Extend  from  pylorus  of  stomach  to  ileo-caecal  valve. 
About  7.6  meters  (25  feet)  long. 

Divisions. — Duodenum  (from  25.5  to  30.5  cm.,  or  10  to  12  inches) — con- 
sists of  First  or  Superior  Curved  Portion  (Superior  Hepatic  Curve)  (not 
quite  5  cm.,  or  2  inches); — Second  or  Descending  (Vertical)  Portion  (not 
quite  7.5  cm.,  or  3  inches); — Third  or  Transverse  (Preaortic)  Portion  (about 
12.5  cm.,  or  5  inches); — Fourth  or  Ascending  Portion  (about  2.5  to  5  cm., 
or  1  to  2  inches): — Fifth  or  Duodenojejunal  angle.  Jejunum — about  upper 
two-fifths  of  remaining  small  intestines  (about  2.9  meters,  or  9  feet  7  inches). 


834  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

Ileum — about  lower  three-fifths  of  remaining  portion  (about  4.3  meters,  or 
14  feet  5  inches). 

General  Form  of  Duodenum. — Usually  has  the  form  of  a  U,  with  which 
the  above  description  corresponds — but  is  sometimes  V-shaped. 

Course  and  Relations  of  First  or  Superior  Curved  Portion  (Superior 
Hepatic  Curve)  of  Duodenum. — Course ;  from  pylorus,  passes  upward  and 
backward  to  right,  ending  at  neck  of  gall-bladder.  Superiorly  and  ante- 
riorly; quadrate  lobe  of  liver;  neck  of  gall-bladder;  foramen  of  Winslow 
(duodenum  forming  its  lower  boundary);  hepatic  artery.  Inferiorly;  head 
and  neck  of  pancreas.  Posteriorly;  common  bile-duct;  venaportae;  gastro- 
duodenal  artery;  vena  cava  inferior;  first  lumbar  vertebra. 

Course  and  Relations  of  Second  or  Descending  (Vertical)  Portion 
of  Duodenum. — Course;  descends  from  neck  of  gall-bladder  down  right 
side  of  vertebral  column,  from  first  to  body  of  third  or  fourth  lumbar  vertebra 
— transverse  colon  crossing  its  middle  third.  Anteriorly;  right  lobe  of  liver 
(duodenal  impression);  right  end  of  transverse  colon;  transverse  mesocolon; 
small  intestine;  mesentery  (right  leaf).  Posteriorly;  right  kidney,  and 
suprarenal  capsule  (sometimes);  renal  vessels;  common  bile  and  pancreatic 
ducts;  inferior  vena  cava;  spermatic  vessels.  Internally  (to  left);  head  of 
pancreas;  common  bile  and  pancreatic  ducts;  pancreatico-duodenal  vessels; 
first  to  fourth  lumbar  vertebra?  and  intervertebral  discs. 

Course  and  Relations  of  Third  or  Transverse  (Preaortic)  Portion  of 
Duodenum. — Course;  from  right  side  of  body  of  third  or  fourth  lumbar 
vertebra,  crosses  vertebral  column  in  horizontal  or  slightly  ascending  manner, 
in  front  of  great  vessels  and  crura  of  diaphragm,  moulding  itself  over  these 
structures.  Superiorly;  head  of  pancreas;  superior  mesenteric  vessels;  in- 
ferior pancreatico-duodenal  artery.  Anteriorly;  root  and  right  and  left 
layers  of  mesentery;  lower  layer  of  transverse  mesocolon;  superior  mesenteric 
vessels;  small  intestines.  Posteriorly;  inferior  vena  cava;  aorta;  dia- 
phragmatic crura;  third  and  fourth  lumbar  vertebra. 

Course  and  Relations  of  Fourth  or  Ascending  Portion  of  Duodenum. 
— Course ;  ascends  vertically  along  left  side  of  spine,  from  third  or  fourth 
lumbar  vertebra  to  side  of  second  or  first  lumbar  vertebra.  Anteriorly; 
transverse  colon;  transverse  mesocolon  (lower  layer);  small  intestine;  mesen- 
tery (left  layer);  antrum  pylori  (sometimes).  Posteriorly;  left  diaphrag- 
matic crus;  left  psoas;  left  renal  vessels;  spermatic  vessels;  kidney  (interno- 
inferior  part).  Internally  (to  right);  head  and  neck  of  pancreas;  aorta; 
fourth  or  third  and  second  lumbar  vertebra?. 

Course  and  Relations  of  Fifth  Part,  or  Duodenojejunal  Angle : 
Position;  at  left  side  of  second  or  first  lumbar  vertebra.  Superiorly;  body 
of  pancreas.  Anteriorly;  mesentery  (left  layer).  Externally;  left  kidney 
(inner  border). 

Peritoneal  Covering  of  Duodenum. — First  part;  covered  by  perito- 
neum, except  parts  of  posterior  surface  near  vena  cava  and  neck  of  gall- 
bladder. Second  part;  covered  in  front  only  (except  that  no  peritoneum 
covers  the  front  opposite  the  divergence  of  two  layers  of  transverse  mesocolon). 
Third  part ;  covered  in  front  only  (except  that  there  is  no  peritoneum  in 
front  opposite  root  of  mesentery).  Fourth  part;  covered  entirely  in  front, 
and  partly  at  sides.  Fifth  part;  entirely  covered  by  peritoneum  where  it 
becomes  jejunum. 

Ligaments  of  Duodenum. — Ligamentum  Hepato-duodenale  (suspensory 
ligament  of  duodenum) — right  edge  of  lesser  omentum — from  hilus  of  liver 
to  first  part  of  duodenum.  Ligamentum  Cystico-duodenale — from  neck  of 
gall-bladder   to   first    part    of   duodenum.     Ligamentum    Duodeno-renale — 


SURGICAL   ANATOMY   OF   THE   SMALL   INTESTINES.  835 

from  summit  of  right  kidney  to  outer  aspect  of  first  part.  Ligamentum 
Duodeno-mesocolica — from  junction  of  left  layer  of  mesentery  with  lower 
layer  of  transverse  mesocolon,  to  outer  aspect  of  fourth  part  of  duodenum. 

Other  Fixation-points  of  Duodenum. — Common  bile-duct  and  pan- 
creatic duct;  cceliac  axis  and  superior  mesenteric  artery;  fibro-nervous  struc- 
tures; muscle  of  Treitz  (passing  from  duodeno-jejunal  angle  upward  beneath 
pancreas  to  left  crus  of  diaphragm). 

Fossae  in  Neighborhood  of  Ascending  Duodenum  and  Duodeno- 
jejunal Angle. — Inferior  duodenal  fossa;  superior  duodenal  fossa  (these 
two  may  coexist) ;  duodeno-jejunal  (mesocolic)  fossa  (non-coexistent  with 
above   two) . 

Position  of  Jejunum. — Extends  from  duodeno-jejunal  angle  to  beginning 
of  ileum.  Position  not  fixed — coils  of  jejunum  generally  to  be  found  upon 
left  side  of  abdominal  cavity,  in  left  lumbar,  left  inguinal,  and  left  half  of 
umbilical  regions.  The  upper  loops  are  apt  to  be  more  transverse  than  the 
lower. 

Characteristics  of  Middle  Portion  of  Jejunum  (as  Compared  with 
Middle  Portion  of  Ileum). — Diameter  about  4  cm.  (i£  inch).  Walls 
thicker,  more  vascular,  and  mucous  membrane  more  complex.  Weight  of 
given  length  greater.  No  valvular  conniventes  (or  poorly  marked).  Its 
position. 

Mesentery  of  Jejunum  and  Ileum  (Attachment  of  Jejunum  and  Ileum) 
— (1)  Passes  obliquely  from  left  side  of  body  of  second  lumbar  vertebra 
downward  and  to  right,  crossing  spinal  column,  aorta,  inferior  vena  cava, 
and  third  part  of  duodenum,  to  right  sacro-iliac  synchondrosis  (or  to  right  iliac 
fossa).  (2)  Middle  and  inferior  loops  of  small  intestine  have  longest  mesen- 
tery— and  are,  therefore,  generally  found  in  pelvis.  Duodenum  has  no 
mesentery.  Lower  part  of  Ileum  has  shortest  mesentery  (opposite  right 
psoas  muscle).  (3)  Mesentery  extends  from  distal  end  of  duodenum  to 
ileo-caecal  junction.  Its  upper  (right)  layer  is  continuous  with  inferior  layer 
of  transverse  mesocolon  and  with  peritoneum  of  ascending  colon.  Its  lower 
(left)  layer  joins  peritoneum  enclosing  descending  colon  and  forming  sigmoid 
mesentery.  (4)  Average  length  of  mesentery  (from  spine  to  intestines) 
from  20  to  25  cm.  (8  to  10  inches). 

Position  of  Ileum. — Extends  from  lower  end  of  jejunum  to  ileo-ca?cal 
valve.  Position  not  fixed — coils  of  ileum  generally  to  be  found  on  right  side 
of  abdomen  and  pelvis,  in  right  lumbar,  right  inguinal  and  in  right  half  of 
umbilical  and  hvpogastric  regions.  The  lower  loops  are  apt  to  be  more 
vertical  than  the  upper. 

Characteristics  of  Middle  Portion  of  Ileum  (as  compared  with 
Middle  Portion  of  Jejunum). — Diameter  about  3  cm.  (i\  inch).  Walls 
thinner,  less  vascular,  and  mucous  membrane  simpler.  Weight  of  given 
length  less.     Valvular  conniventes.     Its  position. 

Meckel's  Diverticulum  of  Ileum  (remains  of  vitelline  duct). — Blind 
diverticulum  of  ileum  and  directly  continuous  with  its  lumen.  Length,  from 
5  to  7.5  cm.  (2  to  3  inches) — extremes,  from  1  to  18  cm.  (^  to  7  inches). 
Arises  about  109  cm.  (43  inches) — extremes,  from  30.5  to  305  cm.  (1  to  10 
feet) — above  ileo-caxal  junction.  Generally  lies  free  in  abdominal  cavity 
(instead  of  passing  to  umbilicus,  as  in  fetus).  But  distal  end  may  be  con- 
nected with  umbilicus,  or  other  site,  by  strong  band  (remains  of  enlarged 
omphalo-mesenteric  vessels).     Its  presence  occurs  in  about  50  per  cent. 

Arteries  of  Small  Intestines. — (1)  Duodenum;  pyloric  of  hepatic;  supe- 
rior  pancreatico-duodenal   branch    of   gastro-duodenal   branch   of   hepatic; 


836  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

inferior  pancreaticoduodenal  of  superior  mesenteric.  (2)  Jejunum  and 
Ileum;  superior  mesenteric. 

Veins  of  Small  Intestines. — Correspond  with  arteries  —  a  single  vein 
accompanying  each  artery. 

Lymphatics  of  Small  Intestines. — End  in  mesenteric  lacteals. 

Nerves  of  Small  Intestines. — From  superior  mesenteric  plexus,  formed 
by  nerves  from  cceliac  plexus,  semilunar  ganglion,  and  right  vagus. 


SURFACE  FORM  AND  LANDMARKS  OF  THE  SMALL  INTESTINES. 

Upper  limit  of  attachment  of  mesentery  (duodenojejunal  angle)  generally 
lies  from  8  to  10  cm.  (3  to  4  inches)  above  the  umbilicus,  slightly  to  left  of 
median  line.  Lower  limit  is  about  10  cm.  (4  inches)  from  middle  of  right 
Poupart's  ligament,  on  a  line  directed  upward  and  inward  in  the  course 
of  psoas  muscle. 

SURGICAL  ANATOMY  OF  THE  LARGE  INTESTINES. 

Description. — Extend  from  lower  end  of  ileum  to  anus.  About  1.5  to 
1.8  meters  (5  to  6  feet)  long. 

Divisions. — Cfficum;  Ascending  Colon;  Hepatic  Flexure;  Transverse 
Colon;  Splenic  Flexure;  Descending  Colon;  Sigmoid  Flexure  (Sigmoid  Colon) ; 
Rectum. 

General  Characteristics  of  Large  Intestines  (as  compared  with  small 
intestines). — Greater  size;  greater  fixity  of  position;  sacculations;  longitu- 
dinal bands;  appendices  epiploicae.  (Last  three  characteristics  not  present 
in  rectum). 

Caecum. — (About  7.5  cm.,  or  3  inches,  broad,  and  6.3  cm.,  or  2\  inches, 
long.)  Position;  lies  in  right  iliac  fossa,  above  outer  half  of  Poupart's 
ligament,  generally  resting  upon  psoas  muscle — sometimes  upon  iliacus  only — 
sometimes  bulk  of  caecum  rests  on  iliacus  and  apex  on  psoas — sometimes 
free  of  both,  being  entirely  in  pelvic  cavity,  or  even  projecting  beyond  median 
line.  Its  apex,  or  lower  point,  lies  slightly  to  inner  side  of  middle  of  Poupart's 
ligament,  just  behind  anterior  abdominal  wall  and  opposite  inner  portion 
of  psoas.  The  caecum  is  entirely  covered  by  peritoneum  and  lies  free  in 
abdominal  cavity.  There  is  no  mesocaecum.  Several  forms  or  types  of 
caecum  occur  (see  Appendix).  Anteriorly;  abdominal  parietes  above  outer 
half  of  Poupart's  ligament.  Posteriorly;  ilio-psoas;  appendix  (origin). 
Superiorly;  ileo-caecal  valve.     Internally;  ileum  (termination). 

Ileo-ceecal  Fossae. — Superior  Ileo-caecal  Fossa,  an  anterior  pouch  be- 
tween end  of  ileum  and  ascending  colon.  Inferior  Ueo-Caecal  Fossa,  an 
inferior  pouch  under  ileum,  between  it  and  caecum. 

Appendix  Caeci. — Description;  small  blind  tube,  generally  hollow  to 
tip,  its  lumen  continuous  with  that  of  caecum  and  sometimes  guarded  by  valve. 
Average  length,  9.2  cm.,  or  3!  inches  (extremes,  from  3.1  to  23  cm.,  or  from 
\\  to  9  inches).  Diameter,  about  6  mm.  {\  inch)  at  base — 5  mm.(f\  inch) 
at  apex.  Origin,  generally  arises  1.7  cm.  {\\  inch)  below  ileo-caecal 
valve,  upon  its  inner  and  posterior  aspect — but  sometimes  forms  the  true 
apex  of  caecum.  Course;  variable — (1)  According  to  Treves,  the  appendix 
generally  passes  upward  from  behind  caecum  toward  spleen,  lying  behind 
lower  end  of  ileum  and  its  mesentery.  (2)  According  to  Berry,  the  order 
of  frequency  of  position  is,  "  (a)  pelvic;  (b)  retrocaecal;  (c)  internal  to  caecum, 
i.  e.,  Treves's  position;  (d)  variable."     (3)  According  to  Bryant,  in  order  of 


SURGICAL  ANATOMY  OF  THE  LARGE  INTESTINES.  837 

frequency,  "(a)  inward;  (b)  behind  caecum;  (c)  downward  and  inward;  (d) 
into  true  pelvis. "  Relations  to  peritoneum ;  Mesentery  always  present 
but  not  extending  to  tip — about  distal  third  being  entirely  enveloped  in  peri- 
toneum and  free.  Meso-appendix,  of  triangular  form — derived  from  left 
leaf  of  mesentery — containing,  in  its  free  margin,  posterior  branch  of  ileo- 
cecal artery  (from  ileo-colic).  Relations  to  caecum;  four  types  of  caecum 
occur  (Treves) — (a)  appendix  arising  from  apex  of  caecum;  (b)  appendix 
arising  between  two  sacculi  of  equal  size;  (c)  appendix  arising  between  two 
sacculi  of  unequal  size  (about  90  per  cent,  of  cases) ;  (d)  appendix  appearing 
to  arise  from  ileo-colic  junction.    Relations  to  anterior  abdominal  wall; 

(1)  According  to  McBurney, — draw  straight  line  from  anterior  superior  iliac 
spine  to  umbilicus,  and  beneath  this  line,  from  4  to  5  cm.  (ih  to  2  inches) 
internal  to  the  spine,  the  base  of  the  appendix  is  found  (in  right  iliac  fossa). 

(2)  According  to  Clado, — draw  a  line  along  outer  edge  of  rectus — another 
between  anterior  superior  iliac  spines — opposite  the  junction  of  these  the 
base  of  the  appendix  is  found  (in  hypogastric  region). 

Ileo-caecal  Valve. — Opens  upon  postero-internal  aspect,  at  upper  border 
of  caecum. 

Ascending  Colon. — Description;  About  20  cm.  (8  inches)  in  length. 
Extends  vertically  upward  from  caecum  to  inferior  surface  of  right  lobe  of 
liver,  at  right  of  gall-bladder  (hepatic  flexure).  Covered  by  peritoneum 
anteriorly  and  laterally,  which  binds  it  to  posterior  abdominal  wall.  Its 
posterior  surface  (where  peritoneum  is  absent)  is  bound  by  areolar  tissue  to 
quadratus  lumborum,  transversalis,  and  right  kidney  (antero-external  part). 
Mesentery  (ascending  mesocolon)  present  in  26  per  cent.  (Treves).  Rela- 
tions; Anteriorly;  ileum;  abdominal  wall.  Posteriorly;  quadratus  lum- 
borum; transversalis;  kidney  (antero-external  part).  Superiorly;  liver  (right 
lobe). 

Hepatic  Flexure  of  Colon. — Upon  under  surface  of  liver,  near  gall- 
bladder, the  ascending  colon  bends  from  posterior  abdominal  wall  sharply 
to  front  and  left,  to  become  transverse  colon. 

Transverse  Colon. — Description;  About  51  cm.,  or  20  inches  (ex- 
tremes, from  30  to  84  cm.,  or  12  to  ^t,  inches),  in  length.  Extends  from 
inferior  surface  of  liver,  in  right  hypochondrium  (hepatic  flexure),  trans- 
versely across  anterior  abdominal  wall,  with  slight  downward  and  forward 
convexity  at  its  center,  to  the  spleen  in  left  hypochondrium  (splenic  flexure). 
Transverse  mesocolon  is  long,  and  connects  transverse  colon  to  posterior 
abdominal  wall — most  movable  part  of  large  intestine.  Transverse  colon  lies 
above  the  umbilicus  four  times  out  of  five — and  below  it  one  time  out  of  five 
(usually  on  a  line  connecting  lowest  parts  of  costal  arches).  Peritoneum 
entirely  surrounds  transverse  colon.  Relations;  Anteriorly;  abdominal 
wall;  great  omentum.  Posteriorly;  transverse  mesocolon;  descending  duo- 
denum; small  intestines;  superior  curvature  of  stomach  (at  times).  Supe- 
riorly ;  liver  and  gall-bladder  (inferior  surfaces) ;  great  curvature  of  stomach ; 
spleen  (inferior end);  pancreas  (tail).     Inferiorly;  small  intestines. 

Splenic  Flexure  of  Colon. — Situated  beneath  lower  end  of  spleen — 
further  back  in  abdomen  than  hepatic  flexure.  Connected  by  phreno-colic 
ligament  (a  fold  of  peritoneum)  passing  between  splenic  flexure  to  diaphragm, 
between  tenth  and  eleventh  ribs. 

Descending  Colon. — Description;  About  21.5  cm.  (8|  inches)  long. 
Extends  from  spienic  flexure  vertically  through  left  hypochondrium  and 
lumbar  regions  to  sigmoid  flexure.  Peritoneum  covers  it  similarly  to  ascend- 
ing colon  (q.  v.).     Mesenterv  (descending  mesocolon)  present  in  36  per  cent. 


838  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

(Treves).  Relations: — Anteriorly;  abdominal  wall;  jejunum.  Poste- 
riorly; diaphragm;  left  kidney  (infero-external  part);  quadratus  lumborum; 
transversalis.     Superiorly;  spleen;  phreno-colic  ligament. 

Sigmoid  Flexure  of  Colon  (Sigmoid   Colon). — Description;  An  S- 

shaped  curve,  about  31  cm.  (13  inches)  long,  lying  in  left  iliac  fossa,  beginning 
at  iliac  crest  and  ending  at  brim  of  true  pelvis,  opposite  left  sacroiliac  syn- 
chondrosis (or  opposite  upper  edge  of  sacrum).  Divisions;  First  Portion, 
of  Colic  Limb,  tends  downward,  inward,  and  slightly  forward  toward  outer 
aspect  of  Poupart's  ligament  and  abdominal  wall — generally  has  a  short 
mesocolon  (though  sometimes  peritoneum  only  anteriorly  and  laterally). 
Second  or  Rectal  Part,  tends  to  hang  into  true  pelvis — mesentery  about 
7.5  cm.  (3  inches) — very  movable.  Insertion  of  Sigmoid  Mesocolon;  in 
line  extending  obliquely  from  left  iliac  crest  across  psoas  and  left  iliac  vessels 
(at  about  their  bifurcation)  to  join  mesorectum  at  sacral  promontory.  Note ; 
More  properly  the  sigmoid  colon,  or  flexure,  should  include  that  portion 
of  large  intestine  usually  described  as  the  first  part  of  the  rectum — and  then 
would  end  where  the  mesorectum  ceases,  opposite  the  third  piece  of  the 
sacrum,  thus  having  more  of  an  omega  than  a  sigmoid  appearance.  Rela- 
tions;  Anteriorly;  abdominal  wall;  small  intestines.  Posteriorly;  left 
ilio-psoas;  posterior  pelvic  wall;  rectum. 

Intersigmoid  Fossa. — In  the  layers  of  the  mesocolon,  generally  over 
bifurcation  of  iliac  vessels — looks  downward  to  left.  Sometimes  found  in 
children — rarely  in  adults. 

Rectum.  —  (Length,  about  20  to  23  cm.,  or  8  to  9  inches.)  Divisions: 
First  or  Superior  Part;  Second  or  Middle  Part;  Third  Part,  or  Anal  Canal. 
Note ;  The  rectum  will  be  here  described  as  consisting  of  three  parts,  as 
mentioned.  More  properly  it  consists  of  but  two  parts,  corresponding  with 
the  second  and  third  parts  just  mentioned — the  first  part  above  mentioned 
being,  strictly,  a  portion  of  the  Sigmoid  Colon  (see  "note"  under  Sigmoid 
Flexure  of  Colon).  First  or  Superior  Part;  8  to  9  cm.  (3 \  to  3^  inches) 
long.  Corresponds  with  lower  part  of  Sigmoid  Colon,  as  sometimes  de- 
scribed. Runs  obliquely  from  left  pelvic  brim  (beginning  opposite  either 
sacro-iliac  synchondrosis,  or  sacral  promontory,  or  even  right  side  of  base 
of  sacrum)  downward,  backward,  and  to  right  to  third  sacral  vertebra  in  the 
median  line.  Almost  entirely  enveloped  in  peritoneum,  except  posteriorly. 
Mesorectum  connects  its  posterior  aspect  to  anterior  surface  of  sacrum.  Mes- 
entery continuous  with  sigmoid  mesocolon  and  terminates  at  third  sacral  ver- 
tebra. Relations  of  first  part;  Anteriorly;  small  intestine;  sigmoid  colon; 
bladder  (posterior  surface)  in  male;  uterus  (posterior  surface)  in  female.  Pos- 
teriorly; mesorectum;  left  pyriformis  muscle;  left  sacral  plexus;  left  internal 
iliac  artery  and  veins;  first,  second,  and  one-half  of  third  sacral  vertebra?.  Ex- 
ternally ;  left  ureter;  left  internal  iliac  artery  and  veins.  Description  of  sec- 
ond or  middle  part ;  10  to  1 1  cm.  (3  to  4  inches)  long.  Extends  in  a  curve  from 
middle  of  third  sacral  vertebra  to  opposite  apex  of  prostate  gland — running 
at  first  along  right  aspect  of  fourth  sacral  vertebra — thence  back  to  median 
line  about  the  sacro-coccygeal  articulation — and  passes  thence  downward  and 
forward  to  opposite  a  line  connecting  the  anterior  aspects  of  the  two  ischial 
tuberosities,  which  is  opposite  the  apex  of  prostate  gland,  and  about  2.5 
cm.  (1  inch)  below  tip  of  coccyx.  Partially  covered  by  peritoneum— covered 
above,  anteriorly  and  laterally — then  only  anteriorly — and  about  2.5  cm. 
(1  inch)  above  prostate  gland  (never  more  than  8  cm.,  or  3I  inch)  it  is  re- 
flected from  anterior  surface  of  rectum  to  posterior  surface  of  bladder,  in 
male,  or  to  posterior  surface  of  upper  one-fifth  of  vagina,  in  female  (forming 


SURFACE  FORM  AND  LANDMARKS  OF  LARGE  INTESTINES.       839 

rectovesical  or  recto-vaginal  pouch).  No  mesorectum  exists.  On  posterior 
surface  of  rectum  there  is  no  peritoneum  below  a  point  12.5  cm.  (5  inches) 
above  anus.  Relations  of  second  or  middle  part  of  rectum;  Anteriorly; 
(a)  In  Male;  recto-vesical  pouch;  small  intestines;  bladder  (trigone);  vesicular 
seminales;  vasa  deferentia;  prostate  gland  (inferior  aspect);  (b)  In  Female; 
vagina  (posterior  surface);  recto-vaginal  pouch;  recto-uterine  pouch;  small 
intestines.  Posteriorly;  sacrum  (lower  portion);  coccyx;  ano-coccygeal 
body;  middle  sacral  vessels;  pyriformis  muscles.  Description  of  third 
part,  or  anal  canal;  About  2  to  3  cm.  (f  to  i£  inch) — little  less  in  female. 
Passes  downward  and  backward,  from  a  point  opposite  apex  of  prostate 
gland  (about  2.5  cm.,  or  1  inch,  below  tip  of  coccyx)  to  end  in  anus.  No 
peritoneal  covering.  Surrounded  by  sphincter  muscles.  Relations  of  third 
part,  or  anal  canal ;  Anteriorly ;  bulb  and  membranous  part  of  urethra 
(male);  perineal  body  (female).  Posteriorly;  ano-coccygeal  body;  coccygei 
muscles.  Laterally;  fatty  areolar  tissue  of  ischio-rectal  fossae;  levatores  ani 
muscles. 

Anus. — Surrounded  by  internal  sphincter,  levatores  ani,  and  external 
sphincter.     (See  Perineum.) 

Arteries  of  Caecum  and  Colon. — Ileo-colic,  colica  dextra,  and  colica 
media,  from  superior  mesenteric;  colica  sinistra  and  sigmoid,  from  inferior 
mesenteric. 

Veins  of  Caecum  and  Colon. — Superior  and  inferior  mesenteric,  emptying 
into  portal  system. 

Lymphatics  of  Caecum  and  Colon. — Those  of  ascending,  transverse, 
and  descending  colon  empty  into  mesenteric  glands.  Those  of  sigmoid  colon 
empty  into  lumbar  glands. 

Nerves  of  Caecum  and  Colon. — Caecum,  ascending  and  proximal  half 
of  transverse  colon  are  supplied  by  superior  mesenteric  plexus,  from  cceliac 
plexus.  Distal  half  of  transverse  colon,  descending  and  sigmoid  colon  are 
supplied  by  inferior  mesenteric  plexus,  from  aortic  plexus. 

Arteries  of  Rectum. — Superior  hemorrhoidal  (of  inferior  mesenteric); 
middle  hemorrhoidal  (of  internal  iliac);  inferior  hemorrhoidal  (of  internal 
pudic) ;  branches  from  sacra  media  (of  abdominal  aorta) ;  branches  from 
sciatic  (of  internal  iliac);  branches  from  vaginal,'  in  female  (of  internal 
iliac). 

Veins  of  Rectum. — Chiefly  from  superior  hemorrhoidal  to  inferior  mesen- 
teric, and  thence  to  portal  system.  Some  blood  passes  back  by  systemic 
system  to  inferior  vena  cava.  Anastomosis  between  systemic  and  portal 
systems  occurs  in  rectum. 

Lymphatics  of  Rectum. — Empty  into  anterior  sacral  and  inguinal 
glands. 

Nerves  of  Rectum. — From  cerebrospinal  system  (sacral  plexus) — and 
from  sympathetic  system  (hypogastric  and  inferior  mesenteric  plexuses). 


SURFACE  FORM  AND  LANDMARKS  OF  THE  LARGE  INTESTINES. 

Caecum  lies  in  right  inguinal  region,  its  lower  border  corresponding,  at 
its  center,  with  the  center  of  a  line  drawn  from  anterior  superior  iliac  spine 
to  symphysis  pubis. 

Ascending  Colon  ascends  through  right  lumbar  and  hypochondriac  regions 
to  hepatic  flexure. 

Hepatic  Flexure  lies  beneath  the  liver  in  the  right  hypochondrium. 


840  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Transverse  Colon  crosses  the  abdomen  transversely  at  about  the  junction 
of  the  umbilical  and  epigastric  regions — its  superior  border  lying  just  below 
the  greater  curvature  of  the  stomach — its  inferior  border  just  above  the 
umbilicus. 

Splenic  Flexure  is  posterior  to  the  stomach  in  the  left  hypochondrium. 

Descending  Colon  descends  through  the  left  hypochondriac  and  lumbar 
regions  to  the  sigmoid  flexure. 

Sigmoid  Colon  lies  in  the  left  inguinal  region. 

Note. — For  the  more  detailed  description  of  the  relations  of  the  parts  of 
the  large  intestines,  see  Surgical  Anatomy  of  the  special  parts. 


GENERAL   CONSIDERATIONS  IN  OPERATIONS  UPON  THE 
INTESTINES. 

Preparation  of  Patient. — Bowels  are  to  be  emptied.  Abdomen  should 
be  shaved. 

Position. — Patient  lies  supine,  usually  in  a  horizontal  position,  near  the 
edge  of  the  table.  Surgeon  may  stand  on  either  side  of  patient,  but  usually 
stands  on  the  patient's  right,  incising  from  above  downward.  Assistant 
stands  opposite  surgeon. 

Portion  of  the  Intestinal  Wall  where  the  Lamina?  of  the  Mesentery 
Separate  to  Enclose  the  Intestines. — In  the  case  of  those  portions  of  the 
intestines  which  have  a  mesentery,  the  lamina?  of  the  mesentery  begin  to 
separate  (in  order  to  surround  the  wall  of  the  gut)  about  1.5  to  2  cm.  (§  to 
f  inch)  from  the  intestine,  leaving,  upon  these  viscera,  a  triangular  interval 
with  a  base  of  about  8  mm.  (fV  inch)  where  the  muscular  coat  is  uncovered 
by  peritoneum — this  triangular  space  being  occupied  by  fatty  areolar  tissue, 
vessels,  and  nerves.  The  practical  bearings  of  the  above  fact  being; — (1)  The 
necessity  of  being  particularly  careful  in  ordinary  suturing,  or  the  adoption 
of  some  special  form  ot  suturing,  in  operations  upon  the  intestines,  in  order 
to  bring  the  peritoneum  of  the  cut  margins  into  contact  with  the  wall  of 
the  intestines  at  the  mesenteric  border,  thus  securing  the  covering  of  the 
denuded  tract  with  peritoneum  and  also  securing  apposition  of  serous  surfaces 
when  two  ends  of  intestine  are  brought  together; — (2)  The  guarding  of  the 
blood-supply  to  the  intestines  transmitted  through  this  triangular  space. 
Note— the  method  of  dealing  with  this  area  of  the  intestine  will  be  mentioned 
under  special  operations. 

Note. — For  other  general  considerations  bearing  upon  operations  upon 
the  intestines,  see  the  introductions  to  the  special  classes  of  intestinal  opera- 
tions. 

INSTRUMENTS  USED  IN  OPERATIONS  UFON  THE  INTESTINES. 

I.  Instruments  used  in  entering  the  peritoneal  cavity — see  the  instru- 
ments for  performing  Abdominal  Section  (page  801). 

II.  Instruments  used  in  general  intestinal  operations; — intestinal  clamps; 
artery-clamp  forceps;  dissecting  and  toothed  forceps;  scissors;  bistouries; 
aneurism-needles;  probe;  grooved  director;  tenaculum;  needles,  ordinary 
straight  cambric,  curved,  calyx-eyed,  Keith's  abdominal;  needle-holder;  fine 
silk;  catgut;  gauze  pads;  gauze  sponges;  sponge-holders;  drains  of  gauze, 
wick,  rubber  tubing,  glass  tubing.  Special  instruments  and  mechanical 
contrivances  required  in  special  operations  upon  the  intestines  in  general, 
particularly  in  the  operations  of  entero-enterostomy. 


ENTERORRHAPHY  IN  GENERAL. 


III.  Instruments  used  in  operations  upon  the  rectum  and  anus — see  the 
operations  upon  those  structures. 


ENTEROTOMY. 

Description. — Incision  of  intestine,  with  closure  of  wound  at  the  same 
sitting.  Generally  resorted  to  for  the  removal  of  foreign  bodies  from  the 
intestinal  canal,  or  as  a  step  in  some  operation.  Formerly  used  in  the  same 
sense  as  enterostomy. 

Preparation — Position — Landmarks — Incision. — As  in  Median  Ab- 
dominal Section  (page  801). 

Operation. — (I)  Having  exposed  that  portion  of  the  intestine  which  is 
to  become  the  site  of  the  operation,  the  coil  involved  is  lifted  out  of  the  ab- 
dominal cavity  and  placed  upon  a  warm,  wet,  sterile  towel — the  rest  of  the 
abdominal  cavity  and  the  other  coils  of  intestine  being  protected  by  gauze 
packing.  (2)  The  intestinal  contents  are  pressed  away  from  the  site  to  be 
opened  and  the  intestine  is  clamped  proximally  and  distally  to  the  operation- 
site.  (3)  Incision  into  the  intestine  is  made  upon  its  anti-mesenteric  border, 
in  the  long  axis  of  the  gut — exercising  care  that  the  opposite  intestinal  walls 
be  not  injured.  If  the  canal  contain  a  foreign  body,  this  may  usually  be 
cut  down  upon  directly,  its  presence  protecting  the  other  coats.  Otherwise 
the  assistant  should  so  hold  the  gut  that  its  walls  are  separated  while  the 
surgeon  makes  a  rapid,  controlled  stab  into  the  lumen  with  a  sharp,  narrow 
bistoury,  in  order  that  the  mucous  membrane  may  not  be  simply  protruded 
ahead  of  the  incision.  The  keeping  of  the  opposite  walls  apart  during  incision  is 
best  accomplished  by  gently  grasping  the  lateral  aspects  of  the  intestine  (a  little 
nearer  the  anti-mesenteric  than  the  mesenteric  border)  with  forceps  (or  with  the 
fingers,  or  thread  retractors  passing  only  through  the  outer  coats)  and  drawing 
them  apart  laterally,  while  the  mesenteric  border  is  simultaneously  drawn 
downward,  thus  forming  a  hollow  triangle  within  the  lumen  of  the  gut.  The 
wound  in  the  intestine  may  be  enlarged  in  the  act  of  withdrawing  the  original 
bistoury — or  by  means  of  a  blunt-pointed  bistoury  separately  inserted — or  one 
blade  of  blunt-pointed  scissors  may  be  introduced  and  the  opening  thus 
enlarged.  (4)  Care  is  used  in  preventing  any  unnecessary  escape  of  in- 
testinal contents — and  all  sites  of  possible  infection  are  packed  off.  (5)  The 
object  of  the  operation  having  been  accomplished,  the  wound  in  the  intestine 
is  closed  by  one  of  the  methods  of  intestinal  suturing  described  under  Enteror- 
rhaphy  (usually  with  Lembert  sutures).  The  abdominal  wound  is  closed  in 
the  ordinarv  manner. 


ENTERORRHAPHY  IN  GENERAL. 

Description. — Union  of  intestinal  tissue  by  suturing.  Sutures  are  of 
two  kinds — Interrupted,  each  suture  being  formed  of  a  separate  thread; — 
Continuous,  the  entire  line  of  suturing  being  formed  of  one  thread.  The 
features  in  favor  of  interrupted  sutures  are: — the  strain  is  upon  many  rather 
than  upon  one  thread,  and  is  more  evenly  distributed;  the  blood-supply  of 
the  edges  of  the  intestine  is  less  interfered  with;  the  giving-way  of  one  thread 
is  not  so  serious.  The  feature  in  favor  of  the  continuous  suture  is  its  rapidity 
of  application.  Linear  Enterorrhaphy  is  generally  used  of  suturing  limited 
wounds  or  incisions  of  the  intestine,  whether  in  the  long  axis  or  transversely. 


842  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Circular  Enterorrhaphy  is  usually  used  of  suturing  the  entire  circumference 
of  intestine  after  complete  transverse  or  oblique  division  of  the  gut. 

Characteristics  of  a  Satisfactory  Intestinal  Suture. — The  following, 
modified  from  Treves,  are  the  features  possessed  by  the  best  forms  of  suture; — 
(a)  Two  broad  peritoneal  surfaces  should  be  brought  into  contact,  (b) 
Closure  should  be  tight  enough  to  hold  water,  (c)  The  mucous  membrane, 
if  included,  should  not  be  penetrated  by  the  same  suture  which  passes  through 
the  serous  coat  (which  might  enable  the  intestinal  contents  to  escape  by 
capillarity).  If  only  one  tier  of  suturing  be  used,  the  mucous  membrane 
should  not  be  included,  (d)  Suturing  should  not  be  sufficiently  tight  to 
strangulate  the  edges  of  the  intestine  compressed  by  the  sutures,  (e)  The 
method  should  be  simple  enough  to  be  easily  and  rapidly  carried  out.  (f) 
The  suture  should  take  a  sufficiently  firm  hold  of  the  intestine  to  run  no 
chance  of  tearing  out  when  put  to  a  fair  test,  (g)  The  suture  should  pass 
through  the  serous,  muscular,  and  part  of  (into)  the  relatively  strong  and 
thick  submucous  coat,  (h)  The  material  of  suture  must  be  sufficiently  dura- 
ble and  of  non-irritating  quality. 

Suture  Materials. — Silk,  fine,  strong  and  preferably  colored  black  (for 
more  easy  detection).  Catgut,  fine,  plain,  or  chromic,  may  also  be  used, 
though  less  trustworthy  and  not  capable  of  making  so  neat  a  suture  knot 
line.     All  suture-materials  should  be  tested  before  being  used. 

General  Considerations  in  Intestinal  Suturing. — (1)  The  intestine  in- 
volved is  exposed  through  the  simplest  incision,  generally  by  median  abdomi- 
nal section,  or  by  enlargement  of  a  previous  wound.  The  portion  of  intes- 
tine to  be  operated  upon  is  drawn  out  of  the  abdomen  and  laid  upon 
a  warm  towel  wrung  out  of  sterile  normal  salt  solution,  and  steadied 
by  an  assistant.  (2)  Some  form  of  intestinal  clamping  should  be  used  to 
prevent  the  escape  of  the  contents  of  the  gut.  One  clamp  should  be  placed 
upon  the  proximal  and  one  upon  the  distal  side  of  the  site  operated  upon. 
The  index-finger  and  thumb  of  each  hand  may  be  used  in  place  of  an  instru- 
mental clamp,  though  generally  less  satisfactorily.  Before  the  application  of 
any  manner  of  clamping,  the  contents  of  the  intestine  should  be  pressed 
away  from  either  side  of  the  site  of  operation  by  a  process  of  manipulation 
resembling  that  of  milking — so  that  the  tract  included  within  the  clamps 
may  be  as  free  of  intestinal  contents  as  possible.  (3)  Avoid,  as  completely 
as  possible,  the  escape  of  intestinal  contents — and  if  the  escape  be  inevitable, 
provide  for  the  catching  of  the  escaping  fluid  upon  abundant  gauze  packing, 
which  is  immediately  removed  and  other  put  in  its  place.  (4)  Control  all 
unnecessary  hemorrhage  by  making  incisions  in  as  non-vascular  regions  of 
the  site  to  be  operated  upon  as  possible.  All  bleeding  vessels  are  caught 
with  artery  forceps  and  tied  with  fine  silk  or  catgut,  preferably  the  latter, 
in  the  case  of  smaller  vessels.  (5)  The  general  feature  of  intestinal  suturing 
is  to  bring  surfaces  of  serous  membrane  into  contact  for  union — preceded  or 
not  by  a  primary  tier  of  suturing  which  approximates  the  mucous  coats 
alone,'  or  all  the  coats.  (6)  Theoretically,  it  is  well  to  aim  at  including  part 
of  the  submucous  coat,  but,  practically,  what  is  generally  done  is  to  include 
all  of  the  serous  and  most  of  the  muscular  coats.  The  submucous  coat 
of  the  intestine  is  tough  and  strong,  and  it  should  be  the  aim  to  include  it 
in  all  intestinal  suturing — though  it  is  sometimes  difficult  to  include  the  sub- 
mucous without  also  including  the  mucous  coat.  (7)  While  theoretically  it 
is  well  not  to  have  the  same  suture  which  passes  through  the  serous  also 
pass  through  the  mucous  coat,  yet  practical  experience  has  shown  that  in 
manv  instances  where  this  is  done  no  harm  has  resulted — and  some  surgeons 


ENTERORRHAPHY  BY  LEMBERT'S  INTERRUPTED  SUTURE.        843 

do  not  attempt  to  avoid  it — though  it  should,  however,  be  avoided  if  possible. 
(8)  All  sutures  should  be  tied  with  a  surgeon's  knot.  In  intestinal  suturing 
it  would  seem  that  the  use  of  two  tiers  of  different  kinds  of  suture  makes 
a  better  juncture  than  the  two  tiers  of  one  kind — thus  a  continued  and  in- 
terrupted combined  may  be  considered  better  than  two  continued  or  two  inter- 
rupted. (9)  Interrupted  sutures  have  a  tendency  to  permit  lateral  expansion 
at  the  site  of  suturing — continuous  have  the  opposite  tendency — and  therefore, 
theoretically  at  least,  the  latter  encroach  more  upon  the  lumen  of  the  gut. 
The  interrupted  form  of  suturing  may  generally  be  considered  the  better 
form  of  intestinal  suturing  in  the  majority  of  cases.  (10)  Often  the  suturing 
can  be  expedited  by  placing  two  or  four  temporary  silk  traction  sutures 
through  the  serous  and  muscular  coats  in  sue!"  a  position  as  to  draw  into  two 
parallel  folds  or  ridges  the  two  edges  to  be  apposed  when  the  traction  sutures 
are  held  by  an  assistant  who  draws  upon  them.  (11)  Needles  should  be  used 
which  displace  rather  than  cut  the  tissues  through  which  they  pass  on  their 
way  through  the  intestinal  coats.  The  straight  domestic  needle  or  the  instru- 
ment-makers' round  straight  or  curved  needle  is  the  best.  The  curved 
needle  always,  and  the  straight  needle  sometimes,  require  a  needle  holder. 

(12)  The  abdominal  cavity  should  be  cleansed,  if  soiled,  at  the  end  of  the 
operation — by  means  of  gauze  mops,  with  or  without  irrigation,  as  indicated. 

(13)  Whether  or  not  the  abdomen  will  be  closed  without  drainage  will  depend 
upon  the  nature  of  the  case.  In  simple,  clean  suturing,  the  abdomen  is 
closed  without  drainage.  (14)  Very  many  forms  of  intestinal  suture  are 
used — only  those  most  generally  employed  will  be  here  given. 


Fig.  592.— ENTERORRHAPHY    BY   THE    LEMBERT    INTERRUPTED    SUTURE. 

ENTERORRHAPHY  BY  LEMBERT'S  INTERRUPTED  SUTURE. 

Description. — (i)  The  suture  is  carried  across  at  a  right  angle  to  the  line 
of  intestinal  wound  to  be  closed — the  needle  picking  up  a  fold  on  one  side 
of  the  wound — and  a  similar  fold  on  the  directly  opposite  side — whereby, 
when  the  knot  is  tied,  the  serous  surfaces  of  the  two  lips  of  the  wound  are 
approximated  and  the  edges  of  the  wound  are  invaginated  into  the  lumen 
of  the  gut.     (2)  The  fold  of  serous,  muscular,  and  part  of  submucous  coats 


844  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

picked  up  will  be  about  2  to  2.5  mm.  (TV  to  y1^  inch  in  width) — the  needle 
emerging  about  2.5  to  3  mm.  (^  to  J  inch)  from  the  edge  of  the  wound — enter- 
ing the  opposite  lip  of  the  wound  at  the  same  distance  from  its  edge  and  travers- 
ing the  same  amount  of  tissue  as  on  the  first  side.  The  sutures  will  be  about 
2.5  to  3  mm.  (TL  to  I  inch^)  apart.  (3)  All  sutures  are  placed  before  any 
are  tied— except  that  where  the  line  to  be  sutured  is  somewhat  long,  a  few 
sutures  may  be  applied  at  intervals  and  at  once  tied,  so  as  to  evenly  divide 
and  fix  the  parts.  The  knots  are  not  to  be  tied  too  tightly  (for  fear  of  cutting 
through  or  strangulating  the  parts) — and  are  cut  quite  short  (so  as  not  to 
interfere  with  the  process  of  invagination  of  the  edges).  (4)  The  sutures  are 
generally  applied  with  one  long  thread  and  a  single  needle,  cutting  the  thread 
at  the  end  of  each  completed  suture.  Or  numerous  needles  may  be  threaded 
with  short  lengths  of  thread.  (5)  Four  temporary  traction-sutures,  passed 
through  the  outer  coats  of  the  intestine,  placed  on  the  opposite  sides  of  the 
wound  and  at  each  of  its  ends,  if  drawn  upon  in  a  line  with  the  suturing, 
will  raise  two  parallel  folds  which  will  make  the  insertion  of  sutures  easier, 
more  rapid,  and  more  regular.  They  should  be  placed  just  to  the  outer 
side  of  the  lips  of  the  wound  so  that  the  folds  caused  by  their  traction  will 
represent  the  surfaces  which  are  to  be  approximated  by  the  permanent 
sutures.  (6)  For  manner  of  application,  see  Fig.  592,  and  also  Fig.  593,  A. 
Comment. — The  best  all  around  suture. 


Fig. 593. — Enterorrhaphy  by  the  Czerny-Lembert  Interrupted  Suture: — A,  Interrupted 
Lembert  suture  through  serous,  muscular,  and  part  of  submucous  coats — applied  from  without ;  B, 
Interrupted  Czerny  suture  through  mucous  and  part  of  submucous  coats — applied  from  within. 
The  latter  is  applied  first.     (Modified  from  Esmarch.) 


ENTERORRHAPHY    BY    THE    CZERNY-LEMBERT    INTERRUPTED 

SUTURE. 

Description. — (1)  By  this  method  the  mucous  membrane  is  first  sepa- 
rately sutured  with  the  Czerny  suture,  the  sutures  being  so  introduced  as 
to  bring  the  knots  within  the  lumen — and  then  the  serous,  muscular,  and 
part  of  the  submucous  coats  are  united  by  the  ordinary  Lembert  method. 
(2)  The  passage  of  the  Czerny  suture  is  a  little  difficult  if  it  be  desired  to 
have  all  the  knots  fall  within.  The  mucous  membrane  of  one  side  of  the 
wound  is  caught  with  delicate  forceps  and  steadied,  and,  at  the  same  time, 
drawn  forward  into  view  and  slightly  everted — a  curved  needle,  held  in  a 
holder,  is  then  passed  from  the  mucous  surface  of  the  mucous  membrane 
outward  entirely  through  that  membrane  and  part  of  the  submucous  coat — 
then  the  mucous  membrane  of  the  opposite  edge  of  the  wound  is  similarly 


ENTERORRHAPHY  BY  HALSTED'S  SUTURE. 


845 


seized  with  forceps,  and,  while  similarly  held,  except  without  eversion,  the 
needle  is  now  passed  in  the  reverse  direction,  from  without  inward,  through 
part  of  the  submucous  coat  and  the  mucous  membrane.  The  two  ends  of 
the  thread  are  therefore  toward  the  lumen  and,  when  tied,  the  knot  will 
be  within.  When  tying  the  last  one  or  two  knots,  it  will  be  necessary  to 
protrude  them  within  the  lumen  with  the  blunt  end  of  a  probe.  The  above 
method  of  applying  the  sutures  is  especially  necessary  in  suturing  short 
wounds  and  in  completing  the  line  of  circular  suturing  after  resection  of  the 
intestine.  For  two-thirds  of  the  distance  in  circular  enterorrhaphy,  following 
intestinal  resection,  the  Czerny  sutures  can  be  readily  applied — it  is  only 
toward  the  latter  part,  when  the  lumen  is  almost  excluded,  that  their  applica- 
tion becomes  more  difficult.  If  there  be  any  likelihood  of  the  first  part  of 
the  last  one  or  two  knots  slipping,  make  that  part  a  friction-knot.  (3)  The 
passage  of  the  Lembert  sutures  is  accomplished  in  the  usual  fashion — and, 
when  tied,  completely  covers  in  the  Czerny  sutures.  (4)  Some  surgeons  apply 
the  sutures  through  the  mucous  membrane  in  the  ordinary  manner,  tying 
the  knots  toward  the  surface,  depending  upon  the  Lembert  row  to  bury 
them.  (5)  For  the  manner  of  applying  the  suture,  see  Fig.  593;  also  see 
Fig.  618  (Czerny-Lembert  Entero-enterostomy). 

Comment. — Confusion  often  exists  between  the  Czerny-Lembert  and  the 
YYolfler  sutures.     They  are  practically  the  same. 


Fig. 594. — Enterorrhaphy  by  Halsted's  Interrupted  Quilt  (or  Mattress)  Suture. 


ENTERORRHAPHY   BY  HALSTED'S   INTERRUPTED  QUILT-   OR  MAT- 
TRESS-SUTURE. 

Description. — (1)  This  is  a  modification  of  the  Lembert  principle — and 
consists  in  an  ordinary  quilt-  or  mattress-suture  (the  terms  being  used  synony- 
mously) so  applied  that  the  looped  end  is  upon  one  side  of  the  wound  and 
the  two  free  ends  upon  the  opposite  side — the  thread  passing  through  the 
serous,  muscular,  and  especially  a  part  of  the  tough  submucous  coats.  (2) 
As  to  the  manner  of  their  application,  each  quilt-suture  may  be  regarded 
as  composed  of  two  parallel  Lembert  sutures,  united  by  the  loop.  When 
the  knot  is  tightened,  folds  of  serous  surfaces  from  the  two  sides  are  brought 


846  OPERATIONS  UPON  THE  AI5DOMINO-PELVIC  REGION. 

into  contact— the  fold  on  one  side  being  held  by  the  loops — on  the  other, 
by  the  knots.     (3)  For  manner  of  application,  see  Fig.  594. 

Comment. — It  is  claimed  that  these  sutures  compress  the  tissues  less, 
take  a  stronger  hold,  and  approximate  the  parts  more  accurately.  It  is 
probably  the  next  best  interrupted  suture  to  Lembert's. 


ENTERORRHAPHY  BY  LEMBERT'S  CONTINUOUS  SUTURE. 

Description. — (1)  This  suture  passes  diagonally  back  and  forth  from  side 
to  side,  between  the  lips  of  the  intestinal  wound,  passing  through  serous, 
muscular,  and  part  of  submucous  coats.  When  the  suture  is  drawn  tight, 
two  folds  of  serous  surfaces,  parallel  with  the  edge  of  the  wound,  and  parallel 
with  each  other,  are  brought  into  contact.  (2)  The  general  principle  of  the 
introduction  of  the  continuous  Lembert  suture  follows  that  of  the  interrupted 
Lembert  suture — except  that  the  former  is  applied  continuously,  and  the 
needle-punctures  are  made  in  a  direction  slightly  obliquely  to  the  cut  margins 


Fig.  595. —ENTERORRHAPHY    BY   THE    LEMBERT    CONTINUOUS   SUTURE. 

of  the  intestinal  wound — the  general  rule  as  to  the  distances  being  about 
the  same  in  both  methods.     (3)  For  the  manner  of  application,  see  Fig. 

595- 

Comment. — The  most  quickly  applied  of  the  regular  continuous  intestinal 

sutures  (those  approximating  serous  surfaces). 


ENTERORRHAPHY  BY  CUSHING'S  RIGHT-ANGLED  CONTINUOUS 

SUTURE. 

Description. — (1)  In  this  suture  the  thread  is  carried  along  in  its  onward 
progress  exactly  parallel  with  the  edge  of  the  wound  in  the  intestine — and 
when  the  wound  is  crossed,  the  crossing  is  always  directly  at  right  angles 
to  the  course  of  the  wound.  The  suture  is  everywhere  buried  except  where 
it  crosses  the  wound,  and  even  this  part  of  the  suture  is  buried  by  the  invagina- 
tion of  the  lips  of  the  wound  when  the  thread  is  drawn  tight.  (2)  Having 
begun  the  suture  by  passing  through  the  serous,  muscular,  and  into  the 
submucous  coats,  a  short  distance  from  and  directly  opposite  one  end  of 


ENTERORRHAPHY  BY  CUSHING'S  SUTURE. 


847 


the  wound,  the  thread  is  knotted  in  the  ordinary  manner — the  needle  is  then 
carried  outside  of  the  intestinal  wall  onward  to  a  point  a  short  distance  to  one 


Fig. 596. — Enterorrhaphy  by  Cushing's  Right-angled  Continuous  Suture. 

side  of  the  edge  of  the  wound — passes  beneath  the  serous,  muscular,  and  into 
the  submucous  coat,  parallel  with  the  edges  of  the  wound — emerges  a  short 
distance  beyond — crosses,  outside,  at  a  right  angle  to  the  wound — to  a  point 


Fig.  597.— Enterorrhaphy  by  Combined  Overhand  Continuous  Suture  of  all  the 
Coats,  Followed  by  Interrupted  Lemberts  of  the  Outer  Coats  : — A,  Continuous  overhand 
suture  ;  B,  Interrupted  Lemberts. 


on  the  other  side  directly  opposite  its  last  emergence — travels  similarly  for- 
ward beneath  the  serous,  muscular,  and  part  of  the  submucous  coat  for  a 


848  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

short  distance — thence  back  across  the  wound  at  a  right  angle,  to  the  original 
side — and  thus  on  to  the  opposite  end  of  the  wound,  beyond  which  it  is 
carried  a  short  distance  and  then  knotted.  Before  the  final  knotting  the 
thread  is  drawn  tight,  thus  infolding  the  margins  of  the  wound  and  approxi- 
mating the  serous  surfaces.     (3)  For  manner  of  application,  see  Fig.  596. 

Comment. — Cushing's  method  of  knotting,  at  either  end,  is  unnecessarily 
complicated. 


ENTERORRHAPHY  BY  COMBINED  OVERHAND  CONTINUOUS  SUTURE 

OF  ALL  COATS,  FOLLOWED  BY  INTERRUPTED  LEMBERT 

SUTURING  OF  OUTER  COATS. 

Description.— (i"i  This  method  consists,  first,  in  whipping  together  the 
edges  of  the  wound  by  a  simple,  running,  continuous,  overhand  suture, 
passing  through  all  the  coats  of  each  margin  of  the  wound,  as  a  preliminary 
suture  of  approximation  and  strength — which  is  then  followed  by  a  secondary 
tier  of  generally  either  the  interrupted  or  continuous  Lembert  sutures  passing 
through  the  serous,  muscular,  and  part  of  the  submucous  coats.  (2)  For 
manner  of  application,  see  Entero-enterostomy  by  simple  suturing  (page  855), 
for  the  general  description  of  the  method, — and  Fig.  597,  for  its  application 
to  a  limited  wound. 


ENTERORRHAPHY  FOR  WOUNDS  OF  THE  INTESTINE. 

Description. — Wounds  of  the  intestines  may  be  divided  into  five  classes; 
(a)  Longitudinal  wounds,  incised  or  lacerated;  (b)  Transverse  wounds,  in- 
cised or  lacerated ;  (c)  Irregular  wounds,  incised  or  lacerated;  (d)  Complete 
transverse  division  of  the  intestine;   (e)  Contused  wounds. 

Preparation — Position — Landmarks. — As  for  median  abdominal  sec- 
tion. 

Incision. — In  the  majority  of  cases  the  incision  will  be  in  the  median 
line,  as  for  median  abdominal  section.  If  the  abdominal  wound,  which  may 
already  exist,  lie  outside  of  either  rectus,  and  especially  if  it  be  indicated 
that  the  wound  has  not  ranged  toward  the  median  line,  the  incision  is  fre- 
quently made  vertical  over  the  external  abdominal  wound. 

Operation. — (1)  Having  entered  the  abdominal  cavity,  the  edges  of 
the  wound  should  be  well  retracted  in  order  to  expose  the  involved  coils  of 
intestine.  (2)  All  bleeding  vessels  should  be  controlled  by  clamp  and  gut- 
ligature  before  proceeding  to  the  intestinal  operation.  (3)  If  the  omentum 
be  found  wounded,  the  lips  of  the  wound  should  be  approximated  by  gut- 
suture.  (4)  Unless  the  wounded  coil  of  intestine  be  readily  detected,  it  is 
best  to  systematically  examine  the  intestines,  beginning  at  the  stomach — 
lifting  the  stomach  and  transverse  colon  to  trace  the  duodenum — and  then, 
catching  up  the  beginning  of  the  jejunum  beneath  the  ligament  of  Treitz, 
follow  down  the  rest  of  the  small  and  large  intestines.  (5)  Some  surgeons 
clamp  each  wound,  in  the  case  of  gunshot  wounds,  as  found — and  suture 
none  until  all  are  clamped — in  order  to  control  intestinal  contents.  (6) 
Coils  of  intestine  temporarily  removed  from  the  abdominal  cavity  should 
be  surrounded  with  warm,  wet,  sterilized  gauze  or  towels,  with  or  without 
a  preliminary  enveloping  with  sterile  rubber  tissue.  (7)  All  escaped  intes- 
tinal contents  should  be  wiped  away  with  gauze,  or,  if  excessive,  by  irrigation. 
(8)  If  the  mesentery  be  wounded,  the  edges  of  the  wound  should  be  sutured 


ENTERORRHAPIIY  FOR  WOUNDS  OF  THE  INTESTINE.  849 

with  gut  sutures.  (9)  Having  brought  the  involved  portion  of  intestine  into 
the  field  of  operation,  the  wound  is  repaired  as  indicated  by  the  special  case. 
(10)  Simple  longitudinal  wounds  are  closed  by  a  line  of  interrupted  Lembert 
sutures.  (11)  Simple  transverse  wounds  are  closed  in  the  same  manner  as 
longitudinal  ones.  (12)  In  irregular  wounds,  if  consisting  of  a  transverse  and 
longitudinal  wound  (the  two  arms  crossing  each  other  at  a  right  angle  or 
diagonally)  and  not  too  extensive,  the  part  of  the  transverse  wound  on  one 
side  of  the  longitudinal  wound  should  be  first  closed  with  interrupted  Lembert 
sutures — then  similarly  the  part  of  the  transverse  wound  on  the  other  side- 
then  the  entire  length  of  the  longitudinal  wound  by  interrupted  Lemberts 
placed  transversely  to  its  length.  (See  Fig.  598.)  Sometimes  the  two  parts 
of  the  transverse  wound  and  the  ends  of  the  longitudinal  are  closed  as  just 
described — and  then  the  remaining  portions  of  the  sides  of  the  longitudinal 
are  sutured  after  the  fashion  of  suturing  the  intestine  in  Enteroplasty  for 
stricture.  (See  Comment.)  Such  an  irregular  wound  as  that  made  by  a  bullet, 
if  not  too  large,  may  be  treated  as  an  ordinary  wound,  being  sutured  with 
Lembert  sutures  in  such  a  way  as  to  infold  its  margins.     Sometimes  the 


fc^A 


Fig. 598.— Enterorrhaphy  in  Irregular  Wounds  of  the  Intestines: — The  two  limbs  of 
the  transverse  wound  being  first  sutured  with  interrupted  Lemberts,  and  then  the  two  limbs  of  the 
longitudinal  wound. 

ragged  edge  of  a  bullet  wound  may  be  advantageously  trimmed  with  curved 
scissors  before  suturing.  Where  destruction  has  been  great,  resection  of  a 
portion  of  the  intestine,  followed  by  some  form  of  intestinal  anastomosis, 
is  generally  safer.  (13)  Complete  transverse  division  of  the  intestine  will 
necessitate  an  end-to-end  anastomosis,  by  means  of  a  simple  suturing  or 
some  mechanical  device.  (14)  Contused  wounds,  if  at  all  bad,  should  be 
treated  as  lacerated  wounds,  as  the  walls  of  such  wounds  are  rendered  of 
lowered  vitality  by  the  traumatism.  The  contused  surface  is  thus  turned 
into  the  lumen  of  the  gut  by  Lembert  sutures,  where,  if  sloughing  of  the 
portion  within  the  line  of  sutures  occurs,  no  harm  is  done.  (15)  The  injury 
to  the  intestine  having  been  repaired,  the  abdomen  is  closed  as  in  median 
abdominal  section,  with  or  without  drainage,  as  indicated  by  circumstances. 
Comment, — (0  Lembert  or  Halsted  interrupted  sutures  are  generally 
best  in  suturing  intestinal  wounds.  (2)  If  any  doubt  exist  as  to  the  efficiency 
of  the  first  row  of  sutures,  a  second  tier,  generally  continued  Lembert,  may 
be  put  in,  burying  the  first.  (3)  Areas  of  suspicious  suturing  may  be  strength- 
ened bv  suturing  over  them  omental  grafts  (elliptical  pieces  taken  from  the 
omentum  followed  by  suturing  up  the  lips  of  the  wound  thus  made  in  the 
54 


850  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

omentum) — these  are  applied  over  the  intestinal  suturing  and  held  in  place 
by  two  or  three  gut  sutures.  (4)  Resection,  followed  by  an  entero-enteros- 
tomy,  is  preferable  to  any  form  of  suturing,  if  by  such  form  of  simple  suturing 
the  lumen  of  the  gut  will  be  reduced  to  less  than  half  its  diameter.  (5)  Trans- 
verse suturing  interferes  less  with  the  vascular  supply  than  the  longitudinal — 
especially  when  the  longitudinal  is  near  the  mesenteric  border.  (6)  A  longi- 
tudinal wound  of  considerable  length,  and  more  or  less  breadth,  the  ordinary 
suturing  of  which  might  reduce  its  calibre  too  greatly,  may  be  repaired  by 
what  is  termed  "elbowing"  (such  as  is  seen  in  the  joining  of  segments  of 
stove  pipes).  The  intestine  is  bent  somewhat  upon  itself,  the  center  of  the 
bending  being  the  center  of  the  wound — then  one  half  of  one  side  of  the 
wound  is  joined,  by  interrupted  Lembert  sutures,  to  the  other  half  of  the 
same  side — and  the  same  steps  are  carried  out  on  the  opposite  side.  -  This 
is  applicable  only  to  wounds  on  or  toward  the  antimesenteric  border.  The 
edges  of  the  wound  may  be  sometimes  trimmed  prior  to  suturing.  Too 
great  narrowing,  as  might  result  from  simple  suturing,  or  even  resection,  is 
hereby  avoided. 


PARTIAL  ENTERECTOMY. 

Description. — By  partial  enterectomy  is  meant  the  excision,  or  resection, 
of  a  part  of  the  intestinal  canal,  with  or  without  the  excision  of  the  corre- 
sponding portion  of  the  mesentery.  By  prefixing  the  name  of  the  part  of 
the  canal,  the  site  of  the  partial  excision  is  designated — Partial  Duodenectomy, 
Jejunectomy,  Ileectomy,  Caecectomy,  Colectomy  (ascending,  transverse,  or 
descending),  Sigmoidectomy,  Rectectomy.  By  the  term  Enterectomy  alone 
is  usually  understood  an  excision  of  some  part  of  the  small  intestine.  As, 
of  course,  excision  of  the  whole  intestine  is  never  considered,  Enterectomy 
is  generally  used  in  the  sense  of  a  partial  excision,  without  the  preceding 
word  "partial."  Enterectomy  carries  with  it  the  idea  of  three  operations — 
partial  excision  of  the  intestine — partial  excision,  or  incision,  of  the  mesentery 
— intestinal  junction.  The  operation  is  generally  resorted  to  where  the  disease 
or  injury  to  a  part  of  the  intestine,  or  its  mesentery,  is  so  extensive  that  a 
portion  of  the  intestine  must  be  cut  out  and  sacrificed. 

Preparation — Position — Landmarks — Incision. — As  for   median  ab 
dominal  section  (page  631). 

Operation, — (1)  Having  opened  the  abdomen,  the  portion  of  intestine 
involved  is  brought  out  into  the  field  of  operation.  (2)  Before  excising  any 
portion  of  the  intestinal  tract,  the  contents  of  that  part  should  be  removed 
from  it  as  much  as  possible — which  is  best  accomplished  by  "  milking"  the 
intestines  in  opposite  directions  from  a  central  point,  the  center  of  the  part 
to  be  excised — and  then  clamping  the  intestines,  proximally  and  distally, 
beyond  the  site  to  be  removed.  Various  forms  of  clamps  are  used  for  this 
purpose,  which  may  be  divided  into  three  categories; — (A)  Special  intestinal 
clamps,  which  are  generally  best  (Figs.  600,  C,  and  599) ; — (B)  Improvised 
clamps  may  be  used,  such  as:  (a)  Pierce  the  mesentery  near  the  intestinal 
border  with  the  closed  ends  of  a  pair  of  forceps — grasp  a  small  rubber  tube  in 
the  bite  of  the  forceps  and  draw  it  through  the  mesentery — and  tie  the  two  ends 
over  the  intestine  (Fig.  600,  E) ;  (b)  Pass  a  sterilized  wooden  toothpick 
through  the  mesentery,  near  the  intestine,  and  make  a  figure-of-8  with  a  rubber 
band  over  it,  compressing  the  intestine  between  toothpick  and  rubber  band 
(Fig.  600,  D) ;  (c)   Pass  the  pin  of  a  safety-pin  through  the  mesentery,  near 


PARTIAL    ENTERECTOMY. 


851 


the  intestine — and  fasten,  in  the  act  of  closing  the  pin,  a  small  piece  of  flat 
sponge  over  the  intestine  (Fig.  600,  A) ;  (d)  Pass  a  piece  of  gauze  through  the 
mesentery,  near  the  bowel,  and  tie  over  the  intestine  after  the  fashion  of  the 
rubber  tube  in  (e)  above: — (C)  The  thumb  and  index  of  each  hand  of  an 
assistant  may  be  used  to  compress  the  intestine  in  the  position  a  pair  of  clamps 
would  occupy — after  having  pressed  away  the  intestinal  contents  (Fig.  600,  B) . 
(3)  The  indicated  portion  of  the  intestine  is  now  excised — by  dividing  the  gut 
on  either  side  of  the  segment  to  be  removed,  with  scissors  or  knife,  exactly  at  a 
right  angle  to  the  length  of  the  intestine  at  the  part  divided — so  that  the  cut  ends 
may  be  afterward  approximated  without  any  tension  at  either  mesenteric  or 


Fig.  599. — Partial  Enterectomy: — The  excision  of  a  part  of  the  small  intestine  is  shown, 
with  the  excision  of  a  corresponding  V-shaped  portion  of  mesentery.  The  intestine  is  divided 
at  a  right  angle  to  its  length,  between  two  clamps  at  either  end  of  the  excised  area.  The  main 
mesenteric  vessels  are  ligated  prior  to  section. 


antimesenteric  aspect  (Fig.  599) .  (There  is  somewhat  greater  retraction  of  the 
antimesenteric  border  naturally.)  Division  of  the  intestine  with  a  knife  is  better 
than  by  means  of  scissors,  which  latter  compress  the  edges  somewhat.  It  is 
well  to  have,  if  possible,  a  good  artery  left  just  to  the  proximal  side  of  the  proxi- 
mal intestinal  incision,  and  one  on  the  distal  side  of  the  distal  intestinal  incision 
— to  furnish  nourishment  to  the  uniting  edges.     The  triangular  space,  at  the 


852 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


separation  of  the  leaves  of  the  mesentery,  will  be  opened  up — and  care  should 
be  exercised  not  to  bare  the  intestinal  tube  further  than  necessary.  (4)  The 
treatment  of  the  mesentery  corresponding  with  the  excised  portion  of  the 
intestine  differs — one  of  the  following  methods  may  be  used: — (a)  Probably 
the  best  plan,  after  having  excised  the  portion  of  intestine,  is  to  remove  a 
triangular  or  V-shaped  piece  of  the  mesentery — whose  base  will  be  a  little 
narrower  than  the  section  of  the  intestine  removed — whose  sides  will  pass 
down  obliquely  toward  each  other  in  the  direction  of  the  root  of  the  mesentery, 
but  meeting  midway  between  the  two  free  ends  of  the  intestine  and  before 


Fig. 600.— Methods  of  Controlling  the  Intestinal  Contents  di-ring  Partial  En- 
terectomy  :— A,  Maunsell's  method  by  means  of  sponge  and  safety-pin  ;  B,  Digital  compression  ;  C, 
Special  intestinal  clamps  ;  D,  Toothpick,  or  similar  object,  piercing  the  mesentery,  with  an  ordinary 
rubber-band  passed  over  it  in  figure-of-eight  fashion  ;  E,  Rubber  tube  passed  through  mesentery  and 
tied  over  the  intestine.  (Whichever  method  of  control  be  used,  the  same  method  is  generally  applied 
on  each  side  of  the  area  to  be  excised.) 


reaching  the  root  of  the  mesentery.  The  division  is  made  with  a  knife  or 
scissors,  from  a  line  with  the  free  ends  of  the  divided  intestines  at  their  mesen- 
teric borders — taking  care  to  preserve  the  artery  supplying  the  free  end  of 
the  intestine,  proximally  and  distally.  In  suturing,  the  edges  of  the  cut 
mesentery  are  approximated  with  gut  by  continuous  or  interrupted  suture 
(Fig.  601,  A  and  B).  Or  the  edges  may  be  slightly  overlapped  and 
then  sutured,  uniting  laterally  (Fig.  601,  C).  All  vessels  which  fall  along 
the  line  of  division  of  the  mesentery,  whose  position  is  shown  through  the 
thin  mesentery,  should  be  ligated,  proximally  in  advance  of  the  division— by 
passing  a  curved  needle  armed  with  gut,  beneath  them, — or  the  vessels  may 


PARTIAL    ENTERECTOMY. 


853 


be  clamped  immediately  after  division  and  then  ligated  (see  Fig.  372). 
This  method  is  especially  advisable  in  malignant  disease  where  the  mesenteric 
glands  may  be  involved,  (b)  Another  method  is,  after  dividing  the  intestine 
at  both  ends,  simply  to  cut  away  the  excised  portion  close  along  the  mesenteric 
attachment,  after  having  ligated  its  vessels  as  in  the  above  method.  In 
suturing,  the  redundant  mesentery  is  simply  folded  upon  itself  and  a  few 
gut  sutures  passed  from  side  to  side,  along  the  angle  of  junction  with  the 
rest  of  the  mesentery — and  by  whipping  the  free  margins  with  a  gut  suture, 
to  prevent  a  hernia  occurring  through  the  opening.  This  method  probably 
insures  a  better  blood-supply  to  the  intestine  (Fig.  601,  D).  (c)  In  addition 
to  the  steps  mentioned  in  the  last  method,  the  entire  triangular  fold  may 


Fig.  001.— Methods  of  Suturing  the  Mesentery  in  Partial  Enterectomy  : — A,  A 
V-shaped  portion  of  mesentery  excised,  with  suturing  of  edge  to  edge  by  continuous  suture  ;  B,  Same 
with  suturing  of  edge  to  edge  by  interrupted  sutures;  C,  Same,  with  edges  overlapped  by  running 
suture;  D,  Mesentery  left  intact,  with  free  edges  sutured  together  by  continuous  overhand  stitch  ;  E, 
Same,  with  suturing  of  both  free  border  and  free  fold  of  redundant  mesentery  to  main  mesentery, 
together  with  closure  by  continuous  suture  of  entrance  to  mesenteric  pocket.  Note — Several  mesen- 
teric vessels  are  shown  ligated,  by  the  passage  of  needle  and  gut-ligature  beneath  them. 


be  sutured  back  to  the  general  mesentery  by  sutures  along  its  folded  border, 
as  well  as  along  its  free  border  (Fig.  601,  E). 

Comment. — Partial  Enterectomy  is  an  incomplete  operation  in  itself — 
and  naturally  carries  with  it  the  idea  of  suturing  together  the  two  free  ends 
of  the  intestinal  canal  left  open  after  the  excision,  and  thus  repairing  the 
intestinal  tract — but  since  the  junction  of  these  two  ends  is  accomplished 
by  a  separate  and  distinct  operation,  it  will  be  treated  of  separately.  (See 
Entero-enterostomy.) 


854  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


ENTERO-ENTEROSTOMY. 

INTESTINAL  ANASTOMOSIS,  APPROXIMATION,  AND  IMPLANTATION,  IN 

GENERAL. 

Intestinal  Anastomosis  was  originally  applied  to  the  operation  of  estab- 
lishing a  communication  between  the  intestine  above  and  the  intestine  below 
the  seat  of  obstruction,  without  the  removal  of  the  portion  of  intestine  in 
which  the  obstruction  was  situated.  As  a  result,  the  larger  part  of  intestinal 
contents  would  tlow  by  the  new  route,  thus  "short-circuiting"  the  obstruction, 
while  the  smaller  portion  would  flow  through  the  partially  obstructed  canal, 
until  the  obstruction  was  relieved  or  became  complete.  As,  in  such  cases, 
no  portion  of  the  intestine  was  removed,  the  Anastomosis  was  always  a 
Lateral  Anastomosis,  that  is,  the  joining  of  the  lateral  aspect  of  one  coil 
with  the  lateral  aspect  of  another  coil.  Subsequently,  however,  Intestinal 
Anastomosis  came  to  be  used,  by  many  surgeons,  in  the  same  sense  as  Intes- 
tinal Approximation,  and  applied  to  both  end-to-end  and  to  lateral  joinings. 

Intestinal  Approximation  was  originally  used  to  signify  the  union  of 
the  portions  of  the  intestinal  tract  following  the  excision  of  a  part  of  the 
canal — the  approximation  being  either  end-to-end  or  lateral.  In  End-to-end 
Intestinal  Approximation,  after  the  excision  of  a  part  of  the  intestine  has 
been  accomplished,  the  free  ends  of  the  intestine  above  and  below  are  ap- 
proximated and  united.  In  Lateral  Intestinal  Approximation,  after  the  partial 
enterectomy  has  been  performed,  the  free  ends  of  the  intestine  above  and 
below  are  closed  by  suture,  and  then  the  lateral  aspect  of  the  closed  upper 
end  is  approximated  and  united  to  the  lateral  aspect  of  the  closed  lower 
end. 

Intestinal  Implantation  has  generally  been  used  to  signify  the  implanta- 
tion, or  union,  of  the  end  of  one  piece  of  intestine  into  an  opening  in  the 
lateral,  antimesenteric  aspect  of  another  coil — following  the  excision  of  a  seg- 
ment of  intestine.  This  process  of  union  imitates  the  union  of  the  ileum  with 
the  colon  (caecum). 

Entero-enterostomy  signifies  the  junction  of  the  lumen  of  some  part  of 
one  intestinal  coil  with  the  lumen  of  some  part  of  another.  Strictly  speaking, 
therefore,  Entero-enterostomy  is  a  term  of  broader  significance  than  those  above 
used,  and  includes  Anastomosis,  Approximation,  and  Implantation.  No  hard- 
and-fast  rule,  however,  exists  as  to  the  use  of  the  terms  designating  the  union 
of  coils  of  intestine,  but  the  shades  of  difference  expressed  in  the  terms 
Intestinal  Anastomosis,  Approximation,  and  Implantation  might  probably  be 
more  accurately  expressed  by  the  terms  Entero-enterostomy  by  Lateral  An- 
astomosis— Entero-enterostomy  by  End-to-end  Approximation  —Entero-en- 
terostomy by  Lateral  Approximation  —Entero-enterostomy  by  End-in-side 
Implantation.  While,  therefore,  Entero-enterostomy  expresses  the  junction  of 
lumina  of  segments  of  intestine,  the  method  of  that  junction  is  best  expressed 
by  following  the  term  with  some  qualifying  words. 

The  Scope  of  the  Methods  of  Intestinal-joining.—  Many  of  the  methods 
used  for  variously  uniting  segments  of  the  intestines  to  each  other  are  also  used 
to  unite  portions  of  the  intestines  with  different  parts  of  the  stomach — and  also 
with  the  gall-bladder.  The  range  of  usefulness  of  any  method  of  intestinal 
joining,  therefore,  is  measured  by  the  ability  of  that  special  method  to  meet  the 
requirements  of  the  following  operations  involving  the  intestines:— Entero- 
enterostomy  by  Lateral  Anastomosis;  Entero-enterostomy  by  End-to-end 
Approximation;  Entero-enterostomy  by  Lateral  Approximation;  Entero-en- 


EXTERO-ENTEROSTOMV    BY    SIMPLE    SUTURING.  855 

terostomy  by  End-in-side  Implantation;  Simple  Gastro -enterostomy  (by 
lateral  anastomosis,  or  end-in-side  implantation);  Gastro-enterostomy  fol- 
lowing pylorectomy;   Cholecystenterostomv. 

The  Methods  of  Accomplishing  Intestinal  Joinings. — (1)  Union  of 
portions  of  Intestinal,  Gastro-intestinal,  and  Cholecyst-intestinal  tracts  by 
simple  suturing; — (2)  Union  of  portions  of  Intestinal,  Gastro-intestinal,  and 
Cholecyst-intestinal  tracts  by  absorbable  mechanical  devices; — (3)  Union  of 
portions  of  Intestinal,  Gastro-intestinal,  and  Cholecyst-intestinal  tracts  by 
non-absorbable  devices; — (4)  Union  of  portions  of  Intestinal,  Gastro-intes- 
tinal, and  Cholecyst-intestinal  tracts  by  mechanical  means  temporarily  used 
during  suturing. 

Note. — In  the  various  operations  of  Entero-enterostomy  it  is  not  necessary 
that  any  previous  excision  (partial  enterectomy)  must  have  been  done — though 
such  an  excision  may  have  been  done.  In  the  following  operations  of  Entero- 
enterostomy  the  joining  of  the  portions  of  intestine  will  (to  make  the  operation 
more  complete)  be  supposed  to  follow,  in  the  majority  of  cases,  excision  of 
some  part  of  the  gut.  Of  course,  the  same  operations  which  are  applicable 
after  the  excision  of  a  part  of  the  intestine  are  also  applicable  after  a  circular 
division  (circular  enterotomy)  of  the  gut  without  any  excision  of  a  part  of 
the  canal. 


(A)  ENTERO-ENTEROSTOMY  BY  METHODS  OF  SIMPLE 

SUTURING 

IX  GENERAL. 

Union  is  here  accomplished  by  the  ordinary  methods  of  suturing,  unaided 
by  mechanical  devices  other  than  sutures. 

(1)  For  the  general  principles  of  intestinal  suturing,  see  Enterorrhaphy  in 
General.  (2)  Fine  silk  or  fine  chromic  gut  may  be  used  throughout.  Or  silk 
may  be  used  for  the  first  tier  and  chromic  gut  for  the  second.  This  applies 
whether  the  first  tier  includes  all  the  coats  or  only  the  mucous  membrane.  (3) 
Some  surgeons  prefer  to  use  only  interrupted  sutures  throughout  in  intestinal 
suturing— upon  the  ground  that  in  continuous  suturing  (especially  when  of 
silk)  the  size  of  the  opening  becomes  more  or  less  fixed  and  less  capable  of  the 
distention  which,  on  the  other  hand,  may  readily  occur  in  all  forms  of  inter- 
rupted sutures.  (4)  It  is  well  to  bear  in  mind  that  sometimes  Lembert  inter- 
rupted sutures  which  may  appear  to  be  near  enough  in  the  undisturbed  condi- 
tion of  the  gut  become  too  far  apart  when  it  is  distended.  (5)  No  matter  what 
form  of  suturing  be  used  for  the  first  tier,  the  second  tier  should  include  only 
the  serous,  muscular,  and,  if  possible,  part  of  the  submucous  coats — and  should 
bury  in  the  first  tier.  (6)  Difficulties  encountered  in  placing  sutures  may  be 
largely  overcome  by  seizing  the  site  to  be  sutured  with  delicate  forceps  and  thus 
causing  that  part  to  meet  the  needle  with  its  proper  aspect  rendered  prominent 
by  eversion,  inversion,  traction,  etc.  (7)  When  segments  of  unequal  size  are  to 
be  approximated  end-to-end,  the  only  way  this  can  be  done  by  simple  suturing 
is  either,  (a)  to  partially  close  the  opening  of  the  larger  gut  down  to  the  size  of 
the  smaller,  which  maybe  accomplished  by  taking  a  V-shaped  piece  out  of  the 
antimesenteric  aspect  of  the  larger  gut  and  then  suturing  together  the  edges  of 
the  V  before  making  the  junction,— or  (b)  by  cutting  the  opening  of  the  smaller 
gut  obliquely  (Wehr's  method)  instead  of  transversely,  at  the  expense  of  the 


856  OPERATIONS    UPON    THE    ABDOM1NO-PELVIC    REGION. 

free  border,  and  thus  increasing  its  size  to  match  the  larger  gut.  The  best 
methods,  however,  of  uniting  segments  of  unequal  size  are  probably  either  by 
the  Murphy  button  or  the  Maunsell  method. 


ENTERO-ENTEROSTOMY      BY      SIMPLE      CONTINUOUS      OVERHAND 
SUTURE  OF  ALL  COATS,  FOLLOWED  BY  INTERRUPTED  OR 
CONTINUOUS  LEMBERT  SUTURES  OF  OUTER  COATS. 

Description. — The  first  tier  of  suturing  is  for  approximation  and  strength 
— the  second,  for  union  of  the  serous  surfaces  and  occlusion  of  the  intestinal 
lumen. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 


Fig.602.— Entero-enterostomy  by  Simple  Continuous  Overhand  Suturing  of  All  Coats, 

FOLLOWED    BY    INTERRUPTED   OR    (CONTINUOUS)   L.EMBERT    SUTURES  OK    OUTER    COATS  : — A  method 

of  holding  the  intestine  and  introducing  the  first  tier  of  simple  continuous  overhand  suturing  of  all 
coats.     Author's  method. 

End-to-end  Approximation — Author's  Method. — (1)  Open  the  ab- 
domen— isolate  and  bring  forward  the  indicated  coil  of  intestine — press 
away  the  intestinal  contents — apply  intestinal  clamps,  proximally  and  dis- 
tally,  to  the  site  to  be  excised — and  excise  the  portion  of  intestine,  with 
or  without  the  corresponding  portion  of  mesentery  (see  Enterectomy). 
The  two  ends  of  the  intestine  are  now  brought  into  convenient  apposition 


EXTERO-EXTEROSTOMY    BY    SIMPLE    SUTURING 


857 


for  suturing,  and  are  held  in  apposition  during  the  placing  of  the  first 
tier  of  sutures.  (2)  The  first  row  of  continuous  suturing  passes  through 
all  the  coats  of  proximal  and  distal  segments  of  intestine,  and  consists 
of  a  continuous  silk  or  gut  suture  carried  upon  a  straight  needle  held  in  the 
fingers.  The  surgeon  holds  the  approximated  borders  of  the  two  coils  of 
intestine  over  the  radial  aspect  of  his  left  first  finger,  approximating  the  op- 
posite borders  with  the  left  second  finger  and  thumb  (or  holds  them  over  his 


Figs.  603-605. — Details  of  Simple  Continuous  Overhand  Suturing  of  All  Coats,  shown 
in  Fig.  602: — A,  Manner  of  knotting  and  beginning  suture,  at  a — traversing  posterior  edges  of 
intestines — and  including  lamina?  of  mesentery  at  b,  whence  the  suture  starts  to  return  ;  P..  Manner 
of  traversing  anterior  edges  of  intestines— and  ending  the  suture  at  a,  preparatory  to  knotting  ; 
C.  Manner  of  tying  final  knot  of  first  tier  of  sutures  at  a,  and  appearance  of  suture-line  and 
approximated  leaves  of  mesentery.     Author's  method. 


left  second  finger,  approximating  with  his  left  index  and  thumb).  (See  Fig. 
602.)  Four  thicknesses  of  gut  are  thus  brought  together,  two  from  the  prox- 
imal and  two  from  the  distal  end  of  the  divided  intestine.  The  adjacent 
aspects  of  the  apposed  edges  should  be  first  sutured.  (See  Fig.  603,  A.)  The 
needle  should  first  enter  at  the  antimesenteric  borders,  the  first  stitch  being  so 
placed  as  to  leave  the  free  end  of  the  suture,  after  knotting,  on  the  outside, 
which  is  done  by  beginning  the  stitch  from  without  and  then  passing  the  needle 
back  into  the  lumen  after  tying  the  first  knot.  After  the  needle  has  passed 
back  into  the  lumen  it  should  always,  in  going  toward  the  mesenteric  attach- 
ment, travel  from  within  outward  through  the  wall  of  the  intestine  on  the  right 
(nearer  the  operator)— then  from  without  inward  through  the  wall  of  the  intes- 
tine on  the  left  (further  from  the  operator) — and  so  on,  descending  toward  the 
mesenteric  aspect.  The  last  stitch,  before  beginning  the  return,  includes,  besides 
the  two  thicknesses  of  the  gut,  also  the  two  laminae  which  are  adjacent  (one 


858  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

from  the  proximal  and  one  from  the  distal  portion  of  gut) .  And  the  first  stitch, 
after  beginning  the  return,  includes,  besides  the  two  thicknesses  of  gut,  also  the 
two  laminae  of  mesentery  (one  from  the  proximal  and  one  from  the  distal  por- 
tion of  gut)  which  are  furthest  from  each  other  at  the  taking  of  the  stitch,  but 
which  will  be  brought  into  contact  by  the  stitch.  (See  Fig.  604,  B.)  The 
suturing  is  then  continued  back  to  the  antimesenteric  aspect  in  an  overhand 
stitch,  as  before — passing,  now,  from  without  inward  through  the  wall  of  the 
intestine  nearer  the  operator,  and  from  within  outward  through  the  wall  of  the 
intestine  further  from  the  operator.  When  the  last  stitch  is  reached,  its  free 
end  on  the  outer  side  is  knotted  to  the  free  end  left  on  the  outer  side  at  the  start. 


Fig.606.— Entero-enterostomy  by  Simple  Continuous  Overhand  Suturing  of  All  Coats, 

FOLLOWED    BY    INTERRUPTED    (OR    CONTINUOUS)    LEMBERT   SUTURES   OF    OUTER    C OATS  :— A  method 

of  holding  the  intestine  and  introducing  the  second  tier  of  interrupted  Lembert  sutures,  which  is  seen 
burying  in  the  first  tier  of  continuous  overhand  suturing.  The  assistant's  hands  are  held  in  pronation 
while  suturing  the  anterior,  and  in  supination  while  suturing  the  posterior  aspect. 


(See  Fig.  605,  C.)  During  the  return-row  of  suturing  care  is  taken  that  the 
stitches  do  not  penetrate  the  coats  already  whipped  together  by  the  first  row — 
which  is  easily  avoided,  as  the  edges  are  all  in  plain  view  as  each  needle-punc- 
ture is  made.  (3)  The  second  row  of  suturing  consists  of  interrupted  Lembert 
sutures  passing  through  the  serous  and  muscular,  and  probably  also  the  sub- 
mucous, coats.  The  sutures  are  silk  or  chromic  gut,  carried  upon  a  straight 
needle  held  in  the  fingers.  The  barrel  of  intestine  is  now  held  out  straight  by 
an  assistant,  who  grasps  it  about  10  cm.  (4  inches)  on  either  side  of  the  suture 
line — while  the  operator  picks  up  a  transverse  fold  of  the  gut  wall  near  the  origi- 
nal suture  line  by  means  of  delicate  forceps  held  in  his  left  hand — and  a  similar 
fold  just  beyond  the  suture-line — passing  the  needle  through  both  folds  in  the 
ordinary  Lembert  fashion.  (See  Fig.  606.)  One  half  of  the  circumference  of 
the  gut  is  sutured  from  one  side,  after  which  the  intestine  is  turned  over  and 
the  other  half  sutured  from  the  opposite  side.     The  sutures  are  inserted  in  the 


EXTERO-ENTEROSTOMY    BY    SIMPLE    SUTURING. 


859 


usual  manner  of  the  Lembert  method — the  forceps  picking  up  the  tissue  in 
transverse  folds  and  thus  drawing  it  away  from  the  opposite  wall,  thereby  mak- 
ing the  passage  of  the  suture  easier,  and  the  penetration  of  the  opposite  wall 
impossible.  Especial  care  is  necessary  as  the  diverging  lamina1  of  the  mesentery 
are  encountered,  in  order  that  each  lamina  may  be  closely  approximated  to  the 
barrel  of  its  own  segment  of  intestine  and  to  the  opposite  lamina  on  the  same 
side  of  the  intestine.     The  Lembert  sutures  should,  therefore,  be  continued  on 


Figs.  607  and  60S. — Entkroenterostomy  by  Simple  Continuous  Overhand  Suturing  of 
All  Coats,  followed  by  Interrupted  (or  Continuous)  Lembert  Sutures  of  Outer  Coats: — 
A.  Another  method  of  holding  the  intestines  and  introducing  the  first  tier  of  simple  continuous 
suturing  of  all  coats;  B.  Diagram  showing  manner  of  introducing  the  three  preliminary  traction- 
sutures.     Author's  method. 

down  to  the  very  junction  of  the  mesentery  with   the  intestine  and   slightly 
beyond. 

Note. — Instead  of  holding  the  intestines  as  above  described  during  the 
placing  of  the  first  tier  of  sutures.  >everal  methods  of  holding  them  in  apposition 
may  be  employed.  Three  interrupted  sutures  may  be  placed  and  knotted  in 
loops  as  temporary  traction-sutures — each  including  all  the  coats  of  the  two 
adjacent  walls  of  the  proximal  and  distal  segments  of  intestine — one  placed  at 
the  mesenteric  aspect — and  the  other  two  dividing  the  circumference  of  the 
severed  ends  into  three  equal  parts.  An  assistant  now  draws  these  three  loops 
in  different  directions  (which  a  single  assistant  can  do  by  hooking  them  over  his 
fingers,  if  the  loops  are  not  too  long) — whereby  two  objects  are  accomplished; 
— one-third  of  the  margins  of  each  gut  are  brought  into  contact, — and  the  mar- 
gins of  the  other  two-thirds  are  held  out  of  the  way  (and  thus  the  penetration  of 
their  wall  by  the  needle  rendered  impossible).  While  held  in  this  manner,  the 
adjacent  margins  of  each  third  are  whipped  together  by  a  continuous  overhand 


S6o 


OPERATIONS    UPON    THE    ABDOMINO-PELYIC    REGION. 


suture — after  which  the  temporary  traction-loops  are  cut  and  withdrawn  (or 
may  he  tied  and  cut  short,  as  permanent  interrupted  sutures  reinforcing  the 
continuous  ones).     (See  Figs.  607  and  608.)    The  second  tier  of  interrupted 


Fig.  609. — Lateral  Intestinal  Approximation  by  Simple  Continuolts  Overhand 
Suturing  of  all  Coats,  followed  by  Interrupted  (or  Continuous)  Lembert  Sutures 
of  Outer  Coats: — I. — Manner  of  placing  posterior  sutures:  A,  Showing  manner  of  placing 
sutures  along  posterior  aspect  and  at  ends  of  incisions;  R,  Manner  of  holding  end  of  intestine 
between  thumb  and  index  while  placing  sutures;  C,  Manner  of  holding  the  ends  with  temporary 
traction-sutures   passed   through  outer  coats,   while  invaginating. 

Lembert  sutures  is  applied  as  just  described.     Or' the  traction  sutures  may  be 
retained  until  the  Lemberts  are  placed,  to  draw  the  edges  parallel. 

Lateral  Approximation. — (1)  Excise  the  indicated  portion  of  intestine, 
with  or  without  the  corresponding  piece  of  mesentery,  as  described  under 
Enterectomy.  (2)  The  proximal  and  distal  free  ends  of  the  intestine  are  now 
each  closed  by  one  of  the  following  methods; — (a)  Hold  the  free  end  of  the  in- 
testine between  the  left  thumb  and  index,  and  whip  together  the  parallel  walls 
by  an  overhand  continuous  suture  of  all  the  coats — followed  by  an  invagination 
of  this  line  of  suturing  by  means  of  a  line  of  interrupted  or  continuous  Lemberts 
(see  Fig.  609,  B). — (b)  Pass  a  traction-suture  at  the  mesenteric  aspect,  and 
another  at  the  antimesenteric  aspect,  near  to  but  not  quite  at  the  free  margins — 
and,  while  these  are  drawn  upon  by  an  assistant,  whip  the  free  edges  together  as 
above — and,  while  further  drawing  upon  them,  invert  the  first  suture-line  with 
a  probe,  and  place  a  row  of  Lemberts  so  as  to  permanently  invaginate  the  first 
tier  (see  Fig.  609,  C). — (C)   The  free  ends  of  the  intestine  may  be  closed  by  a 


ENTERO-EXTEROSTOMY    BY    SIMPLE    SUTURING. 


86l 


continuous  overhand  suture  of  all  the  coats,  while  the  walls  of  the  intestine  are 
still  held  in  contact  by  the  special  forceps  grasping  the  whole  width  of  intestine, 
and  along  which  they  have  been  divided  in  the  operation  of  enterectomy — fol- 
lowed by  an  invaginating  Lembert  tier,  as  above  (see  Fig.  610,  B). — (d)  The 
free  end  of  each  piece  of  intestine  may  be  gathered  together  by  an  ordinary 
purse-string  suture — and  this  first  tier  then  further  invaginated  by  a  second 
tier  of  Lemberts,  as  above  described  (see  Fig.  610,  C).  (3)  Having  closed  the 
open  ends  of  the  gut,  approximate  these  ends  so  that  they  overlap  about  5  to 
7.5  cm.  (2  to  3  inches),  with  their  antimesenteric  aspects  in  contact — and  have 
an  assistant  hold  them  in  this  position.  The  lateral  aspects  of  the  coils  of  intes- 
tine may  be  held  in  approximation  by  the  hands  of  an  assistant  during  the  sutur- 
ing;— but  the  contact  can  be  made  more  satisfactory,  and  the  likelihood  of  leakage 


Fig.  610. — Lateral  Intestinal  Approximation  by  Simple  Continuous  Overhand 
Suturing  of  all  Coats,  followed  by  Interrupted  (or  Continuous)  Lembert  Sutures  of 
Outer  Coats: — II. — Manner  of  placing  anterior  sutures.  A,  Showing  manner  of  carrying 
suture  around  ends  and  along  anterior  aspect  of  incisions;  B,  Manner  of  holding  end  of  intestine 
with  clamp-forceps  while  suturing;  C,  Manner  of  closing  end  of  intestine  with  purse-string  suture 
preparatory  to  placing  final  tier  of  end-sutures. 

less,  by  the  use  of  special  intestinal  clamps  (Fig.  611).  (4)  Place  a  tier  of  con- 
tinuous Lembert  suturing  of  gut,  carried  upon  a  curved  needle  held  in  a  needle- 
holder,  along  what  will  be  the  posterior  line  of  union  between  the  serous  sur- 
faces— extending  the  line  of  suturing  out  at  either  end,  in  a  somewhat  elliptical 
form,  beyond  the  limits  of  the  future  incision — leaving  one  end  of  the  suture, 
after  knotting,  long  and  free — and  the  other  end,  also  after  half  knotting,  long 
and  threaded  upon  the  needle.  (See  Fig.  609.)  (5)  Incisions  in  the  long  axis 
of  both  pieces  of  intestine  are  now  made  opposite  each  other  in  the  correspond- 
ing aspects  of  the  guts — and  sufficiently  far  from  the  posterior  suture-line  to 
leave  two  free  edges  for  suturing — and  equidistant  from  what  will  form  the 
anterior  suture-line  of  the  serous  surfaces.  These  incisions  will  begin  and  stop 
short  of  reaching  the  outer  limits  of  the  surrounding  Lembert  suture-line  which 
will  enclose  them.     (6)  The  corresponding  free  margins  of  the  wounds  are  now 


862 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


sutured  with  continuous  overhand  silk  suture,  carried  in  a  curved  needle  held  in 
a  needle-holder.  Begin  the  suturing  at  the  right  end  of  the  posterior  aspect 
(furthest  from  operator) — knot  the  suture  and  leave  one  end  of  the  thread  free — 
and  continue  the  suturing  toward  the  operator,  until  the  posterior  lips  are 
united.  Having  reached  the  limit  of  the  posterior  aspect  of  the  opening,  the 
direction  of  the  suturing  now  changes  and  is  made  to  traverse  the  anterior  aspect 
of  the  wound,  similarly  whipping  together  the  anterior  lips  of  the  intestinal 
incisions  from  left  to  right,  away  from  the  operator — until  the  point  of  begin- 
ning is  reached,  when  the  end  from  which  the  needle  lias  just  been  withdrawn  is 
knotted  to  the  end  previously  left  free — thus  completely  approximating  the  lips 
of  the  openings  throughout.     (7)   The  threaded  needle  of  the  original  serous 


Fig.  6n. — Lateral  Intestinal  Anastomosis  by  Simple  Continuous  Overhand 
Suture  of  all  Coats,  followed  by  Interrupted  (or  Continuous)  Lembert  Suturing  of 
Outer  Coats,  Aided  by  Intestinal  Clamps: — The  posterior  seromuscular  suture  is  shown 
with  knot  at  its  right  end  and  needle  on  its  left  end; — The  inner  through-and-through  suture  is 
seen,  with  its  right  end  knotted  and  its  left  end  free. 

suture,  which  had  been  temporarily  dropped,  is  now  taken  up — and  this  line  of 
continuous  Lemberts  is  carried  on  around  the  outside  of  the  line  uniting  the 
edges,  at  the  same  distance  from  their  edge  as  the  posterior  serous  line  passed — 
until  the  free  end  of  line  of  serous  suture,  left  at  starting,  is  reached,  when  they 
are  knotted  together, — which  completes  the  union  between  the  intestines. 
(See  Fig.  610.)     (8)   The  mesentery  is  now  sutured  as  indicated. 

Lateral  Anastomosis. — The  operation  is  here  performed  in  a  precisely 
similar  manner  to  the  last  (Lateral  Approximation) — omitting  the  excision  of 
any  portion  of  the  intestinal  canal— the  antimesenteric  aspects  of  the  gut  being 
brought  into  apposition.  Care  is  taken  that  the  intestinal  coils  are  not  twisted 
out  of  their  natural  relations.     (See  Fig.  612.) 


ENTERO-ENTEROSTOMY    BY    SIMPLE    SUTURING. 


863 


Note. — In  Lateral  Approximation  and  Lateral  Anastomosis,  in  order  to 
prevent  bagging,  and  sagging  away  of  the  intestines  near  the  site  of  union,  it  is 
well  to  slightly  scarify  and  suture  (or  suture  alone)  the  free  portions  of  the  in- 
testine together  for  about  2.5  cm.  (1  inch)  on  either  side  of  the  union. 

End-in-side  Implantation.— (1)  Following  excision  (for  example,  of  the 
caecum)  the  free  end  of  the  intestine,  the  lateral  aspect  of  which  is  to  receive  the 
implanted  gut,  is  closed  by  a  double  line  of  suturing  in  precisely  the  same  man- 
ner as  described  under  Lateral  Intestinal  Approximation.     (2)  An  incision  is 


Fig.612  —  Lateral  Intestinal  Anastomosis  by  Simple  Continuous  Overhand  Suturing 
of  All  Coats,  followed  by  Interrupted  (or  Continuous)  Lemberi  Sutures  of  Cuter 
Coats  : — A,  Simple  continuous  overhand  suture  of  all  coats;  B,  Continuous  Lembert  suture  of  outer 
coats.  The  intestinal  current  passes  as  indicated  by  arrows,  "short-circuiting"  the  cancerous 
growth. 

made  near  the  end  of  the  invaginated  gut  corresponding  with  the  end  of  gut  to 
be  implanted.  (3)  The  open  end  of  the  gut  which  is  to  be  implanted  (usually 
of  smaller  calibre)  is  now  brought  into  apposition  with  the  incision  upon  the 
antimesenteric  aspect  of  the  gut  which  is  to  receive  the  implantation,  at  about 
5  cm.  (2  inches)  from  its  sutured  end — and  held  in  contact  by  an  assistant 
throughout  the  operation.  A  line  of  continuous  overhand  silk  sutures,  carried 
upon  a  curved  needle  held  in  a  needle-holder,  is  placed  through  all  the  coats 
of  both  pieces  of  the  intestine,  in  exactly  the  same  manner  as  described  under 
the  Lateral  Approximation  operation,  the  difference  in  the  direction  of  apposi- 
tion of  the  two  pieces  of  gut  in  the  end-in-side  implantation  making  no  differ- 
ence in  the  manner  of  application  of  the  sutures.  Interrupted  sutures  may 
be  used  instead  of  the  continuous.  The  margins  of  the  end-opening  in  one 
piece  of  intestine  and  the  lateral  openings  in  the  other  are  thus  brought  together 
throughout.  (4)  A  continuous  or  interrupted  Lembert  suture  is  now  carried 
through  the  serous  and  muscular  (and  probably  into  the  submucous)  coats  of 
the  two  pieces  of  intestine,  in  such  a  manner  as  to  surround  the  first  line  of 
through-and-through  suture  in  a  somewhat  elliptical  fashion.  (5)  The  mesen- 
teric borders  are  sutured  in  such  a  manner  as  to  leave  no  opening  through  which 
coils  of  intestine  may  pass.     (See  Fig.  613.) 


864 


OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 


Note. — (i)  The  same  ultimate  method  of  union  may  be  accomplished  in  a 
somewhat  different  order.  The  serous  surface  near  the  free  margins  of  the 
smaller  gut  may  be  attached,  by  Lembert  sutures,  to  the  serous  surface  of  the 
invaginated  gut,  in  such  a  position  as  to  correspond  with  the  future  opening — 
the  attachment  being  first  along  the  posterior  aspect,  as  in  Lateral  Approxima- 
tion. An  opening  is  then  made  by  incision  into  the  invaginated  end  corre- 
sponding with  the  partly  attached  free  end  of  intestine.  The  free  edges  of  the 
opening  are  then  united  throughout  by  continuous  silk  suture — after  which 
the  continuous  or  interrupted  Lembert  suture  of  the  serous  surfaces  is  carried 
around  the  anterior  aspect  of  the  opening — thus  completing  the  union.  (2) 
The  process  of  union  may  be  mechanically  aided  by  using  Senn's  rubber  band 
as  a  temporary  ring  within  the  segment  of  intestine  to  be  implanted — where  it 
is  held  for  a  time  by  gut  sutures — and  is  afterward  liberated  and  passed  down 
the  canal. 


Fig. 613.— End-in-side  Intestinal  Implantation  by  Simple  Continuous  (or  Interrupted) 
Overhand  Suturing  of  All  Coats,  followed  by  Interrupted  (or  Continuous)  Lembert 
Sutures  of  Outer  Coats  :— A,  Ileum  ;  B,  Ascending  colon  ;  C,  C,  Interrupted  sutures  of  all  coats 
of  both  intestines;  D,  Continuous  suture  of  outer  coats. 


END-TO-END    ENTERO-ENTEROSTOMY  BY  PERFORATING  MATTRESS 

SUTURES  KNOTTED  IN  THE  LUMEN. 

connell's  method. 

Description. — Interrupted  mattress  sutures  are  so  carried  through  all  the 
coats  of  the  intestine  and  tied  as  to  bring  all  the  knots  within  the  intestinal 
lumen. 


END-TO-END    ENTERO-ENTEROSTOMY. 


865 


Preparation— Position— Landmarks— Incision.— As  for  median  abdom- 
inal section. 

Operation. — (1)  The  mesenteric,  the  most  important,  suture  is  placed  in 
the  following  manner  (Fig.  614,  A) ; — The  needle  (calculating  that  the  stitches 
are  3  mm.  (^  inch)  apart  and  the  same  distance  from  the  free  edge  of  the 
intestine)  passes  through  all  the  coats  of  one  end  of  the  intestine,  from  within 
outward — into  the  free  space  between  intestine  and  leaf  of  the  mesentery — 
through  this  left  from  within  outward — over  to  the  opposite  leaf  of  the  mesen- 
tery— through  this  from  without  inward — through  the  free  space  between 
mesenteric  leaf  to  the  intestine — through  all  the  coats  of  the  other  end  of  the 
intestine,  from  without  inward — thence,  returning,  the  needle  and  thread  take 
a  corresponding  course — to  emerge  parallel  with  the  thread  of  entrance,  within 
the  lumen  of  the  original  end  of  the  intestine — ready  to  be  tied.  This  stitch 
approximates  the  leaves  of  the  mesentery  to  the  barrel  of  the  intestine,  and  the 
two  ends  of  the  intestine  to  each  other.  (2)  Four  traction-sutures  are  inserted, 
dividing  the  intestinal  circumferences  into  thirds,  for  the  purpose  of  aiding  in 
the  mechanical  insertion  of  the  remaining  mattress  sutures.     Two  are  placed 


Fig.  614. — End-to-end  Entero-enterostomy  by  Connell's  Method: — I. — A,  Mes- 
enteric stitch;  B,  B,  Interrupted  mattress  sutures  through  all  coats  of  both  ends  of  intestine, 
knotted  within  the  lumen. 

as  indicated  at  A  and  B,  Fig.  615.  These  pass  through  all  the  coats  of  both 
ends  of  the  intestine,  and  are  separated  from  each  other  one-third  of  the  cir- 
cumference of  the  intestine.  By  traction  upon  them  the  walls  of  the  intervening 
third  of  the  end  of  each  piece  of  intestine  are  put  upon  the  stretch  and  made 
parallel,  thus  rendering  them  easy  of  access  for  the  placing  of  the  sutures  for 
that  third.  Upon  the  completion  of  this  third,  traction-suture  B  is  carried 
toward  the  position  formerly  occupied  by  traction-suture  A,  and  traction-sutures 
C  and  D  are  brought  together  and  drawn  in  the  opposite  direction— which  will 
make  the  second  third  of  the  intestinal  margins  occupy  the  position  originally 
occupied  by  the  first  third.  The  last  third  is  brought  into  line  and  sutured  in 
the  same  way,  with  the  modification  to  be  mentioned.  (3)  The  sutures  pass 
through  all  the  coats  of  both  of  the  intestinal  ends,  as  shown  in  Fig.  614,  B,  B, 
and  in  Fig.  615,  E,  and  are  knotted  as  soon  as  placed.  (4)  The  suturing  is 
thus  rendered  very  easy  until  the  circumference  has  been  nearly  traversed. 
In  the  suturing  of  the  last  third  there  is  greater  mechanical  difficulty,  owing  to 
the  lessened  working-room.  It  is  best  to  place  the  sutures  of  this  third  before 
tying  them.     When  this  is  done,— all  are  tied  except  the  last  one.     The  closure 

55 


866 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


A- 


A- 


^ 


Fig.  615. — End-to-end  Entero-enterostomy  by  Connell's  Method: — II. — A,  B, 
Traction-sutures  drawing  margins  of  first  thirds  of  intestines  parallel;  C,  D,  Traction-sutures 
to  be  used  in  parallelling  remaining  thirds  of  intestinal  margins;  E,  One  of  the  interrupted  mattress 
sutures  placed,  ready  to  be  tied. 


Fig.  616. — End-to-end  Entero-enterostomy  by  Connell's  Method: — III. — Insertion 
of  needle,  eye-end  first,  through  interval  between  sutures — projecting  through  interval  left  by 
yet  untied  last  mattress  suture — the  threads  of  which  are  within  loop  made  by  needle  and  its 
thread,  ready  to  be  drawn  out  through  place  of  entrance  of  eye-end  of  needle. 


ENTERO-ENTEROSTOMY    BY    CZERNY-LEMBERT    SUTURE. 


867 


represented  by  the  last  stitch  is  accomplished  in  one  of  two  ways: — (a)  The 
author  of  the  technic  completes  the  tying  of  the  last  mattress  stitch  by  insert- 
ing a  threaded  needle,  eye  first,  between  two  sutures  of  an  opposite  aspect  of 
the  circumference  (Fig.  616) — the  eye-end  of  the  needle  is  protruded  through 
the  opening  left  by  the  last  stitch — the  two  threads  composing  this  last  stitch 
are  then  carried  through  the  noose  made  by  the  shaft  of  the  needle  and  its 
double  thread — after  which  the  needle  is  withdrawn,  carrying  the  two  threads 
of  the  last  stitch  with  it — which  are  then  knotted  and  cut  short — during  which 
process  the  walls  of  the  lumen  are  approximated — and  regain  their  normal 
relation  upon  the  cutting  of  the  knot — the  serosae  separated  by  the  entrance 
of  the  eye-end  of  the  needle  also  coming  together,  (b)  The  opening  repre- 
sented by  the  last  suture  can,  however,  be  more  simply  closed  by  a  sero-mus- 
cular  mattress  suture,  as  suggested  by  Gould,  Fig.  617. 


Fig.  617. — End-to-end  Entero-enterostomy  by  Connell's  Method: — IV. — Gould's 
method  of  closing  interval  left  by  last  mattress  suture  in  Connell's  operation,  by  means  of  a  sero- 
muscular  mattress   suture.     (Redrawn   from   Gould.) 

ENTERO-ENTEROSTOMY   BY   THE   CZERNY-LEMBERT   INTERRUPTED 

SUTURE. 

Description. — The  edges  of  the  mucous  coat  are  brought  together  by  the 
interrupted  Czerny  suture,  which  passes  through  this  coat  alone — followed 
by  the  ordinary  interrupted  Lembert  suture  through  the  serous,  muscular,  and 
part  of  the  submucous  coats.  The  method  of  application  is  the  same  as  that 
described  under  " Enterorrhaphy  by  the  Czerny-Lembert  interrupted  suture" 
page  844). 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — (1)  The  ends  of  the  intestines  are  held  in 
convenient  apposition — as  described  in  the  same  operation  by  the  last  method. 
The  suture  consists  of  silk  or  gut,  carried  upon  a  curved  needle  held  in  a  needle- 
holder.  The  manner  of  manipulating  is  described  under  Enterorrhaphy  by 
this  method.  The  sutures  are  interrupted  and  are  introduced  and  knotted 
from  within,  in  the  Czerny  fashion.  When  the  circular  enterorrhaphy  is 
almost  completed,  the  last  suture  or  two  are  somewhat  more  difficult  to  place, 
owing  to  the  tendency  of  the  knot  to  remain  upon  the  outer  aspect — which  may 
be  allowed,  as  this  tier  will  be  subsequently  buried  in — or,  better,  maybe  in- 


868  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

vaginated  within  the  lumen  of  the  gut  by  a  probe.  (See  Fig.  618,  B.)  (2) 
Having  completed  the  first  or  mucous  tier  of  sutures,  the  second  or  outer  tier 
of  interrupted  Lemberts  is  carried  through  the  serous,  muscular,  and  part  of 
the  submucous  coats — and  consists  of  silk  or  gut  carried  upon  a  straight  needle 
held  in  the  fingers — and  is  introduced  in  every  respect  as  the  interrupted 
Lemberts  are  introduced  in  the  method  just  described.     (See  Fig.  618,  A.) 

Lateral  Approximation  —Lateral  Anastomosis — End-in-side  Implan- 
tation.— The  methods  of  holding  the  segments  of  intestines  in  contact  and  the 
general  principles  of  completing  the  entero-enterostomy  are  the  same  as  in  the 
corresponding  operations  by  the  overhand  continuous  suture  of  all  the  coats, 
followed  by  the  interrupted  or  continuous  Lembert  suturing  of  the  outer  coats 


Fig.  618 — Entero-enterostomy  by  the  Czerny-Lembert  Interrupted  Siture:  —  B, 
Czerny  interrupted  suture  passing  through  mucous  and  part  of  submucous  coats — applied  from 
within  ;  A,  Lembert  interrupted  suture  passing  through  serous,  muscular,  and  part  of  submucous 
coats — applied  from  without. 

— with  the  exception  that  the  first  tier  of  suturing,  in  the  present  method,  is  of 
the  mucous  coat  alone,  and  the  second  tier  of  the  outer  coats. 

Note. — The  Czerny  suture  should  include  some  of  the  submucous  coat,  to 
hold  well. 

ENTERO-ENTEROSTOMY  BY  HALSTED'S  METHOD  OF  INTERRUPTED 

MATTRESS  SUTURES. 

Description. — The  opposite  intestinal  walls  are  brought  and  held  in  con- 
tact by  a  single  tier  of  the  characteristic  Halsted  mattress  or  quilt  interrupted 
suture,  passing  through  the  serous,  muscular,  and  part  of  the  submucous  coats. 
The  general  method  of  application  of  this  form  of  suturing  to  circular  enteror- 
rhaphy  is  identical  with  the  method  described  under  "Enterorrhaphy  by 
Halsted's  interrupted  mattress  suture"  (page  845).  In  the  end-to-end  ap- 
proximation, six  "  presection  sutures  "  are  used  additionally. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — The  details  of  the  application  of  the 
Halsted  sutures  in  performing  entero-enterostomy  without  artificial  aids  are 
precisely  the  same  as  employed  in  the  Halsted  operation  of  entero-enteros- 
tomy by  means  of  an  inflatable  rubber  cylinder.  The  technic  of  the  opera- 
tion, therefore,  will  be  found  under  the  latter  head — and  may  be  used  here, 


ENTERO-ENTEROSTOMY    BY    HALSTED    SUTURE.  869 

omitting  the  use  of  the  cylinder,  and  accomplishing  the  junction  of  the  seg- 
ments of  intestine  by  end-to-end  approximation  by  means  of  simple  suturing. 
The  ends  of  intestine  to  be  approximated  are,  in  this  case,  simply  held  in  con- 
venient contact  by  an  assistant — the  steps  are  otherwise  the  same  as  in  the 
more  elaborate  operation. 

Lateral  Approximation. — (1)  Having  excised  the  required  portion  of  in- 
testine, the  free  ends  of  both  pieces  of  gut  are  closed  by  a  single  row  of  the  Hal- 
sted  interrupted  mattress  sutures,  introduced  in  the  Halsted  manner  (see  Fig. 
619).  (2)  The  antimesenteric  aspects  of  the  two  pieces  of  intestine  are  then 
held  in  contact  at  about  5  cm.  (2  inches)  from  their  free  ends.  A  posterior  row 
of  interrupted  Halsted  sutures  is  now  placed  along  the  line  which  is  to  form  the 
posterior  boundary  of  the  intestinal  junction,  generally  being  about  eight  in 
number.  At  either  end  of  this  line  two  additional  sutures  are  placed,  coming 
slightly  more  forward,  in  continuation  of  the  posterior  longitudinal  line  in  a  for- 
ward curve.  All  of  these  sutures  are  first  placed  before  any  are  tied — and  then 
all  are  tied  before  placing  the  final  ones.  (See  Fig.  619.)  The  anterior  row  of 
interrupted  sutures  is  now  similarly  placed  before  any  are  tied — and  so  planned 
as  to  form  an  elliptical  figure  surrounded  by  sutures.  (3)  The  sutures  forming 
the  anterior  row  are  now  drawn  apart  in  the  center  (without  drawing  any  of 
them  entirely  out),  and  a  longitudinal  opening  is  made  in  each  gut,  midway 
between  the  two  lines  of  sutures  and  not  extending  quite  to  the  ends  (so  as  to  be 


-  c 


Fig.  619.— Lateral  Intestinal  Approximation  by  Halsted's  Quilt  Sutures: — A,  Show- 
ing posterior  line  of  sutures,  and  end  sutures  beginning  to  outline  an  ellipse;  B,  Line  of  future  in- 
cision into  intestine,  corresponding  to  similar  line  on  opposite  intestine  ;  C,  C,  Ends  of  intestines 
closed  by  same  kind  of  sutures.     t.  Modified  from  Halsted.) 


well  included  within  the  enveloping  line  of  sutures).  (See  Fig.  620.)  (4)  The 
sutures  forming  the  anterior  line  are  now  knotted — thus  completely  apposing 
the  site  of  union  and  enclosing  the  common  opening  between  proximal  and 
distal  segments.     (5)  The  edges  of  the  mesentery  are  treated  as  indicated. 

Lateral  Anastomosis. — The  operation  is  here  performed  in  every  respect 
exactly  as  in  Lateral  Approximation,  except  that  no  excision  of  intestinal  tract 
is  done — and,  consequently,  no  invagination  of   free   ends  of  intestine  is  re- 


870 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


quired.  Two  convenient  antimesenteric  aspects  of  intestine  are  brought  to- 
gether and  the  union  made  at  once  by  the  method  of  suturing  just  described. 
End-in-side  Implantation. — If  this  somewhat  unusual  operation  be  called 
for,  it  is  accomplished  in  the  following  manner; — the  free  end  of  the  bowel  to  be 
implanted  is  brought  into  contact  with  the  antimesenteric  aspect  of  the  portion 
of  bowel  to  receive  the  implantation  (the  free  end  of  which  has  been  closed  as 
in  Lateral  Approximation) — while  held  in  this  relation,  the  interrupted  Hal- 
sted  sutures  are  placed,  passing  from  just  beyond  the  edge  of  the  opening  in  the 
latter  piece  of  bowel,  to  just  beyond  the  free  edge  of  the  former  piece,  and  back 
to  the  latter  piece — thus  drawing,  by  means  of  the  loop,  the  inverted  edge  of  the 


Fig. 620— Lateral  Intesi  inal  Approximation  by  Halsted's  Interrupted  Quilt  Sutures: 
—  Showing  all  the  posterior  and  half  the  end  sutures  tied — and  the  anterior  sutures  in  position  to  be 
tied.     The  two  corresponding  intestinal  incisions  are  seen.     (Modified  from  Halsted.) 

free  end  of  the  bowel  above,  down  upon  the  inverted  edge  forming  the  incised 
opening  in  the  bowel  below — approximating  serous  surfaces  entirely  around 
the  opening  by  the  tying  of  the  knots. 


ENTERO-ENTEROSTOMY    BY    MAUNSELL'S    INVAGINATION    METHOD. 

Description. — In  intestinal  joinings  made  by  this  special  method  of  simple 
suturing  a  temporary  window  is  cut  in  the  intestinal  tract,  near  one  of  the  two 
sites  to  be  united  (always  in  the  larger  piece  of  gut) — and  through  this  opening 
the  two  ends  of  intestine  are  temporarily  invaginated  by  means  of  traction- 
sutures.  The  free  edges  of  gut,  brought  concentrically  through  the  window, 
are  now  united  by  interrupted  sutures — after  which  they  are  drawn  back  into 
their  normal  position  and  the  window  is  closed  by  suturing — thus  completing 
the  operation. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — (1)  Having  brought  the  coil  of  intestine 
into  the  field  of  operation,  excise  the  indicated  portion,  together  with  the  cor- 


ENTERO-ENTEROSTOMY    BY    MAUNSELLS    METHOD.  87 1 

responding  V-shaped  part  of  the  mesentery — and  bring  together  the  edges  of 
the  mesentery  with  gut  sutures.  (2)  Two  horse-hair  sutures  (or  silk)  are  now 
introduced,  which  are  temporarily  left  long  and  serve,  primarily,  as  traction- 
sutures — after  which  they  are  cut  short  and  serve  as  two  of  the  permanent 
sutures.  The  first  is  placed  at  the  antimesenteric  aspect — the  needle  being 
made  to  penetrate  all  the  coats  of  the  proximal  intestine,  near  its  free  border, 
from  within  outward — then  all  the  coats  of  the  distal  segment  of  gut  at  a  cor- 
responding point,  but  now  from  without  inward.  (See  Fig.  621.)  This  suture 
is  then  knotted  upon  the  inner  side,  one  thread  being  cut  short,  the  other  left 
temporarily  long  as  a  traction-suture.  The  second  suture,  somewhat  more 
complicated,  is  placed  at  the  mesenteric  aspect — beginning  with  that  segment 
of  gut  of  larger  calibre  (which  becomes  the  intussuscipiens),  the  needle  passes 
from  within  the  lumen  of  intestine  outward,  penetrating  the  intestine  near  its 
free  border  and  entering  the  triangular  space  where  the  two  laminae  of  the 
mesentery  separate  to  embrace  the  barrel  of  the  intestine — then  going  through 
the  corresponding  lamina  of  that  side  of  the  intestine,  is  carried  across  to  the 
opposite  segment  of  gut  (which  is  to  become  the  intussusceptum),  there  pene- 
trating, from  without  inward,  the  lamina  of  the  mesentery  of  the  same  side — 
and,  passing  onward,  pierces  the  corresponding  wall  of  intestine,  emerging 
upon  its  inner  aspect — crosses  thence  to  the  opposite  side  of  the  same  segment 
of  gut — pierces  its  wall  from  within  outward,  passing  through  the  correspond- 


Fig.62I.— ENTERO-ENTEROSTOMY  BY    MAUNSELL'S    INVAGINATION'    METHOD— PREPARATORY   TO 

Invagination  :— A,  Window  in  antimesenteric  aspect  of  intussuscipiens;  B,  Manner  of  placing  the 
antimesenteric  traction-suture  ;  C,  Manner  of  placing  the  mesenteric  traction-suture. 

ing  lamina  of  mesentery  of  that  side — thence  across  to  the  opposite  segment  of 
gut — where  it  pierces,  from  without  inward,  the  lamina  of  the  mesentery  of  the 
same  side — passing  thence  onward  and  emerging  in  the  lumen  of  that  segment 
of  gut  at  which  the  suture  was  started.  This  important  suture  is  now  drawn 
tight,  thus  approximating,  by  the  peculiar  manner  of  its  passage,  the  laminae 
of  the  mesentery  closely  to  the  barrel  of  the  two  segments  of  intestine  at  their 
most  unprotected  sites.  Its  knot  having  been  tied  on  the  inner  side,  one  thread 
is  cut  short  and  one  left  temporarily  long  as  a  traction-suture.  (3)  A  tempo- 
rarv  window  is  now  made  in  the  segment  of  intestine  of  larger  calibre,  inde- 
pendently of  its  being  proximal  or  distal.  If  both  pieces  are  of  the  same  size, 
the  window  is  generally  made  in  the  proximal  portion.  The  opening  is  made 
upon  the  antimesenteric  aspect  of  the  intestine,  in  the  form  of  a  longitudinal 
slit  of  about  4  cm.  (1$  inches)  in  length,  beginning  about  2.5  cm.  (1  inch) 
from  the  divided  end  of  the  gut  and  extending  in  the  opposite  direction.  This 
slit  is  often  made  by  pinching  up  a  fold  of  intestine  longitudinally,  between  the 


872 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


left  thumb  and  index,  passing  a  knife  through  it  and  cutting  upward — but  as 
this  is  very  uncertain  and  inaccurate,  it  is  best  to  have  an  assistant  so  hold  the 
intestine  as  to  separate  its  walls  and  then  make  the  slit  by  a  controlled  stab-like 
incision  with  a  sharp,  narrow  bistoury,  increasing  its  dimensions  with  the  same 
instrument  or  with  a  pair  of  scissors — or,  even  better  still,  carefully  catch 
the  antimesenteric  aspect  of  the  intestine  with  two  forceps,  about  1.3  cm. 
(J  inch)  apart,  raising  a  transverse  ridge,  which  is  cut  with  scissors  in  the 
long  axis  of  the  bowel,  after  which  one  blade  of  the  scissors  is  intro- 
duced and  the  opening  enlarged.  (4)  A  pair  of  forceps  is  introduced 
through  the  window  and  grasps  first  one  and  then  the  other  of  the  traction- 
sutures,  drawing  them  out  through  the  opening.  While  the  intestines  are 
steadied  in  the  left  hand,  the  traction-sutures  are  drawn  upon,  until  the  free  end 
of  the  segment  of  gut  further  from  the  window  is  drawn  into  the  lumen  of  the 
gut  containing  the  window — the  free  edge  of  the  latter  being  turned  inward  and 
invaginated  by  the  opposite  segment  as  it  enters — the  process  of  invagination 
continuing  until  the  free  ends  of  both  emerge  at  the  window  as  two  concentric 


#0 
TV  I 


■  y 


Fig.  622.— Entero-enterostomy  by  Maunsell's  Invagination  Method— the  Invagina- 
tion Accomplished  : — A,  Window  in  intussuscipiens  ;  B,  Concentric  ends  of  two  pieces  of  intestine 
of  equal  size;  C,  Antimesenteric  traction-suture ;  D,  Mesenteric  traction-suture;  E,  Edges  of  mesen- 
tery sutured. 

circles,  which  are  drawn  sufficiently  far  out  through  the  window  for  subsequent 
manipulations.  Both  peritoneal  surfaces  will  thus  be  in  contact.  (See  Fig. 
622. j  (5)  While  the  ends  of  the  intestines  are  held  upward  and  away  from  the 
opening  by  the  traction-sutures  in  the  hands  of  an  assistant,  a  long  needle 
threaded  with  horsehair  (or  silk)  is  passed  straight  across  the  concentric  circles 
about  midway  between  the  two  traction-sutures,  passing  through  all  the  coats 
of  the  four  thicknesses  of  intestines  at  about  5  mm.  (fV  inch)  from  the  free 
borders.  After  the  passage  of  the  needle,  leaving  a  long  piece  of  suture  at 
either  side,  the  suture  is  caught  with  forceps  at  the  center  of  the  opening  of  the 
concentric  guts  and  drawn  upward  and  outward  a  short  distance  and  cut. 
Each  suture  is  then  tied  over  the  free  borders  of  the  two  thicknesses  of  gut 
embraced  by  it.  Thus  about  twenty  (or  more  if  needed)  sutures  are  placed  at 
equidistant  sites  by  the  passage  of  ten  lengths  of  horsehair  (or  silk) — and  are 
tied  and  cut.     The  two  long  ends  of  the  traction-sutures  are  now  cut  short. 


ENTERO-ENTEROSTOMY  BY  MAUNSELL'S  METHOD.  873 

(If  they  have  been  placed  at  inconvenient  sites,  in  relation  with  the  other 
sutures,  they  may  be  cut  out  and  removed.)  (6)  By  gentle  traction  in  the 
reverse  direction  the  invagination  is  reduced — the  intestines  now  forming  one 
continuous  length.  (7)  The  window  is  then  closed  by  continuous  (or  inter- 
rupted) Lembert  sutures  (see  Fig.  623),  thus  completing  the  operation. 

Comment. — (1)  The  above  method  is  an  imitation  of  nature's  successful 
manner  of  performing  enterorrhaphy,  namely,  by  invagination  and  sloughing. 
(2)  Maunsell  used  horsehair — others  have  used  silk  and  silkworm-gut.  (3) 
By  suturing  the  edges  of  the  excised  mesentery  before  rather  than  after  uniting 
the  intestines  there  is  less  danger  of  further  separating  the  laminae  of  the  mesen- 
tery. (4)  At  the  end  of  the  operation  the  serous  surfaces  should  be  in  contact 
— and  all  of  the  knots  at  the  end  of  the  intestines  should  be  within  the  gut.  In 
thin-walled  guts  there  is  a  tendency  for  the  knots  and  threads  not  to  be  so  well 
buried  as  in  the  thicker  walls.  (5)  The  sutures  may  be  passed  through  the 
walls  of  the  concentric  guts  in  the  ordinary  manner  and  tied  one  by  one,  in- 
stead of  in  the  above  manner.     (6)  The  sutures  should  not  be  tied  too  tightly. 


Fig.  623,  —  Entero-enterostomy  by  Maunsell's  Invagination  Method  — the  Invagi- 
nation Reduced:— A,  External  view  of  suture-line;  B,  Closing  the  window  with  interrupted 
Lemberts. 

(7)  This  is  an  instance  of  using  a  single  layer  of  through-and-through  sutures 
in  intestinal  work — but  practical  experience  has  proved  the  method  a  good  one. 
To  avoid  the  possibility  of  drainage-infection  of  the  peritoneum  by  the  sutures 
which  pass  through  all  the  coats,  some  surgeons  place  additional  interrupted 
Lembert  sutures  outside  of  the  regular  row.     Fine  gut  may  be  thus  used. 

Where  Segments  of  Intestines  of  Unequal  Size  are  to  be  United  End- 
to-end. — (1)  The  traction-suture  through  the  mesenteric  borders  is  introduced 
in  the  above  manner.  A  second  traction-suture  is  introduced  in  precisely  the 
same  manner  as  the  antimesenteric  traction-suture  above,  but  so  placed  as  to 
pass  through  the  edge  of  the  upper  part  of  the  smaller  gut  and  through  the 
edge  of  the  larger  gut  on  its  side,  at  a  distance  from  its  mesenteric  attachment 
about  equal  to  the  diameter  of  the  smaller  gut.  A  third  traction-suture  is 
passed  through  the  antimesenteric  border  of  the  larger  gut  alone  (see  Fig.  624). 
(2)  The  window  is  now  made  in  the  larger  gut — and  the  invagination  accom- 
plished as  in  the  above  case.  The  two  free  ends  of  the  gut  will  not  now  be  con- 
centric, as  in  the  above  instance,  owing  to  the  difference  in  size  and  to  the  fact 


874  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

that  the  circumference  of  the  smaller  gut  is  fixed  to  the  circumference  of  the 
larger  in  two  places  by  suture.  (3)  The  suturing  of  the  borders  of  these  two 
non-concentric  circles  can  be  best  accomplished  by  the  passage  of  a  needle 
through  only  the  two  walls  in  contact  at  a  time — instead,  of  simultaneously 
through  these  two  and  the  opposite  two,  as  in  suturing  coils  of  similar  calibre. 
Each  suture  is  at  once  tied.  The  first  and  second  traction-sutures  become  per- 
manent— the  third  (through  the  larger  gut  alone)  is  removed.  It  is  well  to  put 
the  sutures  in  alternately  on  the  two  sides,  proceeding  from  the  mesenteric  to- 
ward the  antimesenteric  border,  until  the  edges  of  the  small  intestine  have  been 
sutured  to  those  of  the  larger.  When  near  the  antimesenteric  aspect  of  the 
smaller  gut,  the  redundancy  of  the  larger  gut  will  be  apparent.  This  redun- 
dancy, if  at  all  marked,  is  best  disposed  of  by  cutting,  with  scissors,  a  V-shaped 
piece  out  of  the  antimesenteric  aspect  of  the  larger  gut,  of  a  size  calculated  for 
the  individual  case.  This  V  is  now  carefully  sutured  by  approximation  of  its 
margins  by  an  overhand  stitch,  from  its  apex  toward  the  antimesenteric  aspect 


Fig.  624. — Entero-enterostomy  by  Maunsell's  Invagination  Method  in  Intestinal 
Coils  of  Unequal  Size — Preparatory  to  Invagination: — A,  Window  in  intussuscipiens ;  B, 
Mesenteric  traction-suture  ;  C,  Traction-suture  which  is  antimesenteric  for  the  smaller  and  lateral  for 
the  larger  gut ;  D,  Traction-suture  which  is  antimesenteric  for  the  larger  gut. 

of  the  smaller  gut,  being  especially  careful  to  approximate  the  edges  of  the 
larger  intestine,  at  the  base  of  the  V,  with  the  edges  of  the  antimesenteric  border 
of  the  smaller  gut.  (See  Fig.  625.)  (4)  The  invagination  is  reduced  by  gently 
drawing  upon  the  intestines — and  the  window  is  closed  as  in  the  regular  ope- 
ration. While  an  elbow,  marking  the  excess  of  the  larger  over  the  smaller 
intestine,  will  be  present,  the  union  will  be  secure.     (See  Fig.  626.) 

Lateral  Approximation. — (1)  Excision  of  the  intestine  and  corresponding 
mesentery  is  done,  the  clamps  having  been  placed  especially  well  away  from 
the  site  of  operation.  (2)  The  two  ends  of  intestine  are  overlapped  upon  their 
free,  antimesenteric  borders,  and  a  continuous  Lembert  suture  (leaving  the  end 
of  beginning  long,  after  knotting)  is  run  along  what  will  be  the  posterior  aspect 
of  the  junction,  extending  at  either  end  slightly  beyond  the  line  of  future  union 
around  the  common  opening — and  left  long  and  threaded.  (See  Fig.  627.) 
(3)  Two  corresponding  incisions  in  the  long  axis  of  both  guts  are  made.  (4) 
The  posterior  edges  of  the  wounds  are  sutured  together  by  an  overhand,  con- 
tinuous suture  of  all  the  coats,  leaving  the  end  of  beginning  long,  after  knotting, 


ENTERO-ENTEROSTOMY  BY  MAUNSELL'S  METHOD. 


§7: 


and  also  the  end  of  ending  long  and  threaded.     (5)  Forceps  are  protruded 
through  the  opening  and  out  either  free  end  of  the  intestine,  catching  up  the 


Fig. 625.— Entero-enterostomy  by  Maunsell's  Invagination  Method  in  Intestinal  Coils 
of  Unequal  Size — the  Invagination  Accomplished  : — A,  Window  in  intussuscipiens  ;  B,  Non-con- 
centric ends  of  two  pieces  of  intestine  of  unequal  size  ;  C,  Mesenteric  traction-suture;  D,  Traction- 
suture  which  is  antimesenteric  for  the  small  and  lateral  for  the  large  gut  ;  E,  Traction-suture  which 
is  antimesenteric  for  the  large  gut ;  F,  One  of  the  sutures  uniting  the  opposite  edges  of  the  redundant 
portion  of  the  large  gut. 


Fig.  626. — Entero-enterostomy  by  Maunsell's  Invagination  Method  in  Intestinal 
Coils  of  Unequal  Size — the  Invagination  Reduced  : — A,  External  view  of  portion  of  suture-line 
representing  the  end  of  the  small  intestine;  B.  External  view  of  portion  of  suture-line  represented  by 
the  redundancy  of  the  large  intestine;  C,  Closing  the  window  with  interrupted  Lemberts  ;  D,  In- 
terrupted sutures  approximating  the  edges  of  the  cut  mesentery. 

free  end  in  their  grasp  and  drawing  (invaginating)   it  into  the  lumen  and 
through  the  opening.     A  circular  silk  ligature  is  then  tied  around  either  free 


Fig.  627.— Lateral  Intestinal  Approximation  by  Maunsell's  Invagination  Method:-- 
A,  End  of  intestine  invaginated  through  window  and  circular  ligature  placed  around  it  ;  B,  Traction- 
ligatures  grasped  by  forceps  in  act  of  invaginating  opposite  end  of  intestine;  C,  Continuous  overhand 
suture  of  all  coats  ;  D,  Continuous  Lembert  suture  of  outer  coats. 


Figs.  628  and  629.  — Lateral  Intestinal  Anastomosis  by  Maunsell's  Invagination  Method  : 
— A,  Intussusceptum  drawn  through  window  ;  P>,  Intussuscipiens,  with  window  in  its  antimesenteric 
aspect;  C,  Diagram  showing  manner  of  placing  traction-sutures. 

'876 


EXTERO-ENTEROSTOMV  BY  MAUNSELL'S  METHOD. 


877 


end  and  they  are  dropped  into  their  respective  lumina.  (6)  The  needle  at- 
tached to  one  end  of  the  "whipping  over"  suture  then  continues  the  process 
until  the  corresponding  edges  of  the  entire  circumference  are  brought  together 
and  the  long  ends  tied.  (7)  Then  the  needle  upon  the  serous  suture  is  taken  up 
and  the  continuous  Lemberts  through  the  serous  and  muscular  coats  are  con- 
tinued around  the  anterior  aspect  of  the  wound,  burying  in  the  first  layer.  The 
edges  of  the  mesenterv  are  sutured  as  indicated. 


Figs.  630  and  631. -End-in-side  Intestinal  Implantation  by  Maunsell's  Invagination 
Method  :— A,  Colon  ;  B,  Ileum  ;  C,  Free  edge  of  lateral  window  in  colon  ;  D,  Free  edge  of  end  of 
ileum;  E,  Free,  open  end  of  colon;  F,  Traction-sutures  invaginating  free  end  of  ileum  and  lateral 
opening  of  colon  through  open  end  of  colon  ;  G,  Diagram  shoving  manner  of  placing  traction-sutures. 


Comment.— The  circularly  ligated  ends  of  intestine  may  be  reinforced 
with  interrupted  or  continuous  Lemberts. 

Lateral  Anastomosis.— Two  knuckles  of  intestine  are  apposed  along 
their  antimesenteric  borders — two  corresponding  axial  incisions  are  made — a 
window  is  then  cut  about  2.5  cm.  (1  inch)  above — four  traction-sutures  are 
applied  to  the  cut  margins  and  knotted  within — a  pair  of  forceps,  passed 
through  the  window,  catches  the  four  traction-sutures  and  draws  them  back 
through  the  opening — by  means  of  these  traction-sutures  the  lateral  aspects  of 
the  two  pieces  of  intestine  are  invaginated  through  the  window — sutures  are 
applied  to  their  margins,  as  in  the  end-to-end  approximation — the  invagination 


878  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

is  reduced — and  the  window  closed  by  interrupted  or  continuous  Lembert 
sutures.  The  line  of  anastomosis  may  be  reinforced  by  Lemberts,  if  con- 
sidered necessary.     (See  Figs.  628  and  629.) 

End-in-side  Implantation. — Excise  the  portion  of  intestine,  with  the 
corresponding  part  of  mesentery — bring  the  free  end  of  the  smaller  gut  to 
the  antimesenteric  aspect  of  the  larger  gut,  near  its  end — about  2.5  cm. 
(1  inch)  from  the  free  margin  of  the  latter,  upon  its  antimesenteric  aspect, 
make  an  axial  incision,  corresponding  in  length  to  the  diameter  of  the  free 
end  to  be  implanted — place  four  traction-sutures,  knotting  them  within — 
draw  these  traction-sutures  out  through  the  free  end  of  the  gut  in  which 
the  lateral  opening  was  made,  by  means  of  forceps — suture  together  the 
margins  of  the  free  end  and  the  lateral  opening  of  the  larger  gut,  as  in  end- 
to-end  approximation — reduce  the  invagination — close  the  free  end  of  the 
gut  with  the  lateral  opening  first  by  continuous,  overhand  silk  sutures,  which 
are  then  buried  by  interrupted  gut  sutures  of  the  Lembert  type — thus  com- 
pleting the  operation.  The  edges  of  the  mesentery  are  so  sutured  as  to 
close  all  openings.  The  site  of  implantation  may  be  reinforced  by  Lembert 
suturing,  if  considered  necessary.     (See  Figs.  630  and  631.) 

Note. — In  all  the  operations  by  the  Maunsell  method,  the  traction-sutures 
may  be  dispensed  with — the  invagination  being  accomplished  by  forceps 
introduced  through  the  windows,  as  in  Ullmann's  modification  of  Maunsell's 
operation  (page  881). 


(B)  ENTERO-ENTEROSTOMY  BY  MEANS  OF  ABSORBALE  ME- 
CHANICAL DEVICES  LEFT  WITHIN  THE  INTESTINE. 

IN  GENERAL. 

Description. — (1)  The  mechanical  devices,  which  are  made  of  some 
absorbable  material  and  are  inserted  into  the  intestinal  tract  to  serve  as 
distending  frameworks  over  which  the  suturing  may  be  conveniently  applied, 
are  bobbins,  buttons,  cylinders,  plates,  etc.  They  are  left  within  the  lumen 
of  the  intestinal  tract,  either  to  be  entirely  absorbed,  or  to  be  partially  ab- 
sorbed and  the  residue  passed  by  nature.  While  possessing,  in  common 
with  non-absorbable  devices,  the  property  of  aiding  in  the  approximation 
of  the  parts,  they  possess  the  additional  advantage  of  becoming  absorbed 
after  having  accomplished  their  purpose — with  the  concomitant  disadvantage 
of  possibly  sometimes  becoming  absorbed  before  having  done  their  work 
completely.  (2)  The  bobbins  are  in  the  form  of  two  cones  united  at  their 
apices,  which  is  their  smallest  part.  Their  shape  has  a  greater  tendency 
to  approximate  the  intestinal  surfaces  than  has  the  button,  or  reel.  The 
buttons  are  very  much  like  ordinary  buttons,  or  possibly  more  like  reels. 
The  size  of  the  barrel  is  everywhere  equal  between  the  flanges.  Various 
forms  of  plates  are  used,  of  which  the  best  known  are  probably  Senn's  bone- 
plates.  Some  forms  of  cylinders  are  used.  The  terms  designating  these 
devices  are  sometimes  used  interchangeably.  (3)  These  devices  are  made  of 
various  materials — the  most  usual  being  decalcified  bone,  or  some  form  of 
vegetable  (such  as  potato,  carrot,  turnip,  etc.).  In  some,  the  bulk  of  the 
device  is  made  of  entirely  absorbable  material,  and  a  small  part  of  the  center, 
where  the  pressure  is  to  be  borne,  is  made  of  more  imperfectly  absorbable 
or  of  non-absorbable  material.  (4)  These  devices  are  always  used  in  con- 
nection with  some  form  of  suturing — never  alone.  (5)  As  to  their  range  of 
applicability — their  chief  field  of  usefulness  is  in  end-to-end  approximation — 


EXTERO-EXTEROSTOMY  BY  ABSORBABLE  BOBBINS. 


879 


and  only  to  a  limited  extent  in  lateral  approximation,  lateral  anastomosis, 
end-in-side  implantation,  gastroenterostomy,  and  cholecystenterostomy. 
Some  are  used  only  in  lateral  methods  of  entero-enterostomy  (as  the  Senn 
bone-plates). 


ENTERO-ENTEROSTOMY  BY  MEANS  OF  ABSORBABLE  BOBBINS. 

Description. — The  Allingham  partially  decalcified  bone  bobbin  will  be 
taken  as  representing  this  type — the  steps  of  the  operations  being  the  same 
whether  the  bobbin  be  of  this  or  vegetable  material.  In  Allingham's 
bobbin  the  bone  is  decalcified  to  within  3  mm.  (fV  inch)  of  its  very  center, 
which  is  left  firm  to  resist  pressure  made  by  the  suture.  The  two  portions 
of  the  intestinal  tract  are  approximated  over  the  center  of  the  bobbin  by 
running  sutures  inserted,  in  purse-string  fashion,  in  the  free  end  of  each 
piece  of  intestine. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 


Fig.  632.— End-to-end  Intestinal  Approximation  by  an  Absorbable  Bobbin  :— Position  of 
bobbin  is  shown  partly  in  outline;  A,  Purse-string  suture  in  position  ready  to  be  tightened  ;  B,  Purse- 
string  suture  tightened  and  tied  ;  C,  Interrupted  Lembert  suture  in  position  to  be  tied. 


End-to-end  Approximation. — (1)  Having  completed  the  steps  of  a 
preliminary  enterectomy,  place  a  running,  overhand  purse-string  suture  of 
silk  in  the  ends  of  each  piece  of  intestine,  passing  through  all  their  coats, 
the  thread  entering  and  coming  out  at  the  antimesenteric  borders — leaving 
both  free  ends  long.  (See  Fig.  632.)  While  less  simple,  a  more  satisfactory 
form  of  purse-string  suture  (owing  to  the  manner  in  which  it  approximates 
the  laminae  of  the  mesentery)  is  the  one  used  in  connection  with  the  operation 
of  entero-enterostomy  by  means  of  the  Murphy  button  (page  885) — and  this 
suture  is  equallv  applicable  here.  (2)  Insert  one  end  of  the  bobbin  into 
the  proximal,  or  distal,  end  of  the  intestine — and,  having  made  the  double 
turn  of  the  friction-knot,  draw  the  purse-string  rather  tightly  down  upon 
the  intestine  over  the  center  of  the  bobbin — but  do  not  tie  the  final  knot. 
Insert  the  opposite  end  of  the  bobbin  into  the  end  of  the  opposite  piece  of 


88o 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


intestine  and  similarly  tie  it.  (3)  When  both  segments  of  intestine  are 
moulded  well  into  position,  so  that  the  serous  surfaces  are  well  approximated, 
each  suture  is  tightened  with  moderate  firmness  and  the  final  knot  in  each 
tied — thus  securely  bringing  and  fastening  the  ends  of  the  intestines  at  the 
center  of  the  bobbin,  and  holding  in  contact  rather  extensive  serous  surfaces 
for  union.  (4)  The  serous  surfaces  may  be  scarified  with  a  needle  for  about 
1  cm.  (f  inch)  around  the  line  of  suture,  to  cause  exudation  of  lymph  and 
firmer  union.  (5)  A  few  interrupted  Lemberts  of  fine  gut  may  be  applied 
around  the  line  of  union,  further  approximating  the  serous  surfaces,  if  thought 
necessary.  (6)  The  mesentery  is  treated  as  in  other  operations  of  entero- 
enterostomy. 

Comment. — While  especially  applicable  to  end-to-end  approximation, 
the  method  may  also  be  used  for  lateral  approximation,  lateral  anastomosis 
and  end-in-side  implantation — applying  the  same  general  principles  men- 
tioned in  the  preceding  descriptions  of  those  operations.  As  the  junction 
in  the  last  three  operations  mentioned  is  not  so  perfect  as  in  end-to-end 
approximation,  additional  Lembert  sutures  should  always  be  used  to  rein- 
force the  line  of  union. 


ENTERO-ENTEROSTOMY  BY  MEANS  OF  ABSORBABLE  BUTTONS. 

Description. — The  Landerer  potato  button  will  be  taken  as  representa- 
tive of  this  type  of  mechanical  device.  A  purse-string  suture  is  inserted 
into  each  end  of  the  intestinal  opening — these  are  tightened  over  the  barrel 
of  the  button,  or  reel,  thus  relatively  approximating  the  ends  of  the  intestine. 


Fig.633.— End-to-end  Intestinal  Approximation  by  an  Absorbable  Button: — Position  of 
button  is  shown  in  outline  ;  A,  Forceps  everting  lips  of  intestine  to  aid  suturing;  B,  Continuous  suture 
of  mucous  coat;  C,  Interrupted  Lembert  sutures  of  serous  and  muscular  coats. 


But  as  the  barrel  of  the  button  or  reel  is  of  the  same  dimension  for  some 
distance,  there  is  not  the  same  tendency  for  the  approximated  ends  of  the 
intestine  to  be  held  in  close  contact  as  is  the  case  in  the  bobbin,  where  there 
is  the  narrowest  part  of  the  barrel  at  the  center,  into  which  the  segments 


ULLMANN'S  MODIFICATION  OF  MAUNSELL'S  OPERATION.  88 1 

may  be  readily  tied.  An  overlying  line  of  interrupted  or  continuous  Lembert 
sutures  is,  therefore,  placed  over  the  ends  approximated  by  the  purse-strings — 
and  thus  securely  apposes  serous  surfaces. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — (i)  Having  completed  the  steps  of  a 
preliminary  enterectomy,  a  purse-string  suture  of  silk  or  of  chromic  gut  is 
inserted  into  the  end  of  each  piece  of  intestine — in  the  same  manner,  prefer- 
ably, as  in  Murphy's  button-operation  (page  885).  (2)  Each  end  of  the 
intestine  is  drawn  over  the  flange  of  the  button  on  to  the  barrel — the  purse- 
string  is  then  moderately  tightened  and  cut  short,  thus  bringing  the  two 
ends  of  the  intestine  into  contact.  (The  narrower  the  barrel  of  the  button, 
the  closer  will  be  the  contact  at  this  stage.)  (3)  The  circumferential  margins 
of  the  intestines  are  united  with  a  line  of  interrupted  or  continuous  Lembert 
sutures  of  the  serous  and  muscular  coats.  (4)  The  mesentery  is  repaired  as 
in  other  operations  of  entero-enterostomy. 

Comment. — The  comment  made  under  "  Entero-enterostomv  by  means  of 
Absorbable  Bobbins"  is  equally  applicable  here.  Union  may  also  be  accom- 
plished by  an  inner  tier  of  continuous  suture  of  the  mucous  coat,  and  an 
outer  interrupted  tier  of  Lemberts  through  serous  and  muscular  coats.  (See 
Fig-  633-) 

ENTERO-ENTEROSTOMY   BY   MEANS   OF   ULLMANN'S   MODIFICATION 
OF  MAUNSELL'S  OPERATION. 

Description. — Up  to  the  application  of  the  Ullmann  modification,  which 
is  applied  after  the  invagination  of  the  ends  of  the  intestines  through  the 
window  iri  one  of  the  pieces  of  gut,  the  steps  of  the  operation  are  identical 
with  those  described  under  the  Maunsell  method  (page  870).  The  two 
ends  of  intestine  having  been  brought  through  the  window,  a  carrot  (or 
other  vegetable,  or  decalcified  bone)  bobbin  is  inserted  within  their  con- 
centric lumina,  so  that  its  groove  is  grasped  by  their  walls,  which  are  then 
tied  over  the  groove  in  a  circular  manner,  with  gut  or  silk.  The  invagina- 
tion is  then  reduced — and  the  longitudinal  wound,  forming  the  window,  closed. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — (1)  The  operation,  up  to  the  point  of 
invagination,  is  precisely  the  same  as  in  Maunsell's  operation  (page  870). 
(2)  The  invagination  is  now  accomplished  by  passing  two  catch-forceps 
through  the  window — one  catching  the  mesenteric  and  the  other  the  anti- 
mesenteric  aspects  of  the  end  of  the  proximal  gut  (the  gut  in  which  the  window 
usually  is) — and  draws  these  out  simultaneously  through  the  window.  The 
mesenteric  and  antimesenteric  aspects  of  the  edges  of  the  distal  gut  are  similarly 
caught  by  two  catch-forceps  introduced  through  the  window — which  are  also 
drawn  out  simultaneously  through  the  opening.  These  last  two  forceps  are 
removed  from  the  distal  gut  and  made  to  grasp  the  edges  of  both  guts  at 
their  sides.  The  first  two  are  then  also  removed  from  the  first  gut  and  made 
to  grasp  the  edges  of  both  guts  at  the  same  site  each  was  grasped  by  a  single 
forceps.  Thus  the  concentric  ends  of  the  two  intestines  are  readilv  held 
open  by  the  four  pairs  of  forceps  equidistantly  placed.  These  forceps  are 
given  to  an  assistant,  who  holds  them  with  one  hand,  while  holding  the 
bobbin  with  the  other.  (See  Fig.  634.)  (3)  The  bobbin  is  now  introduced 
into  the  concentric  openings  of  the  intestines — the  walls  of  the  two  guts  are 
56 


882  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

then  tied  down  into  the  groove  of  the  bobbin  with  thick  catgut  or  silk  (which 
will  not  likely  cut  through).  (4)  The  forceps  are  relaxed — the  invaginated 
intestines  are  reduced — the  window  is  closed  by  interrupted  or  continuous 


Fig.  634.— Entero-enterostomy  by  Ullmann's  Modification  of  Maunsell's  Invagi- 
nation Method  :  — A,  Window  in  intussuscipiens  ;  B. Concentric  ends  of  intestines  drawn  through 
window;  C,  C.  Traction-forceps  drawing  ends  of  intestines  through  window  ;  D.  Absorbable  bobbin 
within  concentric  ends  of  intestines;  E,  Ligature  binding  ends  of  both  pieces  of  intestine  to  groove 
of  bobbin. 


Wtfi&viiffi* 


Fig.635. —  Entero-enterostomy  by  Ullmann's  Modification  of  Maunsell's  Invagi- 
nation Method  : — Showing  the  reduction  of  the  invagination  and  closure  of  the  window — bobbin 
and  ends  of  intestine  being  shown  in  outline. 


Lembert  sutures — the  mesentery  is  repaired — and  the  operation  concluded. 
(See  Fig.  635.) 

Comment. — Although  more  applicable  to  end-to-end  approximation,  the 


ENTERO-ENTEROSTUMY  BY  COFFEY'S  METHOD.  883 

Ullmann  modification  of   the  Maunsell   method   may  be   applied   to   lateral 
approximation,  lateral  anastomosis,  and  end-in-side  implantation. 


ENTERO-ENTEROSTOMY  BY  COFFEY'S  METHOD. 

Description. — The  free  ends  of  intestine,  after  having  been  first  united 
at  their  mesenteric  aspects  by  two  or  three  Connell  sutures,  are  drawn  over 
a  vegetable  tube  (made  of  potato,  carrot  or  turnip,  preferably  the  first)  and 
made  to  meet  and  overlap  at  its  center  by  means  of  two  long  needles  passed 
through  tube  and  intestines  transversely,  at  right  angles  to  each  other — 
after  which  any  form  of  suture  desired  is  applied — the  pins  then  withdrawn— 
and  the  potato-tube  pushed  on  down  and  crushed. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 


Fig.  636. — End-to-end  Entero-enterostomy  by  Coffey's  Method:  —  I,  Ends  of  intestine 
brought  together  and  their  mesenteric  aspect  united  by  three  Connell  sutures — preparatory  to  insert- 
ing hollow  potato-tube  shown  above.     (Modified  from  Coffey.) 


Operation. — (1)  Having  completed,  one  may  suppose,  the  steps  of  an 
excision  of  a  portion  of  the  intestines,  the  free  ends  are  brought  into  contact 
and,  while  thus  held  by  an  assistant,  three  Connell  sutures  placed  at  the 
mesenteric  aspect,  the  central  one  embracing  both  lamina?  of  the  mesentery 
of  both  ends  of  the  intestine — each  suture  passing  from  within  the  lumen 
of  one  end  outward  through  its  own  wall,  and  from  without  inward  through 
the  corresponding  site  of  the  opposite  end — then  from  within  outward  from 
the  lumen  of  the  opposite  end,  and  from  without  inward  through  the  cor- 
responding site  of  the  original  end,  back  into  the  lumen  of  the  original  end — 
where  the  free  ends  of  the  suture  are  tied  within  the  first  piece  of  intestine. 
(Fig.  636.)  (2)  One  end  of  the  united  pieces  of  intestine  is  then  drawn 
over  the  potato-tube  up  to  the  center  of  the  tube — and  is  held  there  until 
the  opposite  end  of  the  intestine  is  similarly  drawn  over  the  opposite  end 


884  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

of  the  tube  to  meet  it,  and  also  held  in  position.  (3)  Two  long  needles  (or 
hat-pins,  knitting-needles,  probes,  or  toothpicks)  are  now  passed  transversely 
through  the  potato-tube  and  through  the  ends  of  the  intestine,  at  right  angles 
to  each  other — one  entering  near  the  mesenteric,  and  one  at  the  mid-lateral 
aspect.  As  these  needles  enter  and  emerge,  they  are  made  to  pierce  the 
overlapped  edges  of  intestine — and  thus  hold  them  in  four  places — over- 
lapped where  the  needles  penetrate,  and  overlapped  or  in  comparatively 
close  contact  throughout  the  rest  of  the  quadrants  (Fig.  637).  (4)  While 
the  ends  of  intestine  are  thus  held,  any  form  of  suture  desired  may  be  placed — 
interrupted  Lemberts — continuous  Lembert — the  Halsted  quilt  suture — or  a 
double  line  of  sutures.     (5)  Having  completed  the  suturing,  the  pins  are 


Fig. 637. — End-to-end  Entero-enterostomy  by  Coffey's  Method: — II,  Two  ends  of  intes- 
tine drawn  over  tube  and  held  in  relation  with  each  other  by  long  needles  thrust  through  the  potato- 
tube  at  right  angles  to  each  other  and  piercing  the  overlapped  edges  of  intestine.  While  thus  held 
interrupted  Lembert  (or  other)  sutures  are  applied — after  which,  needles  are  withdrawn — and  potato- 
tube  may  be  crushed.     (Modified  from  Coffey .) 

withdrawn.  In  the  case  of  interrupted  sutures,  those  stitches  which  were 
placed  while  the  needles  were  in  situ  can  now  be  more  satisfactorily  drawn 
together  after  the  removal  of  the  needles.  The  potato-tube  is  carefully 
pressed  away  from  the  site  of  operation,  distallv  to  it — and  is  then  crushed  into 
comparatively  small  pieces.    (6)  The  abdomen  is  closed  in  the  usual  manner. 


(C)    ENTERO-ENTEROSTOMY    BY   MEANS  OF    NONABSORB- 
ABLE MECHANICAL  DEVICES  LEFT  WITHIN  THE 
INTESTINAL  CANAL. 


IX  GENERAL. 


Description.— These  devices,  usually  made  of  metal,  serve,  as  in  the  case 
of  absorbable  devices,  as  frameworks  over  which  the  intestinal  joinings  are 


EXTERO-ENTEROSTOMY  BY  MEANS  OF  MURPHY  BUTTON.         885 

made — but  are  left  within  the  intestinal  tract  to  be  passed  out  at  the  anus 
by  the  efforts  of  nature.  The  Murphy  button  may  be  taken  as  the  most 
generally  used  representative  of  this  class. 


ENTERO-ENTEROSTOMY  BY  MEANS  OF  THE  MURPHY  BUTTON. 

Description. — The  junction  between  the  intestinal  coils  is  accomplished 
by  inserting  one  half  of  an  ingenious  button  into  the  free  end  of  each  portion 
of  intestine — these  half-buttons  are  held  in  place  by  specially  applied  su- 
tures— and  the  two  halves  of  the  button  are  then  approximated.  The 
opposite  surfaces  of  the  two  cups  of  the  button,  aided  by  a  spring  in  one 
of  the  cups,  keep  up  a  constant  pressure  upon  the  opposed  surfaces  of  intes- 
tine, thus  holding  their  approximated    serous    surfaces  in  contact.     Union 


Fig. 638.— Cross-section  of  Intestine,  Showing  Manner  of  Placing  the  Purse-string 
Suture  : — A,  Serosa  ;  B,  Muscularis  ;  C,  Submucosa  ;  D,  Mucosa  ;  E,  E,  Laminae  of  mesentery  ;  F, 
Mesenteric  vessel  and  connective  tissue;  G,  Beginning  of  suture ;  H,  Crossing  of  suture,  approxi- 
mating laminae  to  each  other  and  to  barrel  of  intestine;  I,  End  of  suture,  ready  to  be  knotted  with 
opposite  end. 

takes  place  between  the  surfaces  thus  held  together,  especially  along  their 
circumferential  aspects — while  the  buttons  are  freed  by  pressure-necrosis  and 
are  generally  passed  by  bowel. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — (1)  Having  opened  the  abdominal  cavity, 
complete  the  partial  enterectomy  in  the  usual  manner.  (2)  Preparatory  to 
the  insertion  of  half  of  the  button  into  each  free  end  of  the  gut,  a  silk  suture 
is  applied  in  a  special  manner.     (See  Fig.  638.)     A  long,  straight  needle  is 


886  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

threaded  upon  a  piece  of  silk  about  30  cm.  (12  inches)  long — this  suture 
begins  just  to  the  right  of  the  center  of  the  antimesenteric  border,  entering 
about  3  mm.  (£  inch)  below  the  free  edge,  and  passing  from  without  directly 
inward — thence,  following  the  right-hand  margin,  in  an  overhand  stitch, 
over  (not  through)  the  border  of  the  intestine  to  the  outer  side — thence  through 
the  wall  from  without  inward — and  so  on,  until  the  lamina  of  the  mesentery 
belonging  to  that  side  is  reached.  As  the  suture  passes  from  within  the 
lumen,  over  the  wall  outward  for  the  last  time  on  that  side,  it  also  passes 
obliquely  over  the  lamina  of  the  mesentery  of  the  opposite  side.  The  suture 
is  then  carried  through  both  laminae  of  the  mesentery  as  a  reversed  stitch — 
emerging  at  the  outer  aspect  of  the  opposite  lamina.  It  is  now  obliquely 
carried  over  the  lamina  of  the  original  side  (and  across  the  first  limb  of  the 
suture  that  was  carried  over  the  opposite  lamina)  into  the  lumen  of  the  intes- 
tine, toward  its  opposite  wall — and  passes  through  this  wall  of  the  intestine 
from  within  outward.     The  order  is  now  reversed,  and  (to  get  out  of  the 


Fig. 639.— End-to-end  Intestinal  Approximation  by  Murphy's  Button: — Showing  manner 
of  introducing  button  into  lumen  of  intestine, — male  button  on  left,  with  purse-string  ready  to  be 
tightened  ;— female  button  on  right,  with  suture  tightened. 

lumen  on  the  left  side)  the  thread  is  always  carried  through  the  free  border 
of  the  intestine  from  within  outward — thence  passes  over  (not  through)  the 
wall  from  without  inward  into  the  lumen — and  so  on,  until  it  enters  the 
lumen  for  the  last  time,  at  the  antimesenteric  border — here,  at  a  distance 
of  about  5  mm.  (yg-  inch)  from  its  point  of  entrance,  and  on  the  same  level, 
the  needle  passes  through  the  intestinal  wall  from  within  outward.  Thus 
a  "puckering"  or  "draw-string"  is  formed,  so  applied  that  when  drawn  about 
the  button,  it  will  approximate  the  leaves  of  the  mesentery  closely  about  the 
ill-protected  triangle  at  its  base — and  the  two  threads  emerging  side  by  side 
upon  the  outer  aspect  are  ready  to  be  tied  about  the  button.  Although 
these  sutures  pass  through  all  the  coats  of  the  intestine,  they  are  within  the 
spring,  or  pressure-cup,  of  the  button.  Similar  sutures  are  inserted  into  the 
free  ends  of  the  opposite  piece  of  intestine.  (See  Fig.  639.)  (3)  Each  cup, 
or  button,  is  now  grasped  by  its  stem  (not,  as  so  often  shown  in  pictures, 
by  the  cup  itself)  by  the  tip  of  a  pair  of  special  or  pointed  forceps  (forceps 


ENTERO- ENTEROSTOMY  BY  MEANS  OF  MURPHY  BUTTON.    887 

with  rounded  or  squarish  points  would  tend  to  bend  the  perfectly  circular 
opening  of  the  stems).  Both  are  now  ready  for  introduction.  (4)  The  male 
button  (one  with  smaller  stem)  is  always  introduced  into  the  end  of  the 
proximal  gut  (because  when  its  stem  has  slipped  into  the  stem  of  the  female 
button,  a  slight  elbow  or  projection  is  formed  where  its  free  margin  ends — 
which  is  harmless  while  in  the  direction  of  the  intestinal  current,  but  might 
cause  obstruction  by  particles  of  solid  food  lodging  against  it,  if  in  the  opposite 
direction).  This  male  half  of  the  button  is  introduced  into  the  proximal 
gut  just  far  enough  for  the  free  end  of  the  gut  to  come  well  around  the  stem. 
The  suture  is  then  drawn  moderately  tight  and  tied  with  a  double  knot  (the 
first  being  a  friction-knot)  around  the  stem — evenly  distributing  the  puck- 
ered gut  with  a  probe  as  the  thread  is  tightened.  An  assistant  takes  the 
forceps  and  so  holds  them  that  the  stem  of  the  button  does  not  slip 
within  the  intestine.  (5)  The  female  button  (one  with  larger  stem)  is  simi- 
larly introduced  into  the  distal  end  of  the  gut.  The  suture  is  similarly  placed 
and  tightened  about  it — and  the  forceps  given  to  an  assistant  to  hold  in  the 


Fig. 640.— End-to-end  Intestinal  Approximation  by  Murphy's  Button: — The  half-buttons 
approximated  and  pressed  home.  Two  loose,  interrupted  Lembert  sutures  are  shown  in  the  position 
which  a  tier  of  these  sutures  would  occupy,  if  used. 

same  manner  as  with  the  male  button.  (6)  The  assistant  holding  the  buttons, 
so  crosses  the  handles  of  the  forceps  as  to  present  the  buttons  to  the  surgeon 
in  their  right  relation  for  immediate  approximation.  (See  Fig.  639.)  The 
surgeon  now  grasps  a  button  in  the  thumb  and  first  two  fingers  of  each 
hand,  with  the  hollows  of  the  buttons  looking  toward  each  other.  The  as- 
sistant then  simultaneously  releases  the  hold  of  the  two  forceps  upon  the 
stems  of  each  half-button.  At  the  moment  of  release  the  surgeon  guards 
the  buttons  lest  they  slip  out  of  reach  into  the  intestines  (by  pressing  them 
against  the  binding  sutures).  The  surgeon  now  approximates  the  two  half- 
buttons,  one  held  in  the  fingers  of  each  hand — calculating,  in  their  slow  and 
deliberate  approximation,  that  the  intervening  intestinal  walls  will  be  so  dis- 
posed as  to  make  an  even  layer  over  the  cups  of  the  buttons — adjusting  the 
deficiency  or  excess  of  the  puckered  intestine  with  a  probe,  as  indicated — and 
finally  pressing  the  two  halves  home  as  far  as  his  judgment  deems  neces- 
sary to  secure  good  apposition  without  too  great  compression.    (See  Fig.  640.) 


888  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

(7)  The  edges  of  the  mesentery  are  sutured  and  the  intestine  dropped  back 
into  the  abdomen. 

Comment. — (i)  Segments  of  intestine  of  unequal  size  may  be  thus 
united  by  end-to-end  approximation  with  the  Murphy  button — care  being 
exercised  in  tying  the  button  into  the  end  of  the  larger  gut,  and  especially 
in  the  act  of  approximating  the  two  buttons,  to  see  that  the  puckered  excess 
of  the  intestinal  tissue,  particularly  in  the  case  of  the  larger  gut,  is  evenly 
distributed  around  the  stem  of  the  buttons — and  that  when  the  halves  of 
the  buttons  are  finally  pressed  home  the  serous  surfaces  everywhere  come 
together.  (2)  A  line  of  interrupted  or  continuous  Lemberts  is  used  by  some 
surgeons  to  reinforce  the  margins  where  the  buttons  meet,  after  their  appo- 
sition. While  not  generally  necessary,  such  a  line  of  reinforcing  sutures 
may   be   used   where   considered   indicated.     (See  Fig.  639.)     (3)  See   that 


Fig.  641.— Lateral  Intestinal  Approximation  by  the  Murphy  Button  :— The  manner  of 
placing  the  purse-string  suture  is  shown  upon  the  lower  intestine, — and  the  male  button  introduced, 
■with  suture  tightened,  is  seen  within  the  upper  intestine. 


the  purse-string  sutures  are,  after  knotting,  cut  close,  and  that  their  ends 
are  not  held  by  the  cups  of  the  buttons — thus  retarding  the  escape  of  the 
button,  and  possibly  serving  as  infectors  of  the  peritoneal  cavity.  (4)  All 
buttons  used  should  be  of  a  size  that  will  not  press  upon  the  intestinal 
walls,  else  sloughing  may  occur. 

Lateral  Approximation. — (1)  Having  excised  the  portion  of  intestine, 
the  free  ends  of  the  two  pieces  of  gut  are  first  closed  by  overhand,  continuous 
suture  of  all  the  coats — followed  by  a  second  tier  of  interrupted  or  continuous 
Lemberts  burying  in  the  first  row.  (2)  Purse-string  sutures  are  now  placed. 
(See  Fig.  641.)  These  consist  of  silk  and  are  carried  by  an  extra  long,  straight 
needle  (such  as  Keith's  abdominal  needle).  The  site  for  the  insertion  of 
the  half-button  into  each  segment  of  gut  having  been  chosen,  which  will 


ENTERO  ENTEROSTOMY  BY   MEANS  OE  MURPHY  BUTTON.        889 

be  upon  the  antimesenteric  aspect  of  the  guts,  beginning  about  2.5  or  5  cm. 
(1  to  2  inches)  from  their  ends,  it  is  necessary  to  calculate  the  length  of  the 
incision  to  be  made,  as  its  length  will  regulate  the  length  and  position  of 
the  purse-string  suture.  If  the  oblong  button  be  used,  the  length  of  the 
incision  will  be  a  little  less  than  the  transverse  diameter  of  the  button, — 
and  if  the  round  button,  a  little  less  than  the  diameter — in  order  that  when 
the  button  is  insinuated  through  an  opening  requiring  slight  distention  for 
its  entrance,  it  will  close  about  it  sufficiently  to  slightly  grasp  it.  The  sutures 
should  be  put  in  so  that  their  looped  end  is  toward  the  free  end  of  the  gut. 
The  suturing  passes  through  all  the  coats.  Conceiving  an  imaginary  straight 
line,  running  longitudinally,  upon  the  center  of  the  antimesenteric  aspect 
of  the  bowel  to  mark  the  site  for  the  future  incision  for  the  reception  of  the 
button,  the  needle  is  made  to  enter  the  wall  of  the  gut  about  6  mm.  (j  inch) 
above  (or  below,  as  the  case  may  be)  this  imaginary  line,  and  about  3  mm. 
(^  inch)  to  one  side — passing  through  all  the  coats  into  the  lumen — again 
passing  outward  (always  traveling  in  a  straight  line  parallel  with  and  about 
3  mm.  [f  inch]  from  the  imaginary  line)  and  emerging  about  6  mm.  (j  inch) 
from  the  point  of  entrance — and  so  on,  until  it  emerges  finally  about  6  mm. 
(^  inch)  beyond  the  opposite  end  of  the  imaginary  line — here  the  loop  is 
formed,  the  needle  crossing  over  and  entering  the  intestinal  wall  at  a  point 
corresponding  with  its  last  emergence,  but  on  the  opposite  side  of  the  imaginary 
line — and  travels  down  this  side  in  the  reverse  direction,  but  in  the  same 
manner  as  on  the  opposite  side — finally  emerging  at  a  point  corresponding 
with  the  entrance  on  the  original  side.  Both  ends  of  the  suture  are  left 
long  and  the  loop  loose.  (3)  An  assistant  now  so  holds  the  bowel  (which 
has  been  clamped  at  some  distance  from  the  free  ends)  as  to  separate  its 
walls — while  the  surgeon,  by  a  quick,  controlled  stab  of  a  narrow,  sharp 
bistoury,  incises  the  gut  midway  between  the  two  parallel  lines  of  the  purse- 
string  suture,  and  makes  an  opening  a  little  less  in  length  than  the  diameter 
of  the  button  to  go  through  it — and  especially  considerably  less  in  length 
than  the  length  of  the  surrounding  purse-string.  Care  is  taken  that  the 
mucous  membrane  is  not  simply  pushed  ahead  of  the  knife,  instead  of  being 
cut,  and  that  the  lumen  is  well  opened  up.  (4)  The  button,  grasped  by 
forceps,  as  in  the  ordinary  end-to-end  operation,  is  now  insinuated  into  the 
opening,  placing  the  male  button  in  the  proximal  gut.  The  purse-string 
is  drawn  tightly  enough  to  approximate  the  walls  of  the  gut  to  the  stem  of 
the  button  and  tied — evenly  distributing  the  puckered  intestine  around  the 
stem.  The  forceps  holding  the  button  is  then  given  to  an  assistant,  who 
holds  it  as  in  the  end-to-end  operation.  (5)  The  opposite  end  of  the  intestine 
is  similarly  treated  and  the  female  button  inserted.  (6)  The  surgeon,  grasping 
a  button  in  the  fingers  of  each  hand,  with  their  stems  facing  (as  they  have 
been  directed  by  the  crossing  of  the  forceps),  signals  to  the  assistant  to  release 
the  buttons  by  relaxing  the  forceps — and  then  pushes  home  the  two  halves — 
using  the  same  precautions  as  in  the  end-to-end  approximation,  for  the  even 
distribution  of  the  intestinal  walls.  (See  Fig.  642.)  (7)  The  management  of 
the  mesentery  will  here  differ  from  its  management  in  the  end-to-end  opera- 
tion, as  the  continuity  of  the  intestinal  canal  will  not  be  continued  in  one 
straight  line.  It  is  better  (unless  otherwise  indicated)  not  to  excise  a  V-shaped 
portion  of  mesentery,  but  simply  to  fold  over  and  suture  in  contact  with 
each  other,  and  with  neighboring  mesentery,  the  layers  of  the  redundant 
fold  of  mesenterv.  If  a  V-shaped  portion  be  excised,  the  two  free  borders 
of  the  mesenterv  left  should  be  so  sutured  down  to  adjacent  mesentery  as 
to  leave  no  openings  for  hernia. 


890  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Comment. — (1)  See  the  general  comments  under  the  end-to-end  ap- 
proximation. (2)  Care  should  be  used  that  in  approximating  the  two  ends 
of  the  intestines  the  direction  of  the  intestinal  flow  should  be  maintained. 
(3)  The  button  used  may  be  of  the  oblong  type,  which  is  better  for  this 
purpose— or  of  the  ordinary  round  type.  (4)  The  operation  of  lateral 
approximation  after  closure  of  the  ends  of  the  resected  gut  is  but  rarely  indi- 
cated— the  usual  method  of  junction  following  excision  being  by  end-to-end 
approximation.  (5)  Instead  of  using  the  purse-string  suture  to  hold  the 
button-halves  in  place,  Carle  approximates  the  borders  of  the  intestinal 
opening  by  one  or  two  interrupted  Lembert  sutures  placed  at  either  end 
of  the  incision,  thus  lessening  its  length  and  grasping  the  button.  But  the 
regular  method  is  probably  better. 

Lateral  Anastomosis. — In  this  operation  the  two  buttons  are  inserted 


Fig. 642. — Lateral  Intestinal  Approximation  by  the  Murphy  Button: — The  two  half- 
buttons  are  shown  approximated.  Interrupted  or  continuous  Lembert  sutures  may  reinforce  the  con- 
tiguous surfaces,  if  considered  necessary. 


into  the  antimesenteric  aspects  of  the  two  indicated  coils  of  intestine — the 
method  of  insertion  being  identical  with  that  used  in  Lateral  Approximation 
by  the  button.  No  excision  of  intestine  takes  place.  The  oblong  button  is 
to  be  preferred.  Reinforcing  Lemberts  may  be  used.  The  Carle  method 
of  tving  in  the  buttons,  just  mentioned,  may  be  used. 

Lateral  Anastomosis  with  Weir's  Modification  of  Murphy's  Button, 
Introduced  by  Gallet's  Method. — The  male  half  of  the  original  button  is 
so  modified,  by  being  sharpened  and  beveled,  that  it  can  be  made  to  penetrate 
the  walls  of  the  intestine.  Both  buttons  are  introduced,  by  means  of  special 
forceps,  through  a  common  opening  in  a  knuckle  of  intestine — each  being 
carried  down  a  separate  limb  of  the  gut — and  are  then  approximated — fol- 
lowed by  the  closure  of  the  incision  in  the  knuckle.     Following  are  the  steps 


ENTERO-ENTEROSTOMY  15V  MEANS  OF  MURPHY  BUTTON.         S91 

of  the  operation;  (1)  The  sites  of  the  anastomosis  must  be  in  such  positions 
upon  the  antimesenteric  aspects  of  the  intestine  that,  when  the  length  of 
the  intestine  is  doubled  upon  itself,  the  site  to  be  occupied  by  each  button 
will  not  be  beyond  the  reach  of  the  special  forceps  to  be  introduced  through 
an  opening  at  the  knuckle  formed  by  bending  the  intestine  upon  itself.  (2) 
An  incision  in  the  longitudinal  axis  of  the  gut  is  now  made  at  this  knuckle. 
A  button  held  in  the  grasp  of  the  special  forceps  is  then  introduced  through 
the  opening  down  one  limb  of  the  gut — the  male  button  in  the  proximal 
limb.  The  female  button,  similarly  held,  is  then  introduced  down  the  oppo- 
site limb.  (3)  By  pressure  upon  the  forceps  holding  the  male  button,  its 
stem  is  made  to  pierce  the  walls  of  its  own  side  and  the  opposite  gut — and 
is  then  directed  into  the  stem  of  the  female  button.  (4)  The  buttons  are 
then  pressed  home — the  adjacent  surfaces  of  intestine  being  held  in  contact 
without  any  form  of  suturing.  (5)  The  treatment  of  the  opening  in  the 
knuckle  of  gut  is  as  indicated.  In  the  cases  where  the  operation  is  simply 
a  lateral  anastomosis,  the  incision  in  the  knuckle  would  be  closed  by  inter- 
rupted or  continuous  Lembert  sutures  of  gut  or  silk.  In  the  majority  of 
cases  where  this  operation  is  done,  however,  it  is  performed  in  connection 
with  a  gastrojejunostomy,  for  the  purpose  of  aiding  in  the  prevention  of 
bile  and  intestinal  regurgitation  from  the  duodenum  into  the  stomach — so 
that  as  soon  as  the  intestinal  anastomosis  has  been  accomplished,  the  opening 
in  the  knuckle  of  intestine  is  sutured  to  a  corresponding  opening  in  the  anterior 
wall  of  the  stomach,  thus  completing  the  gastrojejunostomy.    (See  Fig.  714.) 

Note. — The  ordinary  Murphy  button  may  be  used  in  practically  the 
same  manner.  After  opening  the  knuckle  of  gut,  one  half  of  the  button 
may  be  dropped  into  each  limb  of  the  intestine — these  are  caught  and  held 
by  the  fingers  of  an  assistant  at  corresponding  positions  within  the  two  pieces 
of  gut,  with  the  free  portion  of  their  stems  held  against  the  antimesenteric 
aspect  of  the  gut.  While  the  intestinal  wall  is  thus  drawn  tightly  over  the 
hollow  stems,  a  limited  crucial  incision  is  made  in  the  center  of  the  stems, 
just  sufficiently  large  for  the  stems  to  be  pressed  through,  with  the  walls 
of  the  intestine  clinging  closely  around  them — immediately  following  which 
the  two  halves  are  pressed  together,  bringing  the  antimesenteric  aspects  of 
the  two  portions  of  gut  into  accurate  apposition — no  reinforcing  suture  being 
necessary.  The  opening  in  the  knuckle  of  gut  is  closed  as  usual.  (See  Figs. 
715  and  716.) 

Multiple  Lateral  Intestinal  Anastomosis  (Jaboulay-Braun's  Opera- 
tion).— In  addition  to  the  single  lateral  intestinal  anastomosis  formed  after 
gastroenterostomy,  as  above  described  (Braun's  operation),  sometimes  a 
second,  or  even  a  third,  lateral  intestinal  anastomosis  may  be  made — for 
the  purpose  of  further  avoiding  the  likelihood  of  intestinal  regurgitation  by 
furnishing  as  direct  and  easy  a  descent  from  the  stomach  to  the  anus  as 
possible.  Supposing,  therefore,  that  a  gastrojejunostomy  has  been  per- 
formed, a  lateral  jejuno-jejunostomy  may  be  done  by  Gallet's  method  of 
using  Weir's  modification  of  the  Murphy  button,  at  the  time  the  intestine 
was  opened  to  unite  it  to  the  stomach — and  then  another  jejuno-jejunostomy, 
or  a  jejuno-ileostomy,  could  be  performed  lower  down  by  the  ordinarv  lateral 
anastomosis  method,  thus  short-circuiting  by  two  routes  the  contents  of  the 
intestines. 

Note. — Multiple  intestinal  anastomosis  can,  of  course,  be  performed  by 
simple  suturing,  as  well  as  by  other  methods. 

End-in-side  Implantation. — Supposing  the  caecum  to  have  been  excised 
and  the  mesentery  ligated,  the  male   Murphy  button  is  introduced  into  the 


892  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

free  end  of  the  ileum  and  tied  in  place,  as  in  the  ordinary  end-to-end  ap- 
proximation. The  edges  of  the  free  end  of  the  caecum  are  then  united  by 
overhand  continuous  silk  sutures  through  all  the  coats — and  these  are  buried 
in  by  the  interrupted  or  continuous  Lemberts  of  gut  or  silk.  An  opening 
is  then  made  2.5  to  5  cm.  (1  to  2  inches)  from  the  sutured  end  of  the  caecum, 
upon  its  antimesenteric  aspect,  and  the  female  button  tied  into  place,  just 
as  in  lateral  intestinal  anastomosis.  The  two  buttons  are  now  brought 
together  in  the  usual  fashion.  The  line  of  union  should  be  here  reinforced 
by  a  tier  of  interrupted  Lembert  sutures.  The  borders  of  the  mesentery 
should  be  sutured  as  indicated. 


LATERAL  INTESTINAL  ANASTOMOSIS  BY  THE    JABOULAY    BUTTON. 

Description. — The  Jaboulay  button,  made  in  three  sizes,  is  made  up  of 
two  halves — each  half  having  an  outer  and  an  inner  cylinder — the  outer  fenes- 
trated cylinder  having  a  break  or  slit  in  its  continuity  extending  into  and  almost 
half  around  the  inner  cylinder.  Its  form  of  structure  is  intended  to  enable  the 
button  to  be  inserted  upon  "the  screw  and  key-ring"  principle  through  an 
especially  small  intestinal  opening,  and  is  used  without  the  reinforcement  of 
sutures  (Figs.  643  and  644). 


Figs.    643    and  644. — The    Jaboulay    Button;    Male   and    Female   Halves.      (Redrawn 

from  Beer.) 

Preparation— Position— Landmarks— Incision.— As  in  median  abdom- 
inal section. 

Operation. — The  coils  of  intestine  are  clamped  and  brought  into  the  field 
in  the  usual  way,  with  their  antimesenteric  aspects  presenting.  In  using  a 
button  of  2.2  cm.  (approximately  f  inch)  diameter,  a  longitudinal  incision  in  the 
antimesenteric  aspect  of  the  bowel  is  made  of  1  cm.  (§  inch)  length.  The 
inner  cylinder  of  the  button  is  grasped  with  a  pair  of  forceps,  as  in  the  case  of 
the  Murphy  button — but,  in  the  present  instance,  the  button  is  insinuated  into 
the  lumen  of  the  bowel  by  a  semi-lateral  cork-screw  movement — the  beak  of 
the  outer  cylinder  first  entering — the  screw-like  movement  being  continued 
until  the  outer  cylinder  has  entirely  entered  the  cavity  of  the  intestine — the 
inner  cylinder  being  left  protruding  from  the  intestinal  wound  and  snugly 
grasped  by  it.  The  opposite  half  of  the  button  is  introduced  into  the  corre- 
sponding lateral  aspect  of  the  opposite  piece  of  intestine.  The  two  halves  are 
then  pressed  tightly  home,  with  considerable  strength  (as  the  pressure  necrosis 
which  liberates  the  buttons  is  here  dependent  upon  the  amount  of  pressure 
used  in  approximating  the  buttons,  and  not  upon  a  special  spring  or  third 
cylinder,  which  continues  to  act,  as  in  the  Murphy  button).  The  walls  of  the 
intestine  are  thus  approximated  and  the  lumen  of  each  piece  of  intestine  is 


ENTERO-ENTEROSTOMY    BY    HARRINGTON'S    RINGS. 


893 


connected  through  the  inner  cylinder.     No  reinforcement  by  suturing  is  used 
unless  the  intestinal  wall  be  torn  in  inserting  the  buttons  (Fig.  645). 

Comment. — Theoretically  the  above  technic  seems  very  satisfactory — 
but  the  following  practical  difficulties  (especially  demonstrated  by  Beer's  work) 
have  arisen  in  the  use  of  this  form  of  button; — In  quite  a  large  percentage  of 
cases  the  button  can  not  be  introduced  through  an  incision  bearing  the  pro- 
portion of  the  diameter  of  the  button  as  indicated  above  (and  as  claimed  for 
it  by  its  author),  and,  in  consequence,  the  intestinal  wall  is  quite  frequently 
split  further  than  intended  and  has  to  be  sutured; — The  button  is  quite  often 


Fig.  645. — Lateral  Intestinal  Anastomosis  by 
means  of  the  Jaboulay  Button: — Male  and  female 
buttons. 


Figs.  646-648. — Harring- 
ton's Segmented  Ring  : — Seen 
in  three  positions  with  handle  in 
position  in  two. 


held  in  situ  and  is  not  passed.  The  especial  advantages  of  the  button  are — 
the  small  incision,  the  rapidity  of  its  introduction,  and  the  absence  of  reinforc- 
ing suturing — where  all  goes  well. 


ENTERO-ENTEROSTOMY 

BY    HARRINGTON'S    SEGMENTED    RINGS. 

Description. — "The  ring,  in  the  language  of  its  author,  is  made  of  hard 
aluminum  in  four  sections.  These  sections  are  jointed  firmly  together  by  a 
small  bar  of  steel,  which  has  a  shoulder  and  a  screw  thread,  and  which  serves 
as  a  handle.     The  outer  surfaces  of  the  ring  are  grooved  to  hold  the  ends  of 


894 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


the  intestines,  which  are  tied  in  place  by  catgut  purse-string  sutures.  The 
segments  tit  together  by  means  of  sliding  tongue-and-groove  joints  so  rounded 
that  they  will  nut  cut  or  catch  in  the  tissues."  The  ring  is  a  mechanical  aid  to 
intestinal  anastomosis,  end-to-end  and  lateral.  Subsequently  to  being  placed 
in  situ  it  collapses  into  its  component  segments,  which  are  so  small  that  they 
are  passed  without  danger  or  discomfort.  The  rings  are  made  in  three  sizes. 
(Figs.  646-648.) 

Preparation — Position — Landmarks — Incision. — As  in  median  abdom- 
inal section. 

Operation. — The  description  of  the  technic  given  by  Harrington  and 
Gould  will  be  here  largely  followed.  The  end-to-end  anastomosis  is  performed 
as  follows  (Fig.  649) :— Clamps  are  applied  in  such  a  way  as  to  exclude  the 


Fig.  649. — Entero-enterostomy  by  means  of  Harrington's  Segmented  Ring: — 
A,  Mesenteric  stitch;  B,  Purse-string  suture  (the  one  on  the  opposite  end  being  tied);  C,  The 
ring  and  handle  in  position.     (Redrawn  from  Gould.) 


general  intestinal  tract.  A  sero-muscular  purse-string  suture  of  No.  2  plain 
catgut  is  placed  around  the  intestines  on  either  side  of  the  area  to  be  excised, 
and  the  first  part  of  a  surgeon's  knot  tied,  without  tightening  the  suture.  The 
intestine  is  excised  3  mm.  (J  inch)  from  the  purse-strings.  A  mesenteric 
mattress  stitch,  after  the  manner  of  the  Maunsell  mesenteric  stitch,  is  first 
applied.  The  segmented  ring  is  then  introduced  into  one  end  of  the  intestine, 
guided  by  the  handle,  and  the  purse-string  of  that  end  is  tied.  The  mesenteric 
mattress  suture  is  then  tied,  after  which  the  other  end  of  the  segmented  ring  is 
placed  within  the  lumen  of  the  opposite  end  of  intestine  and  the  second  purse- 
string  suture  tied.  The  intestinal  margins  are  evenly  adjusted  to  each  other 
at  the  center  of  the  ring.  A  Cushing  right-angle  continuous  sero-muscular 
suture,  beginning  to  one  side  of  the  steel  handle,  is  carried  around  the  intestine, 
with  frequent  knotting,  to  the  opposite  side  of  the  handle.  The  handle  of  the 
instrument  is  then  unscrewed  and  withdrawn — after  which  the  Cushing  suture 


ENTERO-ENTEROSTOMY    WITH    LEE'S    INTESTINAL    HOLDER.        895 

is  continued  over  the  opening  left  by  the  withdrawal  of  the  handle.  The  ring 
is  held  together  by  the  purse-strings. 

Lateral  intestinal  and  gastro-intestinal  anastomoses  are  accomplished  in 
the  same  general  way.  The  purse-string  sutures  here  consist  of  two  parallel 
arms  crossing  at  one  end,  only  far  enough  from  each  other  to  leave  room  for  the 
incision. 

Comment. — It  is  better  to  leave  the  ring  in  place  after  completing  the 
operation — although  if  it  seem  to  exert  undue  pressure,  it  may  be  collapsed  by 
gently  compressing  it  through  the  walls  of  the  intestine.  At  the  end  of  twenty- 
four  hours  the  swelling  is  great  enough  to  hold  the  intestinal  ends  together 
without  the  purse-string  sutures.  But  at  the  end  of  from  four  to  six  days  the 
swelling  subsides,  leaving  the  purse-strings  and  the  lumen  of  the  intestine  con- 
siderably larger  than  the  circumference  of  the  ring — which  then  collapses  and 
passes  on  down. 


(D)  ENTERO-ENTEROSTOMY   BY    MECHANICAL   MEANS 

TEMPORARILY  USED  FOR  APPROXIMATING  THE 

INTESTINAL  EDGES  DURING  SUTURING. 

IN    GENERAL. 

Description. — Various  more  or  less  ingenious  forms  of  devices  have  been 
introduced  for  the  purpose  of  holding  in  contact  the  opposite  margins  of 
the  intestines  during  the  act  of  suturing — to  be  withdrawn  just  prior  to  the 
completion  of  the  suturing.  Many  of  these,  at  the  same  time,  distend  the 
otherwise  flaccid  gut,  and  render  the  application  of  sutures  easier — such  as 
the  Halsted  inflatable  rubber  cylinder,  Laplace's  intestinal  forceps,  Lee's 
intestinal  holder,  and  the  like.  The  last  of  these  will  be  described  as  repre- 
senting this  class  of  work. 


ENTERO-ENTEROSTOMY  BY  MEANS  OF  LEE'S  INTESTINAL  HOLDER. 

Description. — The  instrument,  though  simple  in  principle  and  con- 
struction, is  difficult  to  describe  clearly — but  its  manipulation  is  easy.  The 
holder  is  introduced  into  the  approximated  ends  of  the  intestine  closed — 
is  then  opened — and  serves  as  a  framework  upon  which  suturing  is  done — 
and  is  then  finally  closed  and  withdrawn.  A  single  instrument  fits  any  part 
of  the  intestinal  tract — and  any  suture  may  be  used  in  conjunction  with  it. 
Lee  uses  a  modification  of  the  Connell  stitch.  The  method  is  only  applicable 
to  end-to-end  approximation. 

Preparation— Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

End-to-end  Approximation. — (1)  Open  the  abdomen — clamp  off  the 
site — and  excise  a  portion  of  the  intestine,  with  or  without  a  part  of  its  mesen- 
tery. (See  Fig.  650.)  (2)  The  mesenteric  suture  is  passed — exactly  as  the 
mesenteric  traction  suture  is  passed  in  Maunsell's  operation  (page  870). 
Both  ends  of  the  silk  are  left  long  and  are  knotted  within  the  lumen  of  the 
gut — thus  approximating  the  mesenteric  aspects  of  both  guts  and  both  lamina? 
of  the  mesentery  to  the  barrel  of  the  gut  (Fig.  651).  Each  end  of  the  threads 
is  then  needled — and  the  needles  are  made  to  pass  out  of  the  gut  near  the 
knot  and  the  threads  are  drawn  after.     (3)  The  intestinal  holder  is  now 


896 


OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 


introduced  and  opened — distending  each  gut  flatwise — the  distal  arms  being 
against  the  mesenteric  border  and  the  proximal  arms  against  the  antimesen- 
teric  border — the  free  borders  of  intestine  lying  in  parallel  contact — there 
being  no  marked  tension  anywhere.     (4)  The  half  of  the  intestine  nearer 


I 


Fig. 650.— End-to-end  Entero-enterostomy  by  Lee's  Intestinal  Holder: — A,  A.  Clamps 
upon  a  coil  of  intestine  from  which  a  portion  has  been  excised  ;  B,  Intestinal  holder  beinj,  inserted 
into  the  ends  of  intestine— its  blades  extended  ;  C,  C,  The  two  ends  of  the  mesenteric  suture.  (Modi- 
fied from  Lee.) 

the  surgeon  is  now  sutured  with  right-angled  continuous  suture  (Fig.  652), 
passing  through  all  the  coats,  tightening  the  thread  after  each  stitch.  When 
the  site  of  the  emergence  of  the  stem  of  the  instrument  is  reached,  the  final 
stitch  is  made  on  the  side  opposite  to  the  one  on  which  the  preceding  stitch 
was  made— and  this  final  stitch  is  only  a  half-stitch,  passing  from  without 


ENTERO-ENTEROSTOMY   WITH   LEE'S    INTESTINAL    HOLDER.       897 

and  ending  on  the  interior  of  the  gut  (Fig.  652).  (5)  The  instrument  is 
now  so  turned  as  to  present  the  opposite  side  (Fig.  653) — which  is  sutured 
in  a  similar  manner — the  final  half-stitch  ending  on  the  same  end  of  gut 
as  the  last  half-stitch  of  the  first  side,  and  on  the  interior  of  the  gut.     (6) 


Fig. 65 1.— Entero-enterostomy  by  Lee's  Intestinal  Holder  : — A,  A,  Mesenteric  suture  tied 
and  ends  passed  out  of  intestine  ;  B,  B,  Showing,  first,  manner  of  tying  mesenteric  suture — and,  sec- 
ondly, manner  of  passing  ends  of  suture  out  of  intestine.     (Modified  from  Lee.) 


Fig.652. — Entero-enterostomy  by  Lee's  Intestinal  Holder  : — Manner  of  placing  and  end- 
ing the  right-angled  continuous  sutures  upon  the  aspect  of  the  intestine  further  from  surgeon. 
(Modified  from  Lee.) 


The  instrument  is  now  folded  and  withdrawn  (Fig.  654) — leaving  two  free 
ends  of  silk  ready  to  be  tied.  (7)  To  enable  the  ends  to  be  knotted  on  the 
interior,  a  threaded  needle  is  insinuated  between  the  stitches  of  the  opposite 

57 


8o8 


OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 


side,  the  eye  first — and  is  pushed  upward  until  the  threaded  eye  protrudes 
through   the  opening  formerly  occupied   by  the  handle  of  the  instrument. 


Fig.  653.— Entero-enterostomy  by  Lee's  Intestinal  Holder  :— Manner  of  placing  and 
ending  the  right-angled  continuous  sutures  upon  the  aspect  of  the  intestine  nearer  the  surgeon. 
(Modified  from  Lee.  1 


Fig.654.— Entero-enterostomy  by  Lee's  Intestinal  Holder  :— A,  Holder  closed  and  with- 
drawn from  intestine;  B,  Ends  of  the  two  sutures  emerging  from  the  same  side  and  within  the  in- 
testine ;  C,  Loop  introduced  upon  head  of  needle  through  suture-line  at  D,  under  which  loop  the  ends 
of  the  main  suture  are  caught  and  withdrawn  at  D.     (Modified  from  Lee.) 


ENTERO-ENTEROSTOMY    WITH    LEES    INTESTINAL    HOLDER. 


899 


The  thread  of  the  needle  is  then  loosened  into  a  loop,  under  which  the  free 
ends  of  the  two  sutures  are  passed — and  by  means  of  which  these  free  ends 
are  drawn  out  when  the  needle  is  withdrawn  through  the  line  of  suturing, 
at  the  point  where  the  head  of  the  needle  was  pushed  through.  (8)  These 
sutures  are  then  knotted,  during  which  process  the  bowel  is  flattened  and 
its  mucous  membrane  near  the  final  half-knots  is  approximated  to  the  site 
where  the  sutures  are  being  tied — the  sutures  are  then  cut  short — and  the 
knots  slip  into  place  and  the  intestine  regains  its  form  by  a  little  manipulation 
(Fig- 655). 

Comment. — Any  other  less  intricate  form  of  suturing  may  be  used.     Rein- 
forcing Lemberts  may  be  used  if  thought  necessary. 


Fig.  655.— Entero-enterostomy  by  Lee's  Intestinal  Holder: — Tying  the  final  knot  upon  the 
outside — which,  upon  cutting  the  threads,  recedes  within  the  intestine.     (Modified  from  Lee.) 


EXCISION  OF  THE  ILEO-CECUM. 

Description. — Consists  in  the  removal  of  the  caecum,  together  with  more 
or  less  of  the  adjoining  portions  of  the  ileum  and  ascending  colon — followed 
by  some  form  of  entero-enterostomy  between  the  small  and  large  intestines. 
The  operation  is  generally  resorted  to  for  malignant  or  tubercular  disease 
of  this  region,  or  for  intussusception  of  this  portion. 

Preparation — Position — Landmarks. — As  for  Appendicectomy  (page 
900). 

Incision. — About  13  cm.  (5  inches)  long,  beginning  in  the.  anterior 
axillary  line  (a  vertical  line  from  the  anterior  border  of  the  axilla),  midway 
between  the  lower  margin  of  the  costal  cartilages  and  the  iliac  crest — passing 


900  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

downward  to  within  about  4  cm.  (ij  inches)  of  the  anterior  superior  iliac 
spine — and  thence  obliquely  downward  and  forward,  parallel  with  the  outer 
half  of  Poupart's  ligament,  ending  to  the  outer  side  of  the  position  of  the 
external  iliac  artery. 

Operation. — (1)  Divide  the  skin,  fascia,  external  oblique,  internal  ob- 
lique, transversalis,  transversalis  fascia,  subperitoneal  connective  tissue,  and 
peritoneum.  The  size  and  condition  of  the  parts  generally  necessitates  an 
operation  of  a  magnitude  too  great  for  the  intramuscular  method  of  opening 
the  abdomen— but  in  so  far  as  this  method  can  be  adopted,  it  should  be 
carried  out.  Both  the  muscular  and  aponeurotic  portions  of  the  external 
oblique  can  ordinarily  be  separated  in  the  cleavage  line.  The  abdominal 
vessels  and  nerves  should  be  preserved  as  far  as  possible.  Having  exposed 
the  abdominal  cavity,  retract  the  lips  of  the  wound  well  and  deeply.  (2) 
If  adherent  omentum  be  encountered,  ligate  off  with  gut  and  divide.  (3) 
Separate  the  caecum  from  the  iliopsoas  fascia  upon  which  it  lies.  This  is 
accomplished  by  displacing  the  caecum  and  colon  inward  and  cutting  through 
the  peritoneum  along  the  outer  aspect  of  the  caecum  and  colon  where  it  binds 
those  structures  to  the  posterior  abdominal  wall,  ligating  where  necessary 
with  gut.  These  structures  are  then  displaced  outward  and  the  peritoneum 
divided  along  the  inner  side — but  on  this  side  the  colic  vessels  are  encountered 
as  they  diverge  to  supply  the  bowel — so  that  this  region  is  ligated  off  in  sections 
and  divided.  This  inner  line  will  cross  the  ileum  where  it  joins  the  colon. 
The  mesentery  of  this  small  intestine  is  ligated  in  sections,  as  far  as  may 
be  necessary,  and  divided.  (4)  Having  thus  freed  the  caecum  and  several 
inches  of  both  colon  and  ileum,  the  contents  of  the  bowel  are  pushed  away, 
the  intestines  clamped,  the  neighboring  regions  protected  with  gauze  packing, 
and  the  intestines  divided  at  a  right  angle  to  their  axis.  (5)  Having  excised 
the  ileo-caecal  region,  an  entero-enterostomy  is  accomplished  in  one  of  the 
following  ways  (previously  described  in  detail) : — (a)  End-to-end  approxima- 
tion by  simple  suturing,  by  Murphy's  button,  or  by  Maunsell's  invagination 
method — the  first  or  second  probably  being  preferable;  (b)  Invaginate  the 
ends  of  both  guts  by  overhand  followed  by  Lembert  sutures,  and  then  make 
a  lateral  anastomosis  between  the  ileum  and  colon  by  simple  suture,  or  by 
a  Murphy  button  (or  by  one  of  the  other  methods  already  described) ;  (c) 
Divide  the  ileum  obliquely,  to  give  a  larger  opening,  and  unite  it  to  the  trans- 
verselv  divided  colon  by  simple  suturing — (often  the  ileum  has  been  dis- 
tended so  long,  by  obstruction  below,  that  it  has  become  the  same  size  as 
the  colon) ;  (d)  Close  the  end  of  the  colon  by  invagination,  by  a  double  row 
of  sutures,  and  then  implant  the  end  of  the  ileum  upon  the  lateral  aspect 
of  the  colon  (resembling  nature's  junction  of  the  small  and  large  intestines). 
(6)  Drop  the  parts  back  into  the  abdomen,  and  close  the  abdomen,  with 
or  without  drainage,  as  indicated,  as  in  abdominal  section. 

Comment. — Remove  all  diseased  glandular  tissue. 

APPENDICECTOMY 

BY  McBURNEY'S  INTRAMUSCULAR  OPERATION. 

Description. — Appendicectomy  consists  in  the  removal  of  the  appendix 
vermiformis.  The  feature  of  McBurney's  operation  is  based  upon  the 
exposure  of  the  appendix  through  a  successive  separation,  in  the  cleavage 
line,  of  the  overlying  abdominal  muscles  and  aponeuroses.  The  fibers  of 
the  muscles  and  aponeuroses  are  not  cut  but  are  separated.  The  appendix 
is  exposed  and  is  treated  by  one  of  several  methods.     This  form  of  the  opera- 


APPEXDICECTOMY.  901 

tion  is  chiefly  applicable  to  the  "  interval  period  "  of  appendicitis — but  is 
sometimes  used  in  acute  cases  and  in  pus  cases. 

Preparation. — Site  of  incision  to  be  shaved. 

Position. — As  in  median  abdominal  section. 

Landmarks. — McBurney's  point,  which  is  located  on  an  imaginary  line 
extending  from  the  anterior  superior  iliac  spine  to  the  umbilicus,  at  a  distance 
of  3.8  cm.  (1^  inches)  internal  to  the  anterior  superior  iliac  spine. 


Fig.  656. — McBurney's  Intramuscular  Appendicectomy : — I. — Separation  of  the 
fibers  of  the  external  oblique  in  their  cleavage  line  by  blunt  dissection  with  the  handle  of  a 
knife. 

Incision. — Commences  about  2.5  cm.  (1  inch)  above  the  imaginary  line 
just  mentioned,  and  passes  obliquely  downward  and  inward  in  the  direction 
of  the  fibers  of  the  external  oblique  muscle  and  aponeurosis — crossing  the  above 
line  at  McBurney's  point — and  ending  about  the  same  distance  below  as  above 
it.  The  length  of  the  incision  may  be  greater  or  less  than  the  above,  according 
to  the  space  required.  A  free  skin  incision  greatly  aids  the  muscular  retraction 
(Fig.  576,  E). 

Operation. — (i)   Having  incised  the  skin  and  fascia  in  the  above  lin 
(which  will  correspond  with  the  cleavage  line  of  the  skin),  and  having  co 


902 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


trolled  hemorrhage  and  retracted  the  lips  of  the  wound,  the  muscular  and 
tendinous  fibers  of  the  external  oblique  will  be  exposed.  (2)  Incise  the  exter- 
nal oblique  with  a  sharp  scalpel,  directly  in  a  line  with  its  muscular  fibers 
above,  and  their  tendinous  continuation  into  the  aponeurosis  below — con- 
tinuing the  separation  with  scalpel  and  scissors,  incising  between  the  fibers 
without  severing  them  (Fig.  656) .  The  two  lips  of  the  incised  external 
oblique  are  drawn  respectively  upward  and  inward,  and  downward  and  out- 


Fig.  657. — McBurney's  Intramuscular  Appendicectomy: — II. — The  separated  fibers 
of  the  external  oblique  are  retracted  upward  and  inward  and  downward  and  outward.  The 
fibers  of  the  internal  oblique  are  being  separated  in  their  cleavage  line.  The  libers  of  the  trans- 
versalis  are  seen  in  the  floor  of  the  wound.  Branches  of  the  hypogastric  and  ilioinguinal  nerves 
and  lumbar  arteries  lie  between  the  internal  oblique  and  transversalis. 

ward — thus  exposing  the  intermuscular  fascia  between  the  external  and 
internal  oblique.  (3)  The  sheath  and  fibers  of  the  internal  oblique  (the  muscle 
being  here  quite  thick)  are  now  similarly  separated  by  scalpel,  scissors,  or  blunt 
dissection,  in  the  line  of  their  cleavage  (which  is  nearly  at  a  right  angle  to  the 
cleavage  line  of  the  fibers  of  the  external  oblique),  the  center  of  the  separation 
of  the  fibers  being  about  opposite  the  anterior  superior  iliac  spine.  The  lips 
of  the  internal  oblique  are  now  retracted  respectively  upward  and  outward, 


APPENDICECTOMY.  903 

and  downward  and  inward — thus  exposing  the  intermuscular  fascia  between  the 
internal  oblique  and  transversalis.  Guard  with  special  care  all  nerves  lying 
in  this  intermuscular  plane  (Fig.  657).  (4)  The  fibers  of  the  transversalis, 
which,  for  practical  purposes,  run  very  nearly  in  the  same  direction  as  those  of 
the  internal  oblique,  are  now  similarly  separated  in  their  cleavage  line.  The 
lips  of  the  transversalis  may  be  separately  retracted  upward  and  downward, 
but  are  generally  included  in  the  grasp  of  the  same  retractors  which  retract 


Fig.  658. — McBcrxey's  Intramuscular  Appendicectomy : — III. — The  fibers  of  the 
external  oblique  are  retracted  as  above.  The  fibers  of  the  internal  oblique  are  retracted  upward 
and  outward  and  downward  and  inward — beneath  which  are  seen  the  separated  fibers  of  the 
transversalis — and  in  the  interval  lie  the  appendix  and  caecum. 

the  internal  oblique.  The  transversalis  fascia  at  the  bottom  of  the  wound  is 
thus  exposed  for  2.5  cm.  (1  inch)  or  more.  (5)  The  transversalis  fascia  is 
grasped  with  forceps  and  divided  in  the  line  of  the  transversalis  muscle  (trans- 
versely)— when  the  subserous  areolar  tissue  and  peritoneum  will  be  exposed. 
(6)  The  peritoneum  is  grasped  with  two  delicate  toothed  forceps,  manipulated 
as  in  the  median  abdominal  section,  and  divided  with  scissors  to  a  limited  and 
guarded  extent.     One  blade  of  the  scissors  is  then  carefully  introduced  within 


904  OPERATIONS    UPON    THE    ABDOM1NO-PELVIC    REGION, 

the  abdominal  cavity  and  the  opening  enlarged  toward  the  median  line  and 

~1 


Fig.  659.— Appendicectomy  :— A,  Caecum;   B,  Ileum;  C,  Appendix;  D,  D,  Ligatures  tying  off  the 

mesentery  of  the  appendix. 

the  anterior  superior  iliac  spine.     The  subperitoneal  areolar  tissue,   trans- 
versalis  fascia,   and  peritoneum   may  be   simultaneously  incised — but  it  is 


Fig. 660—  Appendicectomy:— A,  Edges  of  the  mesenteriolum  sutured  together;  B,  B,  Purse-string 
suture  placed,  the  loop  being  grasped  by  forceps  and  the  ends  free. 

better  to  incise  down  to  and  recognize  the  peritoneum,  and  then  to  incise  it 
separately  and  alone  (Fig.  658). 


APPENDICECTOMY. 


9°5 


Operation. —The  right  index-finger  is  inserted  within  the  abdominal 
cavity  and  the  appendix  sought.  The  caput  coli,  or  some  part  of  the 
ascending  colon,  is  generally  encountered  at  once — and  may  even  bulge 
into  the  wound.  Sometimes  the  appendix  itself  presents  at  once— though 
exceptionally.  If  the  appendix  is  not  at  once  manifest,  its  base  is  sought 
in  its  usual  position— that  is,  upon  the  internal  and  posterior  aspect  of  the 
caecum,  about  1.7  cm.  (ji  inch)  below  the  ileo-caecal  valve.  If  the  appendix 
is  not  readily  found  by  this  manoeuvre,  draw  out  the  first  part  of  the  ascending 
colon  encountered,  and  then  follow  it  down  to  the  caput  coli — the  anterior 
of  the  three  longitudinal  bands  of  the  colon  will  lead  to  the  base  of  the  appendix. 


Fig.   661. — Appendicectomy  : — Dilatation    of    canal   of    thickened    appendix    preparatory   to 
invagination,  where   invagination  would  be  otherwise  difficult. 

The  appendix  is  now  drawn  out  of  the  wound,  and  its  treatment  will  depend 
upon  the  nature  of  the  appendix  and  the  individual  views  of  the  operator. 
(See  Fig.  659.)  (7)  As  soon  as  the  appendix  has  been  delivered  without  the 
abdominal  cavity,  it  is  well  to  pass  a  silk  ligature,  upon  an  aneurism-needle, 
around  the  appendix,  about  2  cm.  (f  inch)  from  its  base,  piercing  its  mesentery. 
This  ligature  may  be  tightened  at  once  or  later — it  is  only  a  temporary  traction- 
ligature  or  its  tip  may  be  grasped  with  forceps.  The  mesentery  of  the  appendix 
should  be  ligated  off  with  chromic  gut,  carried  in  a  laterally  curved  aneurism- 
needle,  proceeding  from  apex  to  base,  or  in  the  opposite  direction  if  more  con- 
venient— and  tied  in  sections — the  mesentery  being  then  divided  between 


906  OPERATIONS    UPON   THE    ARDOMINO-PELVIC    REGION, 

appendix  and  ligatures.     The  main  artery  near  the  base  should  be  securely  tied. 


Fig.662.— Appendicectomy  : — The  stump  of  the  appendix  being  invaginated  in  the  grasp  of  forceps, 
and  the  purse-string  about  to  be  tightened. 

If  bound  down  by  adhesions,  these  should  be  separated  by  blunt  dissection, 
or  ligated  and  cut.     Often  the  mesentery  of  the  appendix  must  be  ligated  off 


Fig.663.— Appendicectomy  :— A,  The  free  ends,  after  knotting,  of  the  purse-string  which  has 
invaginated  the  stump  of  the  appendix  into  the  caecum  ;  B,  Position  which  reinforcing  Lemberts 
would  occupy,  if  used  ;  C,  The  sutured  edge  of  the  mesenteriolum. 

within  the  wound  before  the  appendix  can  be  delivered.     The  peritoneum 
should  be  sutured  over  the  stump  of  the  mesentery.     The  appendix  is  now 


APPENDICECTOMY. 


907 


treated  in  one  of  several  ways.     It  is  well  to  ascertain  the  patulousness  of  the 
lumen  of  the  stump  in  advance,  by  the  passage  of  a  probe  through  its  canal 


Fig. 664.— Appendickctomv  :— A  Method  of  Dealing  with  Thick  Appendices,  by  Ligation 
and  Depression  into  Cecum  : — A,  Clamping  off  appendix  from  caecum  ;  B  (to  left),  Cuff  of  serosa 
turned  back  ;  C,  Stump  of  appendix  ligated  ;  B  (to  right),  Edges  of  meseiiteriolum  sutured. 


Fig.  665.— APPENDICECTOMY: — A.  Stump  of  appendix  depressed  into  caecum  ;   B,  Interrupted  Lembert 
sutures  closing  serosa  over  stump  ;  C,  Sutured  edges  of  mesenteriolum. 

into  the  caecum,  that  drainage  into  the  main  intestine  may  be  assured.     The 
following  methods  of  closing  the  appendix  may  be  used; — (a)   Dawbarn's 


908 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


Purse-string  Method;  a  continuous  silk  purse-string  suture,  carried  upon  a 
straight  needle,  is  passed  through  the  serous  and  muscular  coats  of  the  caecum 


Fig.  666.— Appendicectomy  : — The  depressed  appendix-stump  and  the  invaginated  serosa  themselves 
invaginated  into  the  caecum  by  a  purse-string  suture  of  the  surrounding  area. 


Fig.  667. — Halsted's  Three-clamp  Method  or  Removing  the  Appendix: — I. — 
Dawbarn's  purse-string  suture  surrounds  the  base  of  the  appendix.  The  artery  of  the  mesentery 
is  ligated  and  the  severed  margins  sutured  by  an  overhand  suture.  The  appendix  is  crushed 
by  three  parallel  artery-clamps. 

in  a  circle,  about  6  mm.  (J  inch)  from  the  base  of  the  appendix,  but  not  first 
tied.     (See  Fig.  660.)     The  loop  opposite  the  free  ends  of  this  purse-string 


APEND1CECTOMY 


909 


suture  is  grasped  by  forceps  held  by  an  assistant,  to  steady  the  appendix  against 
the  counter-pull  of  the  operator,  who  holds  the  free  ends.  The  appendix  is  then 
divided  transversely  about  1.2  cm.  (J  inch)  from  its  base — the  canal  of  the 
stump  may  be  dilated  with  special  fine  forceps  (to  aid  in  invagination) — 
and  sometimes  sterilized  by  the  actual  cautery  point — the  free  end  of  the 
stump  is  then  seized  with  the  same  forceps  and  invaginated  into  the  caecum. 
(See  Fig.  661.)  While  the  stump  of  the  appendix  is  held  invaginated  into 
the  caecum,  the  operator  draws  upon  the  free  ends  of  the  purse-string  suture 
(which  have  been  loosely  knotted  with  a  friction-knot)  until  the  slack  of 
the  loop  held  by  the  assistant  is  taken  up — the  assistant,  letting  go  his  grip 


Fig.  668. — Halsted's  Three-clamp  Method  of  Removing  the  Appendix: — II. — 
The  central  clamp  is  removed  and  the  append  x  severed  through  its  crushed  portion  by  the 
actual  cautery. 


of  the  loop  with  the  forceps,  takes  the  two  free  ends  of  the  suture — tightening 
the  friction-knot  accurately  at  the  very  moment  the  operator  quickly  with- 
draws the  invaginating  forceps.  A  second  knot  is  tied  and  the  ends  cut 
short.  (See  Fig.  662.)  If  considered  necessary,  two  or  three  interrupted 
gut  Lemberts  may  be  used  to  further  bury  in  the  stump.  (See  Fig.  663.) 
This  method  of  closure  is  especially  applicable  to  appendices  whose  walls 
are  of  more  or  less  natural  thickness  and  softness — capable,  in  other  words, 
of  invagination,  (b)  Divide  circularly  the  peritoneal  coat  of  the  appendix 
about  6  mm.  (I  inch)  from  the  caecum — peel  back  this  serous  coat  toward 


910 


OPERATIONS    UPON    THE    ABDOM1M  >-PELYIC    REGION. 


the  caecum — and,  on  a  level  with  the  turned-back  serosa,  divide  the  middle 
and  internal  coats  of  the  appendix  very  near  the  caecum.  (See  Fig.  664.) 
See  that  the  lumen  of  the  stump  is  patulous  by  means  of  a  probe,  and  cauterize 
the  interior  of  the  stump  with  a  fine  Paquelin  point.  The  edges  of  the  stump 
are  then  brought  together  either  by  fine  silk  sutures  or  by  circular  ligature. 
This  short  stump  itself  is  then  depressed  (rather  than  invaginated)  into  the 
caecum  (see  Fig.  665) — and,  after  suturing  the  serosa  over  the  stump,  the 
surrounding  area  of  the  caecum,  to  the  extent  of  3  mm.  (£  inch)  from  the 
base  of  the  appendix,  is  invaginated  by  means  of  a  purse-string  suture  which 
had  been  previously  placed  in  the  same  manner  as  in  the  last  method.  (See 
Fig.  666.)  Additional  interrupted  gut  Lemberts  may  bring  the  edges  of  the 
furrow  together,  if  considered  necessary.     This  method  is  particularly  appli- 


Fig.  669. 


-The  Dissection  of  an  Adherent,  Embedded  Appendix — with  the  Suturing 
of  the  Peritoneum  over  its  Denuded  Bed. 


cable  to  thick,  hard,  narrow-calibered  appendices,  (c)  The  peritoneal  coat 
may  be  peeled  back — the  middle  and  internal  coats  divided  transversely — 
and  the  peritoneal  coat  sutured  over  the  cut  middle  and  internal  coats  with 
Lemberts.  (d)  The  mucous  coat  may  be  excised  with  fine,  curved,  sharp- 
pointed  scissors,  or  burnt  out  with  the  actual  cautery — and  the  serous  and 
muscular  coats  sutured  over  it.  (e)  The  same  steps  may  be  carried  out 
as  in  "b,"  except  that  the  stump  may  be  simply  depressed  into  the  caecum 
and  the  walls  of  the  caecum  brought  together  with  Lembert  sutures  in  a 
straight  line,  (f)  The  Halsted  "three-clamp"  method  of  removing  the 
appendix  is  especially  to  be  recommended.  The  appendix  is  clamped  near 
its  base  with  a  clamp  strong  enough  to  crush  it  (a  large  size  artery-clamp) — 
a  second  one  is  applied  above  this,  with  handle  in  the  opposite  direction— and 


APPENDICECTOMY.  911 

a  third  one  below  the  middle  one,  with  its  handle  running  with  the  uppermost 
(Fig.  667).  The  middle  clamp  is  then  removed — and  the  crushed  appendix 
severed  with  the  actual  cautery — after  which  it  is  invaginated  into  the  caecum 
and  the  purse-string  suture  tightened — and  the  site  reinforced  by  two  or  more 
Lemberts  (Fig.  668).  (8)  The  appendix  having  been  removed  and  its 
stump  sutured,  the  bowel  is  returned  to  the  abdominal  cavity — and  the  wound 
closed  in  the  usual  manner.  Drainage  is  ordinarily  not  employed — unless 
specially  indicated. 

Comment. — (i)  If  at  any  time  during  the  operation  more  room  be  required, 
this  may  be  gained  by  continuing  the  separation  either  upward  or  downward. 
In  the  latter  direction  the  separation  is  accomplished  by  the  Harrington- Weir 
method  (page  810).  (2)  It  often  happens  that  the  appendix  must  be  dis- 
sected from  a  mass  of  more  or  less  dense  adhesions — in  which  cases  the 
denuded  bed  should  be  protected  by  suturing  peritoneum  over  it. 


APPENDICECTOMY  THROUGH  THE  RECTAL  SHEATH. 

Description. — This  is,  practically,  the  Battle- Jalaguier-Kammerer  oper- 
ation (page  811) — and  is  especially  adapted  to  acute  cases,  or  cases  in  which 
complications  are  apt  to  be  encountered  and  in  which,  therefore,  the  freest 
possible    exposure    is    necessary. 


APPENDICECTOMY 

BY    THE    NOX -INTRAMUSCULAR    METHOD. 

Description. — In  this  operation  no  attempt  is  made  to  separate  the 
muscle-fibers  of  the  abdominal  wall,  which  are  freely  cut  where  they  cross 
the  line  of  incision.  The  method  is  applicable  to  "interval"  and  to  pus 
cases — but  guards  the  abdominal  wall  from  hernia  less  well  than  does  the 
method  just  described. 

Preparation — Position. — As  in  the  Intramuscular  Operation  (page  901). 

Landmarks. — Anterior  superior  iliac  spine;  umbilicus;  outer  border  of 
right  rectus  muscle. 

Incision. — Draw  an  imaginary  line  from  the  anterior  superior  iliac  spine 
to  the  umbilicus — the  incision  will  begin  about  2.5  cm.  (1  inch)  above  this 
line,  and  will  run  obliquely  downward  and  inward,  parallel  with  and  about 
1.2  cm.  (h  inch)  to  the  outer  edge  of  the  right  rectus  muscle. 

Operation. — (i)  The  incision  divides  skin  and  fascia — passes  through 
the  external  oblique  approximately  parallel  with  its  fibers — divides  the  internal 
oblique  and  transversalis  more  or  less  transversely,  and  just  to  the  outer  side 
of  the  ending  of  their  muscular  fibers.  (2)  All  bleeding  vessels  are  seized, 
and  the  wound  well  retracted.  (3)  Divide  the  fascia  transversalis,  subperi- 
toneal areolar  tissue,  and  peritoneum  in  the  line  of  the  original  wound  and 
with  the  usual  precautions — especially  guarding  against  adhesions.  (4) 
Having  opened  the  abdomen  and  retracted  the  lips  of  the  wound  well,  the 
isolation  and  treatment  of  the  appendix  are  carried  on  just  as  in  the  Intra- 
muscular operation  of  McBurney  (page  901).  (5)  And  the  wound  is  closed 
as  in  median  abdominal  section  (page  805). 


912  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

APPENDICOSTOMY. 
weir's  operation. 

Description. — The  operation  is  practically  an  enterostomy — in  which  the 
appendix  is  made  to  open  upon  the  skin  surface — and  through  which  drainage 
and  irrigation  of  the  intestinal  tract  are  carried  on.  This  measure  finds  its 
chief  application  in  intractable  cases  of  amebic  dysentery.  The  appendix 
is  exposed  through  the  steps  of  the  McBurney  intramuscular  exposure  of  the 
organ. 


I 

Fig.  670. — Appendicostomy  : — The  appendix  is  seen  emerging  from  between  the  separated 
fibers  of  the  internal  oblique,  below — and  between  the  separated  fibers  of  the  external  oblique, 
above.     A  rubber  tube  is  in  its  lumen. 

Preparation — Position — Landmarks — Incision. — As  in  McBurney's 
intramuscular  appendicectomy  (page  901). 

Operation. — The  steps  of  the  operation  are  carried  out  as  detailed  in  the 
above  operation.  The  appendix  is  isolated  and  delivered  through  the  smallest 
available  intramuscular  opening  (Fig.  905).  Whatever  adhesions  are  encoun- 
tered are  separated.     The  appendix  is  put  under  gentle  traction  and  drawn 


ENTEROSTOMY    IN    GENERAL.  913 

out  of  the  abdomen  until  its  base  is  in  contact  with  the  parietal  peritoneum — 
where  it  is  anchored  to  the  parietal  peritoneum  by  two  catgut  stitches,  one 
through  the  mesoappendix  and  one  through  the  seromuscular  coats  of  the 
antimesenteric  aspect  of  the  appendix.  The  muscles  are  all  allowed  to  fall 
together — and  are  reinforced  by  catgut  suturing  if  indicated.  The  skin  and 
fascia  are  sutured  up  to  the  exit  of  the  appendix.  The  appendix  itself,  at  its 
exit  from  the  outer  surface  of  the  abdominal  wall,  is  anchored  to  the  skin  by 
two  seromuscular  stitches  of  silkworm-gut.  If  practicable,  the  appendix  is 
not  opened  for  a  couple  of  days — delaying  until  the  general  cavity  is  shut  off 
by  adhesions.  The  end  of  the  appendix  is  then  cut  off  transversely.  Through 
its  lumen  a  rubber  or  silk  catheter  is  passed  on  into  the  caecum — and  through 
this  catheter  the  bowel  is  irrigated  or  drained.  The  catheter  may  remain 
in  situ  or  be  introduced  during  irrigations.  When  the  appendicostomy  has 
ceased  to  be  of  service,  the  wound  sometimes  closes  spontaneously.  At  other 
times  the  abdomen  must  be  opened,  by  a  repetition  of  the  original  steps  and 
the  appendix  removed  in  the  usual  manner. 

Comment. — In  some  cases  the  appendix  can  not  be  brought  into  the  wound, 
owing  to  its  situation  or  to  adhesions,  and  in  such  cases,  a  caecostomy  may 
be  done  through  the  same  wound.  This  latter  technic,  indeed,  is  preferred 
by  some  surgeons  to  an  appendicostomy. 


ENTEROSTOMY  IN  GENERAL. 

Description. — (1)  Enterostomv  consists  in  the  making  of  a  more  or  less 
permanent  opening  into  some  part  of  the  intestinal  canal,  for  the  purpose 
of  relieving  obstruction  or  of  furnishing  nourishment — the  opening  thus  made 
communicating  with  the  external  abdominal  surface.  This  opening  may  be 
a  Jejunostomy,  Ileostomy,  or  Colostomy.  When  not  specially  designated. 
Enterostomy  is  generally  understood  to  mean  an  opening  of  the  small  intes- 
tine, in  which  sense  it  will  be  here  used.  (Enterotomy  has  been  incorrectly 
used  to  designate  this  operation.)  If  the  opening  be  made  high  up  in  the 
small  intestine,  it  may  serve  as  an  artificial  mouth  for  nourishment  (e.  g., 
jejunostomy,  near  the  stomach).  If  the  opening  be  low  down  in  the  small 
intestine  (e.  g.,  an  ileostomy,  low  down),  or  anywhere  in  the  large  intestine 
(e.  g.,  colostomy),  it  will  serve  the  role  of  artificial  anus.  In  the  last  category 
of  cases  it  is  generally  performed  for  some  more  or  less  permanent  obstruction, 
the  opening  being,  of  course,  above  the  seat  of  obstruction.  (2)  The  manner 
of  performing  enterostomy  will  differ — as  to  whether  a  temporary  opening  is 
sought,  which  will,  of  its  own  accord,  tend  to  close, — namely,  a  fecal  fistula, 
which  is  generally  done  in  some  form  of  removable  obstruction, — or  whether 
a  permanent  opening  is  desired,  which  will,  through  a  spur-like  formation, 
tend  to  remain  patulous — namely,  an  artificial  anus,  which  is  generally  done 
in  some  form  of  irremovable  obstruction.  The  technic  of  enterostomy, 
whether  for  artificial  mouth,  temporary  fecal  fistula,  or  permanent  artificial 
anus,  is  practically  the  same  as  that  for  colostomy  performed  for  temporary 
fecal  fistula  or  permanent  artificial  anus — the  chief  difference  being  in  the 
site  of  the  operation.  (3)  Enterostomy  (of  the  small  intestine)  is  generally 
done  upon  the  right  side,  and  as  near  the  caecum  as  possible.  Where  the 
operation  is  done  for  obstruction,  the  site  is,  naturally,  always  above  the 
obstruction.  The  operation  may  be  done  in  the  median  line  or  upon  the 
left  side.  Frequently,  especially  in  desperate  and  weak  cases,  the  first  coil 
of  distended  gut  is  opened.  A  permanent  artificial  anus  is  generallv  made, 
58 


914  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

where  possible,  in  the  course  of  the  descending  colon,  a  description  of  which 
is  given  under  colostomy.  (4)  The  cause  having  been  removed,  for  which 
the  fecal  fistula  or  artificial  anus  has  been  made,  it  is  indicated  to  close  the. 
opening  by  operation  if  nature  does  not  do  so.  (5)  The  site  of  choice  for 
opening  the  intestine  for  temporary  fecal  fistula,  or  permanent  artificial  anus, 
is  in  the  colon.     (See  Colostomy,  page  916.) 


RIGHT  INGUINAL  ENTEROSTOMY  (OR  ILEOSTOMY)  FOR  THE  ESTAB- 
LISHMENT  OF  A   TEMPORARY    FECAL   FISTULA   OR   A 
PERMANENT  ARTIFICIAL  ANUS. 

Description. — (A)  Temporary  Fecal  Fistula  0}  Small  Intestine.- — An  in- 
cision having  been  made  in  the  right  inguinal  region,  the  first  distended  coil 
of  intestine  above  the  caecum  is  drawn  out  and  attached  to  the  abdominal 
wall,  on  a  level  with,  or  but  slightly  projecting  above,  its  surface.  While  the 
operation,  as  originally  devised  by  Nelaton,  did  not  follow  the  intramuscular 
lines,  it  should  do  so  where  possible.  No  attempt  is  ordinarily  made  to 
remove  the  cause  of  the  obstruction.  The  opening  is  meant  to  be  but 
temporary,  and  if  it  does  not  close  spontaneously,  it  is  closed  by  operation 
subsequently. 

(B)  Permanent  Artificial  Anus  of  Small  Intestine. — Enterostomy  for  the 
establishment  of  a  permanent  artificial  anus  differs  from  enterostomy  for  tempo- 
rary fecal  fistula,  in  that  the  former  is  performed  in  cases  where  the  obstruction 
is  irremovable,  and  also  where  it  is  sought  to  prevent  the  passage  of  intestinal 
contents  into  the  limb  of  the  bowel  below  the  opening.  The  typical  operation 
of  enterostomy  for  the  establishment  of  a  permanent  artificial  anus  is  seen  in  the 
operation  of  Colostomy  (as  performed  for  inoperable  obstruction  of  the  rectum, 
q.  v.) .  The  operation  to  be  here  considered  is  simply  an  application  of  those 
principles  to  cases  of  the  small  intestine  where,  upon  opening  the  small  bowel 
above  the  seat  of  obstruction,  it  is  found  the  opening  must  be  more  or  less 
permanent.  It  is  even  of  greater  importance  that  a  permanent  artificial 
anus  of  the  small  intestine  should  be  lower  down  than  a  temporary  fecal 
fistula.  It  is  well  to  follow  the  intramuscular  manner  of  abdominal  incision, 
where  possible — both  as  a  guard  against  hernia  and  for  gaining  something 
of  a  sphincteric  control  of  the  intestinal  opening.  The  only  practical  differ- 
ence between  this  and  the  preceding  operation  is  in  the  manner  of  attaching 
the  knuckle  of  intestine  to  the  abdominal  wound. 

Preparation. — As  for  median  abdominal  section. 

Position. — Patient  supine,  with  right  side  near  edge  of  table.  Surgeon 
on  side  of  operation — assistant  opposite. 

Landmarks. — Outer  portion  of  Poupart's  ligament;  deep  epigastric 
artery. 

Incision. — About  5  to  7.5  cm.  (2  to  3  inches)  (according  to  the  thickness 
of  the  abdominal  wall) — placed  about  4  cm.  (1^  inches)  above  and  parallel 
with  the  outer  part  of  Poupart's  ligament,  and  external  to  the  deep  epigastric 
artery. 

Operation  for  Temporary  Fecal  Fistula  of  Small  Intestine. — (1) 
Having  followed  the  steps  of  the  intramuscular  incision  of  the  abdominal 
wall  (page  807)  and  retracted  the  lips  of  the  wound,  the  caecum  is  sought 
with  the  finger  and  located  as  a  rallying-point.  The  site  of  the  obstruction 
is  then  located  if  possible,  and,  if  so,  the  first  distended  coil  of  intestine  above 
the  obstruction  is  caught  and  brought  into  the  wound.     Where  the  source  of 


RIGHT    INGUINAL    ENTEROSTOMY    FOR    TEMPORARY    FISTULA.      915 

obstruction  cannot  be  found,  any  distended  coil  of  intestine  is  taken  and  brought 
forward  (which  will  probably  be  a  portion  of  the  lower  ileum) .  In  bringing  the 
gut  forward  into  the  wound,  its  normal  relations  and  direction  should  be  main- 
tained, as  far  as  possible — and  only  its  convex,  antimesenteric  aspect  should 
project  from  the  wound,  but  this  aspect  should  well  fill  the  portion  of  the  wound 
to  be  left  open,  and  any  excess  of  intestine  from  above  should  be  returned  to  the 
cavity,  that  the  upper  part  may  not  sag  down  upon  the  lower.  (2)  The  excess 
of  length  of  the  wound  is  now  closed  from  either  end,  either  by  through-and- 
through  suturing  of  all  layers  with  silkworm-gut  or  silk,  or  by  layer-suturing 
with  chromic  gut.  When  shortened  to  the  desired  extent,  in  cases  where  the 
length  has  been  excessive — or  from  and  beginning  with  the  first  suture  at 
either  end,  where  the  length  has  only  been  moderate — the  serous  and  muscular 
coats  of  the  intestine  are  included  in  the  suture  at  either  end  of  the  wound, 
thus  fixing  the  gut  to  the  abdominal  wall  at  the  same  time  the  lips  of  the 
ends  of  the  wound  are  approximated.  If  necessary,  two  fixation-sutures  may 
be  applied  laterally,  passing  through  serosa  and  musculosa  of  the  intestine 
and  all  the  layers  of  the  abdominal  wound.  (3)  An  elliptical  area  of  the 
presenting  gut  is  now  sutured  to  the  parietal  peritoneum  by  a  continuous  or 
interrupted  fine  silk  suture,  passing  through  serous  and  muscular  coats  of 
the  intestine,  on  the  one  hand,  and  peritoneum  and  transversalis  fascia,  on 
the  other.  A  second  row  of  continuous  or  interrupted  silk  or  gut  sutures 
may  then  be  placed,  uniting  the  skin  of  the  abdominal  wound  to  the  serous 
and  muscular  coats  of  the  intestine,  including  the  free  margin  of  the  parietal 
peritoneum  external  to  the  elliptical  suture  in  the  presenting  gut.  Or  the 
second  row  of  sutures  may  simply  unite  the  edge  of  the  abdominal  skin  to 
the  free  margin  of  the  parietal  peritoneum.  A  union  considered  firmer  bv 
some  may  be  secured  by  first  suturing  the  parietal  peritoneum  to  the  skin 
all  around  the  permanent  opening — and  then  suturing  the  intestine  to  this. 
(4)  If  haste  be  necessary,  an  opening  is  at  once  made  into  the  lumen  of  the 
gut,  by  a  quick,  controlled  stab  with  a  narrow,  sharp  knife  and  increased 
to  the  desired  extent  with  blunt  scissors  (having  ascertained  that  all  the 
coats  of  the  intestine  have  been  pierced  before  inserting  the  blade  of  the  scis- 
sors). If  no  haste  be  necessary,  a  delay  of  two  or  three  days  for  union  of 
the  serous  surfaces  and  exclusion  of  the  abdominal  cavity  is  preferable 
("operation  in  two  stages").  The  intestinal  contents  are  allowed  to  escape 
of  their  own  accord. 

Comment. — (i)  The  operation  may  be  performed  through  a  median  or 
other  incision — or  the  obstruction  may  be  located  through  a  median  incision 
and  enterostomy  done  through  a  lateral  incision — thus  giving  greater  room 
for  diagnosis  and  possibly  for  correcting  the  cause  of  trouble — the  excess  in 
length  being  closed  in  at  either  end  before  attaching  the  intestine.  Left 
inguinal  enterostomy  may  also  be  done.  (2)  Avoid  wounding  the  deep  epi- 
gastric artery  and  twisting  the  gut.  (3)  As  small  an  opening  as  consistent 
with  efficient  emptying  should  be  made,  to  make  the  subsequent  closing 
easier. 

Operation  for  Permanent  Artificial  Anus  of  Small  Intestine. — (i)  The 
early  steps  of  the  operation  are  the  same  as  when  a  temporary  fecal  fistula  is  to 
be  made  (page  914).  (2)  When  the  knuckle  of  bowel  to  be  drawn  into  the 
wound  is  isolated,  it  is  important  and  necessary  to  determine  which  is  the  prox- 
imal part  of  the  coil.  This  having  been  done,  and  the  knuckle  having  been 
drawn  into  the  wound,  the  excess  of  intestinal  length  which  tends  to  sag  down 
into  and  out  of  the  upper  angle  of  the  wound  is  taken  up  and  passed  on  down 
through  the  lower  angle  of  the  wound  (so  as  to  do  away  with  the  likelihood  of 
future  hernia  of  the  proximal  limb  of  the  intestine  through  the  wound) .     (3) 


0l6  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

The  desired  knuckle  of  intestine  having  been  isolated  and  retained  within 
reach  by  a  temporary  loop  of  silk  passing  through  the  antimesenteric  aspect  of 
its  outer  coats,  the  two  ends  of  the  wound  are  closed  toward  the  center,  as  far  as 
thought  necessary,  by  tier  suture  or  by  through-and-through  suture.  (4)  The 
parietal  peritoneum  is  drawn  out  and  sutured  to  the  abdominal  skin,  or  as 
nearly  in  contact  with  it  as  possible  all  around  the  wound.  (5)  The  knuckle  of 
intestine  is  now  drawn  entirely  out  of  the  wound,  until  the  mesenteric  attach- 
ment is  on  a  level  with  the  skin.  Care  is  taken  that  the  intestine  is  not  twisted 
and  that  the  normal  relations  are  maintained,  as  nearly  as  possible.  Care  is 
also  especially  taken  that  the  proximal  limb  of  the  loop  is  identified  and  kept 
uppermost  in  the  wound,  is  given  plenty  of  room  in  the  opening,  and  that 
it  is  made  to  compress  the  distal  limb  against  the  lower  angle  of  the  wound 
(to  prevent  the  passage  of  intestinal  contents  from  the  proximal  into  the 
distal  limb).  While  held  in  this  position,  the  knuckle  of  intestine  is  sutured 
into  permanent  position — by  continuous  or  interrupted  silk  sutures  passing 
through  the  serous  and  muscular,  and  part  of  the  submucous,  coats  of  the 
intestine,  on  the  one  hand,  and  the  parietal  peritoneum  (which  has  been 
already  attached  to  the  skin)  on  the  other.  (6)  If  no  haste  exist,  the  opening 
of  the  intestine  is  deferred  for  two  or  three  days,  until  serous  adhesions  have 
occurred.  If  haste  be  necessary,  the  opening  may  be  made  at  once,  by  cutting 
out  transversely,  with  scissors,  a  triangular  piece  of  the  whole  thickness  of  the 
intestine,  with  its  base  at  the  free  border  and  its  apex  at  the  mesenteric  attach- 
ment. 

Comment. — (1)  This,  as  well  as  the  operation  for  fecal  fistula,  may  be 
made  in  the  median  or  left  lateral  regions,  but  it  is  even  more  important 
than  in  temporary  fecal  fistula  that  the  opening  be  as  low  as  possible,  to 
prevent  starvation.  (2)  A  somewhat  smaller  opening  in  the  peritoneum  is 
generally  made  than  in  fecal  fistula.  (3)  A  glass  rod  may  be  run  through 
the  mesentery,  as  is  sometimes  done  in  colostomy — to  hold  the  coil  of  intestine 
in  place.  (4)  It  is  well  to  put  a  few  interrupted  Lembert  sutures  along  the 
lateral  aspect  of  the  two  limbs  of  the  knuckle,  where  they  come  in  contact. 
(5)  Where  the  intestine  must  be  opened  at  once,  only  a  limited  opening  is 
then  made — the  permanent  opening  being  made  after  adhesions  form. 

COLOSTOMY  IN  GENERAL. 

Description. — Colostomy  signifies  the  establishment  of  an  artificial  open- 
ing, either  temporary  (fecal  fistula),  or  permanent  (artificial  anus),  in  some 
part  of  the  Colon.  While  a  similar  opening  of  the  caecum  is  termed  cfficos- 
tomy,  and  of  the  sigmoid  colon,  sigmoidostomy,  both  operations  are  generally, 
though  less  specifically,  included  under  the  term  colostomy.  The  descending 
colon  is  the  site  generally  chosen — the  cause  usually  being  obstruction,  or  some 
condition,  distal  to  the  site  of  operation. 

Chief  Varieties  of  Colostomy. — (1)  Inguinal  Colostomy  (Iliac  Colos- 
tomy, Anterior  Colostomy,  operation  of  Littre)  signifies  the  opening  of  the 
sigmoid  flexure  of  the  colon  in  the  left  iliac  region,  through  the  peritoneal 
cavity.  The  ascending  colon  is  much  less  frequently  opened.  (2)  Lumbar 
Colostomy  (Posterior  Colostomy,  operation  of  Amussat)  signifies  the  opening 
of  the  ascending  or  descending  colon,  preferably  the  latter,  through  the  loin, 
extraperitoneallv. 

In  Favor  of  Inguinal  Colostomy. — The  artificial  anus  is  more  conve- 
niently placed; — the  operation  is  both  easier  and  quicker; — the  position  for 
anesthesia  is  better; — the  wound  is  not  so  deep; — there  is  no  chance  of  failing 
because  of  the  presence  of  a  mesentery  (which  sometimes  interferes,  by  its 


LEFT    INGUINAL    COLOSTOMY.  917 

presence,  with  the  operation  posteriorly) ; — the  exploration  of  the  abdomen  is 
possible; — the  shallower  wound  makes  the  formation  of  a  spur,  or  any  other 
indicated  step,  easier. 

In  Favor  of  Lumbar  Colostomy. — The  peritoneum  is  generally  not 
opened; — where  the  sigmoid  colon  is  bound  down,  and  therefore  not  easily 
accessible  by  the  anterior  operation; — prolapse  (hernia)  is  not  so  likely. 

Observations. — (i)  Left  Inguinal  Colostomy  is  the  operation  of  choice. 
Lumbar  colostomy  is  now  rarely  performed.  (2)  The  ascending  colon  has 
a  mesentery  in  26  per  cent. — and  the  descending  colon  in  36  per  cent,  of 
cases  (Treves).  This  means  that  in  those  cases  where  a  mesentery  is  en- 
countered, in  operating  posteriorly,  the  operation  cannot  be  completed  extra- 
peritoneally  unless  the  leaves  of  the  mesenterv  can  be  separated  and  the 
mesenteric  aspect  of  the  colon  thus  approached.  (3)  The  positions  of  the 
ascending  and  descending  colons  are  represented,  in  the  loins,  by  vertical 
lines  drawn  upward  from  a  point  1.3  cm.  (^  inch)  posterior  to  the  center 
of  the  crest  of  the  ilium  (that  is,  a  point  1.3  cm.,  or  \  inch,  posterior  to  a 
point  midway  between  the  anterior  and  posterior  superior  iliac  spines).  (4) 
If  a  temporary  fecal  fistula  be  sought,  no  spur  should  be  formed  in  suturing 
the  knuckle  into  position.  If  a  permanent  artificial  anus  be  sought,  a  spur 
should  be  made  in  the  knuckle,  to  prevent  the  flow  of  contents  of  the  proximal 
into  the  distal  gut.  (5)  By  operating  in  the  intramuscular  manner,  hernia 
is  less  apt  to  follow — and,  additionally,  greater  sphincteric  control  is  secured. 
(6)  Where  a  temporary  opening  is  sought,  the  bowel  is  opened  longitudi- 
nally— and  transversely  where  a  permanent  opening  is  planned. 

LEFT  INGUINAL  COLOSTOMY. 

Description. — Left  Inguinal  (Iliac  or  Anterior)  Colostomy  consists  in 
making  a  more  or  less  permanent  opening  in  the  sigmoid  flexure  of  the  colon, 
in  the  left  iliac  region,  through  the  peritoneal  cavity.  The  manner  of  suturing 
the  intestine  to  the  abdominal  wall  will  differ,  dependent  upon  whether 
a  temporary  fecal  fistula  or  a  permanent  artificial  anus  be  sought.  Also 
the  final  steps  of  the  operation  will  differ,  dependent  upon  whether  the  bowel 
is  to  be  opened  at  once,  or  whether  the  operation  is  to  be  performed  in  two 
stages  and  the  bowel  opened  in  three  or  four  days,  after  adhesions  have 
formed  and  the  peritoneal  cavity  is  shut  off — and  also  as  to  whether  the 
opening  is  to  be  temporary  or  permanent.  The  operation  is  generally  done 
upon  the  left  side — though  it  may  be  done  upon  the  right — the  steps  being  the 
same  in  either  case.  The  operation  is  generally  done  for  some  obstruction 
(usually  cancer  of  the  rectum),  or  other  condition,  distal  to  the  site  of  the 
colostomy. 

Preparation — Position. — As  for  median  abdominal  section. 

Landmarks. — Umbilicus;  left  anterior  superior  iliac  spine;  Poupart's 
ligament. 

Incision. — About  5  to  6.5  cm.  (2  to  2\  inches)  long — crossing,  at  right 
angles,  an  imaginary  line  from  the  umbilicus  to  the  left  anterior  superior 
iliac  spine,  at  a  point  about  4  cm.  (\\  inches)  internal  to  the  iliac  spine,  the 
center  of  incision  being  upon  this  imaginary  line.  The  incision  will,  there- 
fore, be  about  parallel  with  Poupart's  ligament  and  with  the  fibers  of  the 
external  oblique.  This  incision  corresponds  with  McBurney's  incision  for 
appendicectomy,  except  that  it  is  upon  the  left  (see  Fig.  576). 

Operation. — Up  to  the  opening  into  the  peritoneal  cavity,  the  steps  are 
practicallv  the  same  as  in  McBurney's  intramuscular  operation  for  the  re- 
moval of  the  appendix  (page  807).     (•)  Incise  the  skin    and  fascia  in  the 


gi8 


OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 


above  line,  clamping  the  bleeding  vessels.  (2)  Separate  and  retract  the 
fibers  of  the  aponeurosis  of  the  external  oblique  in  the  line  of  their  cleavage. 

(3)  Separate  and  retract  the  fibers  of  the  internal  oblique  in  their  cleavage. 

(4)  Similarly  separate  and  retract,  intramuscularly,  the  fibers  of  the  trans- 
versalis.  (5)  Divide  the  transversalis  fascia  and  subperitoneal  connective 
tissue  in  the  line  of  separation  of  the  transversalis  muscle,  for  about  4  to 
5  cm.  (ij  to  2  inches).  (6)  While  holding  the  parts  apart,  replace  the  re- 
tractors which  have  retracted  the  several  tissues  in  their  cleavage  line  by 
two  retractors — drawing  the  lips  of  the  wound  asunder  in  the  two  most  con- 
venient directions.  (7)  Introduce  the  right  index-finger  into  the  peritoneal 
cavity  toward  the  left  iliac  fossa — entering  at  the  outer  angle  and  passing 
downward  and  toward  the  median  line,  with  the  finger  held  in  a  hook-like 


Fig. 671. —Left  Inguinal  Colostomy — for  Temporary  Fecal  Fistula: — A,  A,  Temporary 
ligatures  drawing  sigmoid  flexure  of  colon  into  wound  ;  B,  B,  Sutures  uniting  peritoneum  and 
lower  part  of  muscular  wall  of  wound,  to  serous  and  muscular  coats  of  intestine  ;  C,  C,  Sutures  pass- 
ing through  peritoneum  and  lower  part  of  muscular  wall,  on  one  side  ;  serous  and  muscular  coats  of 
intestine,  in  center  ;  and  peritoneum  and  lower  part  of  muscular  wall,  on  opposite  side  ;  D,  D,  Sutures 
passing  through  entire  thickness  of  muscular  wall.  Position  of  future  axial  incision  in  colon  is  shown 
by  dotted  lines. 

fashion — hooking  up  the  sigmoid  flexure  of  the  colon  and  bringing  it  out 
into  the  wound — recognizing  it  by  its  appendices  epiploicae,  its  sacculations, 
and  its  longitudinal  bands.  After  drawing  the  loop  well  out,  return  into 
the  lower  angle  of  the  wound  all  the  excess  drawn  out  of  the  upper  angle, 
until  checked  by  the  mesocolon — thus  assuring  that  there  will  be  no  downward 
sagging  of  the  intestine  from  above,  with  consequent  tendency  to  hernia  of 
the  proximal  gut  through  the  artificial  opening.  The  steps  of  the  operation 
from  this  point  on  will  be  determined  by,  (a)  the  object  sought,  as  to  per- 
manency of  opening — and,  (b)  as  to  whether  the  intestine  must  be  opened 
at  once,  (a)  Where  a  temporary  fecal  fistula  is  intended  : — In  this  case 
the  presenting  convexity  alone  (representing  from  one-half  to  three-fourths 
of  the  circumference  of  the  intestinal  tube)  is  sutured  into  the  wound,  the 


LEFT    INGUINAL    COLOSTOMY. 


919 


convexity  of  the  gut  being  held,  during  suturing,  into  contact  with  the  wound 
by  two  silk  traction-sutures  passed  through  the  serous  and  muscular  coats, 
preferably  through  the  superior  longitudinal  band  of  the  colon — (or  this 
aspect  of  the  intestine  maybe  gently  grasped  with  forceps).  (See  Fig.  671.) 
Continuous  or  interrupted  silk  or  chromic  gut  sutures  are  now  passed  through 
the  serous  and  muscular  coats  of  the  intestine,  on  the  one  hand,  and  the 
peritoneum  and  muscle  tissue  of  the  abdominal  wound,  on  the  other — passing 
sufficiently  far  from  the  free  edge  of  the  peritoneum  so  that  some  width 
of  peritoneum  will  be  approximated  to  gut — thus  bringing  serous  surfaces 
into  contact.  Preferably  the  lower  line  of  sutures  is  passed  through  the 
lower  longitudinal  band — and  the  upper  line,  near  the  mesentery.  Any 
excess  of  abdominal  wound  is  first  closed  from  either  end  by  interrupted 
sutures  passed  as  in  abdominal  section.  If  haste  is  unnecessary,  the  opening 
is  made  in  two  or  three  days,  when  the  serous  surfaces  have  united.  An 
incision  of  about  2  cm.  (f  inch)  is  made  into  the  long  axis  of  the  gut — and 


Fig.  072. — Left  Inguinal  Colostomy — for  Permanent  Artificial  Anus  : — A,  A,  Temporary 
traction-ligatures  drawing  sigmoid  flexure  of  colon  into  wound  ;  B.  B,  Sutures  uniting  peritoneum  and 
lower  part  of  muscular  wall  of  wound,  to  serous  and  muscular  coats  of  intestine ;  C,  C,  Sutures  pass- 
ing through  peritoneum  and  lower  part  of  muscular  wall,  on  one  side ;  serous  and  muscular  coats  of 
intestine,  in  center;  and  peritoneum  and  lower  part  of  muscular  wall,  on  opposite  side  ;  D,  D,  Sutures 
passing  through  entire  thickness  of  muscular  wall.  Position  of  future  excision  of  triangular  piece  of 
colon  is  shown  by  dotted  line. 

the  edges  of  the  intestinal  wound  (all  of  the  coats)  are  sutured  to  the  skin 
of  the  abdominal  wound.  If  haste  is  necessary,  the  above  is  done  at  once. 
(b)  Where  a  permanent  artificial  anus  is  intended: — The  knuckle  of 
intestine  is  drawn  well  out  of  the  wound,  exposing  its  mesentery.  Incise 
the  mesentery,  in  a  line  with  its  vessels,  and  near  the  bowel — and  insert 
a  short  glass  rod,  or  similar  object,  through  this  opening — the  ends  of  the 
glass  rod  resting  on  either  side  of  the  edges  of  the  wound.  If  the  slit  through 
the  mesenterv  be  excessive,  the  excess  is  gut-sutured.  The  two  limbs  of 
the  knuckle  above  and  below  the  rod  are  sutured  to  each  other  by  gut  sutures 


920  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

passing  through  serous  and  muscular  coats  and  approximating  their  mesen- 
teric aspects,  thus  forming  a  spur  of  the  walls  so  brought  into  apposition. 
(See  Fig.  672.)  Having  first  closed  in  any  excess  of  abdominal  wound  from 
either  end,  by  sutures  applied  as  in  abdominal  section,  the  protruded  knuckle 
is  then  sutured  into  the  wound  by  silk  or  chromic  gut  sutures  passing  through 
serous  and  muscular  coats  of  the  intestine,  on  the  one  hand,  and  through 
peritoneum  and  muscle  tissue  of  the  abdominal  wound,  on  the  other.  If 
haste  be  not  necessary — wait  two  or  three  days  until  the  serous  surfaces 
have  united  and  the  peritoneum  has  been  shut  off — then  seize,  with  rat- 
tooth  forceps,  the  prominent  knuckle  of  intestine  and  cut  out  transversely, 
in  a  line  with  the  rod,  a  V-shaped  segment  of  gut,  with  scissors — excising 
the  entire,  or  nearly  the  entire,  diameter  of  gut,  with  the  apex  of  the  excised 
portion  ending  where  the  limbs  have  been  sutured  together.  Let  the  distal 
end  of  the  intestine  retract.  Suture  the  margins  of  the  proximal  end  to  the 
skin  of  the  abdomen.  Remove  the  glass  rod  in  about  seven  days — and 
the  sutures  in  about  ten.  If  haste  be  necessary — the  above  is  done  at  once. 
Comment. — (1)  Slight  variations  occur  in  the  operation  as  done  by 
Maydl; — the  knuckle  of  intestine  is  drawn  out — the  glass  rod  passed  through 
the  mesentery — the  limbs  of  the  loop  sutured  together  as  above, — following 
which  the  steps  will  differ  as  to  the  object  sought; — (a)  If  the  intestine  is 
to  be  opened  at  once — it  is  stitched  to  the  parietal  peritoneum,  as  described 
above; — (b)  If  the  intestine  is  not  to  be  opened  at  once — it  is  not  stitched, 
but  simply  gauze  is  packed  around  and  under  the  glass  rod; — (c)  If  the 
opening  is  to  be  permanent — the  bowel  is  to  be  divided  transversely  in  from 
four  to  six  days,  through  one-third  of  its  diameter — an  irrigating  tube  is 
then  inserted  and  the  intestines  washed  out — and  in  two  or  three  weeks 
later  the  transverse  division  is  completed — the  edges  of  the  proximal  gut 
are  sutured  to  the  margins  of  the  skin  and  the  distal  end  left  unsutured — 
and  the  rod  is  then  withdrawn; — (d)  If  the  opening  is  to  be  temporary — 
the  intestine  is  incised  in  its  long  axis — and,  when  the  opening  is  ready  to 
be  dispensed  with,  the  rod  is  withdrawn  and  the  knuckle  of  intestine  allowed 
to  retract  (no  suturing  to  the  skin  having  taken  place) — the  opening  often 
closing  of  its  own  accord.  (2)  As  small  an  abdominal  incision  as  possible 
should  be  made,  in  order  to  lessen  the  chance  of  hernia.  The  higher  up 
the  abdominal  wall  the  opening  is  made,  the  less  the  chance  of  hernia.  Some 
surgeons  make  the  incision  parallel  with  the  outer  third  of  Poupart's  ligament. 
(3)  If  the  small  intestine,  mesentery,  or  omentum  present  during  operation, 
they  are  pushed  back  into  the  abdomen.  (4)  If  the  sigmoid  flexure  cannot 
be  located  readily,  it  can  be  found  by  injecting  water  through  the  rectum, 
while  the  finger  in  the  wound  feels  for  the  enlarging  bowel.  (5)  The  use 
of  the  rod,  or  other  object,  to  pierce  the  mesentery  is  not  absolutely  necessary. 
The  mesocolon  can  be  sutured  to  the  edges  of  the  abdominal  wound  instead. 
(6)  In  stitching  the  intestine  into  the  wound,  the  stitching  is  so  done  as  to 
give  the  proximal  part  of  the  loop  ample  room,  and,  at  the  same  time,  make 
pressure  upon  the  distal  part,  to  prevent  the  passage  of  intestinal  contents 
into  it.  (7)  Sometimes  the  parietal  peritoneum  is  drawn  sufficiently  out  to 
be  sutured  to  the  margin  of  the  skin  around  the  wound,  the  muscle  layers 
not  being  included — and  the  intestine  is  then  sutured  to  this  parietal  perito- 
neum. But  firmer  union  is  probably  secured  by  the  principal  method  de- 
scribed above.  (8)  Sometimes  (though  hardly  to  be  recommended)  instead 
of  making  a  spur,  which  is  often  inefficient,  the  bowel  is  cut  through  above 
the  obstruction  (when  performed  for  that  purpose)  and  the  lower  end  is 
closed  by  inverting  the  edges  of  the  distal  end  by  a  double  row  of  sutures, 
the  outer  row,  an  overhand,  continuous  suture;  the  second,  a  row  of  Lem- 


ANTERIOR    INTRAMUSCULAR    COLOSTOMY. 


921 


berts;  and  this  end  is  dropped  into  the  abdominal  cavity.  The  edges  of  the 
proximal  gut  are  then  sutured  into  the  abdominal  wound  by  two  tiers  of 
sutures;  the  lower,  of  chromic  gut,  through  the  serous  and  muscular  coats 
of  the  gut  (a  short  distance  from  the  edge),  and  peritoneum  and  muscles 
of  the  abdominal  wound;  the  marginal,  of  silk,  through  all  the  coats  of 
the  gut,  and  the  skin.  The  method,  however,  is  not  indicated  when  it  is 
desirable  to  keep  the  upper  end  of  the  distal  gut  patulous,  where  drainage 
below  is  difficult. 

Note. — Right  Inguinal  Colostomy,  or  Caecostomy,  is  but  rarely  done. 
The  contents  of  the  ascending  colon  (from  the  nearness  of  the  small  intestine) 
are  more  liquid  and  less  easily  controlled  through  such  a  fistula  or  anus. 
The  absence,  or  shortness,  of  the  mesentery  also  makes  the  attachment  to 
the  abdominal  wall  more  difficult.  The  operation  is,  practically,  done  only 
when  the  site  of  the  trouble  is  uncertain,  the  caecum  at  the  same  time  being 
distended, — or  when,  in  doing  a  Left  Inguinal  Colostomy,  it  is  impossible 
to  find  the  sigmoid  colon.  When  the  operation  is  done  at  all,  it  is  generally 
only  a  temporary  fistula  which  is  made,  as,  when  this  site  is  selected,  it  is 
usually  an  operation  of  emergency  only.  A  Transverse  Colostomy  is  even 
rarer. 


Fig.  673.— Mixter's  Anterior  Colostomy:— I.— Quadrilateral  flap  of  skin  and  fascia 
turned  outward,  exposing  rectus.  Separation  of  libers  in  outer  part  of  rectus.  (Redrawn 
from  Gould.) 


ANTERIOR  INTRAMUSCULAR  COLOSTOMY. 
mixter's   operation. 

Description. — The  sigmoid  is  broughtout  through  the  split  rightrectus  mus- 
cle, which  is  sutured  between  the  limbs  of  the  loop — after  which  a  bridge  of  skin 


922 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


and  fascia  is  sutured  under  the  loop  and  between  the  distal  and  proximal 
limbs.  In  this  method  some  muscular  control  of  the  openings  is  secured, 
and  the  openings  of  the  proximal  and  distal  ends  are  separated  some  distance 
from  each  other. 

Preparation — Position — Landmarks. — As  in  Left  Inguinal  Colostomy, 
page  917. 

Incision. — Commences  on  a  level  with  the  umbilicus,  over  the  outer  third  of 
the  right  rectus  muscle — passes  vertically  downward  for  5  cm.  (2  inches)  through 
skin  and  fascia  to  the  musculature — thence  turns  inward  at  a  right  angle  and 
runs  in  a  straight  line  for  5  cm.  (2  inches) — thence  downward  at  a  right 
angle  and  runs  in  a  straight  line  for  5  cm.  (2  inches) — thence  outward  at  a 


V 


Fig.  674. — Mixter's  Anterior  Colostomy: — II. — Loop  of  sigmoid  drawn  through  separ- 
ated fibers  of  rectus — taut  mesentery  incised — median  portion  of  rectal  fibers  sutured  together 
between  proximal  and  distal  coils.      (Redrawn  from  Gould. J 

right  angle  and  runs  in  a  straight  line  for  5  cm.  (2  inches) — and  finally  turns 
again  at  a  right  angle  and  runs  downward  in  a  straight  line  for  5  cm.  (2  inches) 
— as  shown  in  Fig.  673. 

Operation. — The  flap  thus  indicated,  consisting  of  skin  and  connective 
tissue,  overlying  the  abdominal  muscles  is  raised  and  retracted  outward — as 
shown  in  Fig.  673.  The  anterior  layer  of  the  rectal  sheath  is  incised,  and 
the  longitudinal  fibers  of  the  rectus  are  separated  in  the  outer  part  of  the 
rectus  by  blunt  dissection.  The  posterior  layer  of  the  rectal  sheath,  trans- 
versalis  fascia,  subserous  areolar  tissue,  and  peritoneum  are  incised  in  the 
same  longitudinal  line.  The  sigmoid  is  located  and  brought  out  of  the 
abdomen  through  this  opening  and  the  loop  of  intestine  pulled  upon  until 
both  of  its  limbs  are  taut — to  render  prolapse  less  likely.     The  mesentery 


ANTERIOR    INTRAMUSCULAR    COLOSTOMY. 


923 


of  the  sigmoid  is  incised  at  a  right  angle  to  the  long  axis  of  the  bowel  for 
about  5  cm.  (2  inches).  The  incised  edges  of  the  mesentery  are  retracted — 
while  the  central  portion  of  the  separated  border  of  the  split  rectus  are 
sutured  together  with  catgut  sutures  through  the  margins  of  the  incised 
mesentery  (Fig.  674).  Over  the  sutured  portion  of  the  rectus  muscle  and 
under  the  coil  of  sigmoid  the  skin-flap  is  sutured  into  its  original  position, 
by  means  of  one  layer  of  interrupted  sutures  through  the  fascia  and  another 
through  the  skin.  The  two  limbs  of  sigmoid  are  thus  separated,  over  a  space 
of  about  5  cm.  (2  inches),  by  a  bridge  of  muscle,  fascia,  and  skin.  Where 
acute  obstruction  exists,  a  right-angled  Mixter  glass  tube,  of  large  size,  is 


Fig.  675. — Mixter's   Anterior   Colostomy: — III. — Skin  and  fascia  flap  sutured  back  into 
place  beneath  arch  of  sigmoid.     Mixter  tube  sutured  into  intestine.     (Redrawn  from  Gould.) 


introduced  into  the  lumen  of  the  intestine  at  once  and  held  in  situ  by  a  purse- 
string  suture  (Fig.  675).  A  rubber  tube  is  attached  to  the  glass  tube  and 
carried  to  a  receptacle  for  feces.  The  intestine  is  dusted  with  zinc  oxid 
powder  and  covered  with  gutta-percha  tissue,  in  order  to  prevent  the  peritoneal 
coats  from  adhering  to  the  dressings.  If  no  necessity  exist  for  haste,  the 
dressing  is  removed  in  four  or  five  days  and  the  loop  of  intestine  excised  about 
1.3  cm.  (^  inch)  above  the  skin  surface.  The  mucous  membrane  is  trimmed 
to  the  level  of  the  muscle  coats,  and  the  free  margins  whipped  with  a  continuous 
suture  (Fig.  676).  The  upper,  or  proximal,  and  the  lower,  or  distal,  openings 
will  lie  some  distance  from  each  other — thus  preventing  feces  from  the  former 


924 


OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 


getting  into  the  latter — the  proximal  opening  serving  for  the  escape  of  feces 
and  the  distal  for  irrigation  of  the  lower  bowel,  where  that  is  indicated.     The 

split  rectus  muscle  furnishes  some  de- 
gree of  sphincteric  control. 

LEFT  LUMBAR   COLOSTOMY. 

Description. — Left  Lumbar  (Pos- 
terior) Colostomy  consists  in  making 
an  opening  posteriorly  through  the  loin, 
over  the  descending  colon — extra-peri- 
toneally.  Rarely  the  opening  is  made 
over  the  ascending  colon,  in  the  right 
loin. 

Preparation — Position. — As  for 
median  abdominal  section. 

Position. — Patient  lies  upon  oppo- 
site side  and  near  edge  of  table,  with 
a  hard  pillow,  or  support,  under  the 
opposite  loin,  to  render  prominent  the 
site  of  operation, — Surgeon  on  side  of 
operation, — Assistant  opposite. 

Landmarks. — Position  of  descend- 
ing colon — namely,  a  line  extending 
vertically  upward  from  a  point  about 
1.2  cm.  {\  inch)  posterior  to  the  center 
of  the  iliac  crest  to  the  twelfth  rib — 
which  line  will  about  correspond  with 
the  outer  border  of  the  quadratus 
lumborum. 

Incision. — About  7.5  to  10  cm.  (3 
to  4  inches)  long — placed  obliquely 
between  the  twelfth  rib  and  the  crest 
of  the  ilium,  with  its  center  over  the 
center  of  the  vertical  line  representing 
the  course  of  the  descending  colon — 
which  incision  will  run  in  the  direction  of  a  line  extending  from  the  anterior 
superior  iliac  spine  to  the  angle  formed  by  the  twelfth  rib  and  the  outer 
border  of  the  erector  spina?  muscle,  the  incision  beginning  at  about  the  outer 
border  of  this  muscle.     (See  Fig.  677.) 

Operation. — (1)  Divide  the  skin  and  the  thick  subcutaneous  fatty  fascia, 
clamping  all  vessels.  (2)  Divide  the  latissimus  dorsi  and  its  aponeurosis  in 
the  posterior  part  of  the  wound — and  the  posterior  part  of  the  external  oblique 
in  the  anterior  part.  (3)  Divide  the  internal  oblique,  exposing  the  lumbar 
fascia  posteriorlv.  (4)  Recognize  and  protect  the  twelfth  dorsal  nerve  and 
accompanying  branch  of  the  lumbar  artery.  (5)  Divide  the  lumbar  fascia 
and  the  transversalis  muscle,  exposing  the  anterior  margin  of  the  quadratus 
lumborum  (which  rarely  requires  division)  in  the  posterior  angle  of  the 
wound,  and  the  transversalis  fascia.  (6)  Divide  the  transversalis  fascia, 
from  the  quadratus  lumborum  to  the  anterior  angle  of  the  wound,  exposing 
the  subperitoneal  tissue — avoiding  the  twelfth  nerve  on  its  way  from  the 
quadratus  lumborum  to  the  transversalis  muscle.  (7)  A  distended  colon  may 
now  protrude  through  the  subperitoneal  connective  tissue  into  the  wound- 


Fig.  676. — Mixter's  Anterior  Co- 
lostomy:— IV. — The  sigmoid  loop  excised 
1.3  cm.  (^  inch)  from  skin — and  the  afferent 
and  efferent  ends  sutured  to  the  skin.  (Re- 
drawn from  Gould.) 


LEFT    LUMBAR    COLOSTOMY 


925 


this  areolar  fatty  tissue,  often  very  thick  and  fatty,  lying  around  the  kidney, 
being  separated  by  the  fingers  and  forceps,  or  by  a  blunt  dissector.  If  the 
colon  does  not  thus  protrude,  insert  an  index-finger  through  this  subperi- 
toneal areolar  tissue,  while  the  parts  are  well  retracted  behind  the  lumbar 
fascia — following,  with  the  back  of  the  finger  toward  the  patient's  back, 
along  the  anterior  surface  of  the  quadratus  lumborum,  aiming  for  the  angle 
between  the  quadratus  lumborum  and  the  psoas,  toward  which  angle  the 
posterior  surface  of  the  colon  presents,  lying  anterior  to  the  plane  of  the 
kidney,  the  lower  portion  of  which  (kidney)  is  generally  felt.  The  finger 
which  has  passed  through  the  subperitoneal  areolar  tissue  and  is  carefully 
working  behind  the  peritoneum  is  aided  in  its  search  by  rolling  the  body 
over  toward  the  side  of  operation,  while  the  assistant  presses  the  anterior 
abdominal  wall  firmly,  so  as  to  aid  the  colon,  by  gravity  and  pressure,  to 
fall,  as  it  were,  into  the  curved  index  finger.  The  colon  is  generally  recog- 
nized by  the  thickness  of  its  wall,  by  the  absence  of  the  peritoneal  coat,  and 
sometimes  by  the  posterior  longitudinal  band.  (8)  Grasp  the  non-mesenteric 
aspect  of  the  colon  with  the  fingers,  or  special  forceps,  and  bring  it  out  to 
a  level  with  the  surface — no  loop  being  here  drawn  out  of  the  wound  as  in 
the  anterior  operation.  The  colon  is  held  in  place  with  forceps,  or  traction- 
sutures,  or  temporarily  allowed  to  fall  back  into  place — while  the  excess 
of  the  abdominal  wound  is  closed  from  either  end — by  layer  suturing  with 
chromic  gut,  or  by  mass-suturing  with  chromic  gut,  silk,  or  silkworm-gut, 
leaving  just  space  enough  for  the  emergence  of  the  gut.  (9)  The  convex 
dome  of  the  gut  is  sutured  into  the  lips  of  wound — by  interrupted  sutures 


Fig.  677.— Left  Lumbar  Colostomy  :— A,  Twelfth  rib;  B,  Iliac  crest;  C,  Latissimus  dorsi 
muscle;  D,  External  oblique  muscle ;  E,  Left  kidney;  F,  Descending  colon;  G,  Line  of  incision  for 
left  lumbar  colostomy. 


of  silk  passing  through  the  fibrous  and  muscular  coats  of  the  intestine,  on 
the  one  hand,  and  the  skin  of  the  abdomen,  or  as  near  it  as  possible,  on  the 
other.     (10)  If  haste  be  unnecessary — several  days  are  allowed  to  pass,  for 


926 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


union  of  intestine  to  abdominal  wound  to  occur,  and  then  the  intestine  is 
incised  and  the  lips  of  the  intestinal  wound  sutured  to  the  lips  of  the  ab- 
dominal wound— by  interrupted  sutures  of  silk,  or  silkworm-gut,  passing 
through  all  the  coats  of  the  bowel,  and  through  the  skin  of  the  abdomen, 
or  as  near  it  as  possible — the  sutures  being  passed  from  the  skin  into  the 
gut  (making  infection  less  likely).  (11)  If  haste  be  necessary— the  above 
incision  is  made  at  once.  (12)  If  a  temporary  fecal  fistula  be  intended — 
the  gut  is  incised  in  its  longitudinal  axis.  (13)  If  a  permanent  artificial  anus 
be  intended — the  gut  is  drawn  as  far  into  the  wound  as  possible  (which  is 
never  as  far  as  in  the  anterior  operation)  and  divided  nearly  through — the 
object  being  to  form  a  spur  as  in  the  anterior  operation. 

Comment. — (1)  The  outer  border  of  the  erector  spinae  is  the  superficial 
muscular  guide  to  the  colon.  The  outer  border  of  the  quadratus  lumborum 
mav  be  cut  to  expose  the  colon  if  necessary.  (2)  The  operation  is  difficult 
in  very  thick  loins — thorough  retraction  aids  the  steps.  (3)  It  is  important 
to  recognize  and  open  up  the  transversalis  fascia — and  not  mistake  it  for 
the  peritoneum.  The  bulging  peritoneum  has  been  mistaken  for  the  colon. 
The  duodenum  has  been  mistaken  for  the  ascending  colon  in  operating  on 
the  right  side — and  the  stomach  for  the  descending  colon  in  operating  on 
the  left  side.  The  kidneys  and  small  intestines  have  been  mistaken  for 
the  colon.  The  small  intestines,  when  encountered,  lie  external  to  the  colon. 
The  colon  is  generally  distinguished  by  its  longitudinal  bands,  anterior, 
posterior  (at  the  mesocolon,  when  the  mesentery  is  present),  and  one  internal, — 
by  its  greater  fixity, — and  by  its  sacculations  (often  filled  with  scybala). 
The  descending  colon  is  sometimes  congenitally  absent.  The  large  intestine 
may  be  distended  with  air  or  water  to  aid  its  recognition.  The  empty  colon 
is  often  hard  to  detect.     If  all  means  of  detection  fail,  do  a  median  abdominal 


Fig.  678.— Transverse  Section  of  the  Posterior  Abdominal  Wall  in  the  Lumbar 
Region  :— A,  Erector  spinae  muscle;  B,  Quadratus  lumborum;  C,  Psoas  magnus  ;  D,  Latissimus 
dorsi;  E,  External  oblique  ;  F,  Internal  oblique;  G,  Transversalis  ;  H,  The  descending  colon  shown 
in  its  usual  position,  and  without  a  mesentery,  as  usual  ;  I,  The  ascending  colon  shown  with  a  mes- 
entery (an  exceptional  occurrence).     (Modified  from  Gray.) 


section — find  the  bowel — and  then  complete  the  lumbar  operation.  (4)  If 
the  peritoneum  be  accidentally  opened,  close  it  by  gut  suture  if  possible. 
If  this  cannot  be  done,  no  harm  is  generally  done  by  accidentally  opening 
the  peritoneum  in   this  locality.     Draw  the   intestine  into   the  wound   and 


OPERATION    FOR    FECAL    FISTULA    AND    ARTIFICIAL    ANUS. 


927 


fix  it  there.  (5)  If  the  mesocolon  be  present,  the  abdominal  cavity  must  be 
opened,  unless  the  laminae  of  the  mesentery  can  be  split — which  can  generally 
be  done.  (See  Fig.  678)  A  branch  of  the  inferior  mesenteric  artery  may 
guide  to  a  separation  of  the  laminae.  (6)  The  non-peritoneal  surface  of  the 
colon  is  generally  thickly  covered  with  fatty  areolar  tissue — which  also  inter- 
venes between  the  colon,  in  front,  and  kidney,  diaphragmatic  crura,  and 
quadratus  lumborum,  behind.  (7)  The  empty  descending  colon  is  apt  to 
tend  further  toward  the  median  line,  behind  the  border  of  the  quadratus 
lumborum,  than  a  distended  one — so  that,  in  such  cases,  the  normal  site 
of  the  distended  colon  is  more  apt  to  be  occupied  by  peritoneum,  which 
is  consequently,  under  these  circumstances,  more  apt  to  be  opened.  (8) 
Owing  to  the  fixity  of  the  colon,  it  is  often  hard  to  get  enough  of  it  into  the 
wound  to  form  a  spur,  in  the  operation  for  artificial  anus — though  enough 
for  a  fecal  fistula  is  generally  to  be  gotten.  If  difficulty  be  experienced  in 
causing  sufficient  bowel  to  protrude,  a  Paul  tube  may  be  tied  into  the  gut, 
the  balance  of  the  wound  being  closed  about  it.  (9)  Right  lumbar  colostomy 
may  be,  but  rarely  is,  performed. 


OPERATION  FOR  THE  CLOSURE  OF  FECAL  FISTULA  AND 
ARTIFICIAL  ANUS. 

Description. — Sometimes  occurring  alone,  and  sometimes  as  a  result  of 
the  operations  just  described  for  the  formation  of  fecal  fistula  and  artificial 
anus,  a  more  or  less  permanent  fistulous  tract  between  the  intestinal  canal 
and  the  abdominal  wall  is  left.  The  simplest  forms  of  such  fistulous  tracts 
tend  to  close  of  their  own 
accord,  but  the  more  com- 
plicated generally  require 
some  operation  for  their 
closure.  These  fistula?  lead- 
ing to  some  part  of  the 
large  or  small  intestine 
are  generally  one  of  three 
kinds: — (1)  The  gut  is  not 
bent  upon  itself  to  any 
extent;  there  is  no  spur; 
but  little  of  the  intestinal 
wall  is  involved;  the  open- 
ing is  small;  the  skin  and 
intestinal  mucous  mem- 
brane are  connected  by  a 
sinus-like  communication 
(see  Fig.  679,  A);— (2) 
The  gut  is  bent  somewhat 
more  upon  itself;  an  in- 
complete spur  is  present; 
more  of  the  intestinal  wall 
has  been  lost;  the  opening 
is  larger;  the  intestinal 
mucous     membrane      and 

the  abdominal  skin  are  more  nearly  in  contact  (see  Fig.  679,  B);   (3)  The 
gut   is   more  acutely  bent  on  itself;    a  marked  spur  is  present,   forming  an 


Fig.  679.— Forms  of  Fecal  Fistula  and  Artificial 
Ani  : — A,  First  form,  intestine  connected  with  skin  by  sinus- 
like communication;  B,  Second  form,  intestine  and  skin  more 
directly  in  contact  and  gut  slightly  bent  on  itself;  C,  Third 
form,  showing  formation  of  marked  spur. 


928 


OPERATIONS    UPON    THE    ARDOMINO-PELYIC    REGION. 


obstruction  to  the  intestinal  passage;  the  amount  of  intestinal  wall  lost  may 
be  variable;  the  condition  present  generally  being  an  exaggeration  of  (2)  (see 
Fig.  679,  C).  The  procedure  for  the  closure  of  the  fistulous  tract  will  be 
modified,  therefore,  by  the  various  degrees  of  fistula  found  and  by  the  extent 
of  the  adjacent  adhesions. 

Preparation. — Neighboring  skin  should  be  gotten  as  healthy  as  possible 
preliminarily.  Evacuation  of  intestinal  canal;  local  irrigation;  vicinity  of 
fistula  shaved.  Just  preceding  operation,  sinus  is  to  be  gently  scraped  and 
again  irrigated — after  which  it  is  packed  with  a  small  sponge',  or  with  gauze, 
attached  to  a  piece  of  silk,  the  end  of  which  is  left  out — and  the  lips  of 
the  fistula  are  then   tightly  and  deeply  sutured   and   the   long  ends  of  the 


Fig.  680. — Operation  for  Cure  of  Fecal  Fistula  or  Artificial  Anus: — A,  Skin  opening 
of  fistula  closed  by  sutures  used  as  traction-sutures;  B,  Ellipse  of  abdominal  wall  to  be  removed,  with 
its  center  occupied  by  external  opening  of  fistula  ;  C,  Ellipse  of  intestine  to  be  removed,  including  neck 
of  fistulous  tract ;  D,  Position  of  some  of  the  Lembert  sutures  which  will  close  in  entire  elliptical 
opening  in  intestine  after  excision  of  fistulous  tract. 

sutures,  after  tying,  are  knotted,  or  grasped  by  clamp-forceps,  and  drawn 
upward. 

Position. — Patient  supine  on  edge  of  table  nearer  fistula;  Surgeon  on  side 
of  fistula;  Assistant  opposite. 

Landmarks. — Site  of  fistula  and  known  relation  of  neighboring  parts. 

I.  Cases  in  which  the  operation  involves  the  peritoneal  cavity — no 

extensive  adhesions  existing — or  where  it  is  desired  to  free  existing  adhe- 
sions before  excising  the  fistula: 

Incision. — An  elliptical  incision  is  made  around  the  fistulous  opening — 
its  long  axis  will  generally  be  vertical  in  operating  upon  fistulae  of  the  small 
intestine,  and  will  usually  correspond  with  the  long  axis  of  the  large  gut 
in  operating  upon  parts  of  the  colon — and   the  length  and  breadth  of  the 


OPERATION    FOR    FECAL    FISTULA    AND    ARTIFICIAL    ANUS.  929 

ellipse  will  be  planned,  as  far  as  possible,  to  extend  beyond  the  adhesions 
probably  surrounding  the  sinus. 

Operation. — (i)  Having  sutured  the  fistulous  opening  and  using  the 
sutures  as  traction-loops,  this  incision  is  carefully  deepened  on  each  side — 
clamping  bleeding  vessels — and  guarding  against  opening  the  peritoneum 
prematurely,  or  cutting  into  an  adherent  coil  of  intestine.  (See  Fig.  680.) 
(2)  In  passing  through  the  thickness  of  the  abdominal  wall,  the  course  of 
the  incision  is  directed  by  the  sensation  and  form  of  the  distended  fistula 
and  by  the  left  index-finger  within  the  wound.  In  difficult  cases,  and  espe- 
cially in  devious  fistula1,  it  may  be  necessary  to  introduce  a  sound,  or  bougie, 
through  the  sinus  as  a  palpable  guide.  (3)  Having  deepened  the  incision, 
all  around,  down  to  the  peritoneum,  the  abdominal  cavity  is  now  carefully 
opened  in  the  line  of  the  original  ellipse.  If  the  ellipse  lie  without  the  site 
of  adhesions,  no  great  difficulty  will  be  experienced.  If  it  lie  in  part  over 
adhesions,  a  finger  introduced  through  the  site  leading  into  the  free  peritoneal 
cavity  and  swept  around  the  sinus  will  serve  for  exploration  and  as  a  guide 
to  the  separation  or  incision  of  the  adherent  portion.  If  the  ellipse  lie  wholly 
over  adhesions  and  come  down  upon  these  all  around,  great  care  is  required 
to  recognize  the  plane  of  adhesions  when  reached,  and  greater  care  still 
in  separating  or  dividing  them  in  the  line  of  the  ellipse.  (4)  Having  thus 
reached  the  intestines,  an  isolated  oval  island  of  tissues  (included  in  the 
original  ellipse  and  in  deepening  the  ellipse  to  the  intestinal  wall)  will  be 
evident — free  above  and  continuous  with  the  intestine  below — through  the 
center  of  which  the  sinus  extends.  The  intestine  is  carefully  freed  and  drawn 
out  into  the  abdominal  wound,  with  the  oval  island  of  tissues  still  adherent — 
and  the  neighboring  parts  packed  off  with  gauze.  (5)  Having  pressed  away 
the  intestinal  contents  and  clamped  the  gut  above  and  below  the  site  of  the 
sinus,  a  small  elliptical  incision  is  made  in  the  gut,  circumscribing  the  con- 
nection of  the  sinus  with  the  gut,  and  having  its  long  axis  coincident  with 
that  of  the  gut — and  the  incision  is  deepened  through  the  wall  of  the  gut, 
thus  excising  an  elliptical  piece  of  the  intestinal  wall,  representing  the  intes- 
tinal end  of  the  sinus.  The  escape  of  intestinal  contents  is  especially  guarded 
during  this  excision.  (6)  The  wound  of  the  intestine  is  at  once  closed  by 
a  double  row  of  sutures — a  continuous  overhand  suture  of  all  the  coats,  thus 
bringing  together  the  free  edges — followed  by  interrupted  Lemberts  of  the 
outer  coats.     (7)  The  abdominal  wound  is  closed  in  the  usual  manner. 

II.  Cases  in  which  the  operation  does  not  involve  the  peritoneal  cavity- 
extensive  adhesions  extending  around  the  sinus,  and  it  being  possible  to 
excise  the  fistula  and  close  the  intestinal  wound  without  passing  beyond 
the  adhesions: 

Incision. — Same  in  form  as  above,  but  less  extensive. 
Operation. — (i)  The  operation  is  conducted  as  above,  except  that  care 
is  exercised  to  avoid  entering  the  abdominal  cavity,  which  can  be  done  only 
when  more  or  less  extensive  and  strong  adhesions  exist.  The  sinus  is  fol- 
lowed down  to  its  intestinal  end  by  cutting  directly  through  all  intervening 
tissues  to  the  intestinal  wall,  which  is  then  incised  in  such  a  way  as  to  elli] id- 
eally excise  the  intestinal  end  of  the  fistula — guarding  against  injury  to  neigh- 
boring coils  of  intestines  and  viscera.  (2)  Having  excised  the  sinus  without 
entering  the  peritoneal  cavity,  the  borders  of  the  wound  on  a  plane  with 
the  upper  wall  of  the  intestine  are  inverted  and  sutured  together  by  inter- 
rupted chromic  gut  or  silk  sutures,  applied  after  the  manner  of  Lembert's 
59 


930  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

approximating  surfaces,  which,  while  not  peritoneal,  have  been  left  raw 
from  the  excision  of  the  sinus.  The  sinus  is  closed  throughout  the  rest  of 
its  extent  by  deeply  buried  chromic  gut  sutures. 

III.  In  other  cases  : — 

In  cases  where  large  and  obstinate  spurs  exist,  or  where  there  has  been 
much  loss  of  intestinal  wall — which  may  be  found  to  be  the  case  after  having 
exposed  the  parts  as  in  the  first  category  of  cases  mentioned  above,  a  partial 
enterectomy  may  be  done,  followed  by  one  of  the  methods  of  entero-enteros- 
tomv.  Or  the  necessary  calibre  of  intestine  may  be  gotten  by  some  form 
of  "  elbowing, "  without  excision.  Or  junction  of  the  involved  coil  of  intestine 
with  a  neighboring  coil  may  be  secured  by  lateral  anastomosis  without  partial 
excision  of  the  intestine,  after  having  closed  the  wound  in  the  intestine  left 
by  excision  of  the  intestinal  end  of  the  sinus.  Or,  where  a  moderate  spur 
exists,  attempts  may  be  made  to  remove  the  spur  by  means  of  a  piece  of 
rubber  tubing  introduced  into  the  lumen  of  the  gut  and  held  against  the 
spur.  Formerly  the  use  of  an  enterotome,  whereby  the  spur  was  crushed, 
was  much  resorted  to. 


ENTEROPLASTY. 

Description. — By  enteroplasty  is  generally  understood  a  plastic  operation 
carried  out  for  the  purpose  of  increasing  the  calibre  of  the  intestinal  lumen 
in  the  case  of  a  strictured  gut — without  resection  of  the  bowel.  The  technic 
of  the  operation  is  exactly  similar  to  that  of  pyloroplasty — an  axial  incision 
is  made  through  the  strictured  portion  of  the  gut  and  this  incision  is  then 
sutured  in  a  transverse  direction.  For  description  and  illustration  of  the 
principle,  see  Pyloroplasty,  page  984,  and  Fig.  726. 

Note. — Other  methods  of  increasing  the  calibre  of  the  narrowed  portion 
of  intestine  are  employed  in  connection  with  operations  of  resection : — Jeannel, 
after  partial  enterectomy,  cuts  the  ends  of  both  pieces  of  intestine  obliquely 
from  above  downward  (the  right-hand  piece  from  right  to  left,  and  the  left- 
hand  piece  from  left  to  right) — and  then  unites  their  edges  by  suturing — 
forming  an  "elbow,"  as  in  the  junction  of  pieces  of  stove-pipe.  Chaput, 
after  performing  partial  enterectomy,  united  the  ends  of  the  bowels  by  circular 
suturing — then  made  a  longitudinal  incision  through  the  walls  of  the  united 
intestines  opposite  the  mesentery  and  sutured  this  longitudinal  division  trans- 
versely— employing,  in  the  latter  part  of  the  operation,  the  principle  of  the 
usual  enteroplastic  operation.  Chaput,  by  another  method,  completely 
divides  the  bowel  obliquely,  from  above  downward  and  from  side  to  side — ■ 
forming  two  oblique  ellipses  of  the  same  size,  but  in  opposite  directions, 
at  the  ends  of  the  intestines — followed  by  union  of  the  intestinal  margins. 


OPERATION  FOR    INTUSSUSCEPTION. 

THE    JESSETT-BARKER    METHOD. 

Description. — An  incision  is  made  through  the  intussuscipiens  over  the 
base  of  the  intussusceptum — and  through  this  incision  the  intussusceptum  is 
excised,  the  free  ends  of  the  intestine  sutured — and  the  window  in  the  intussus- 
cipiens closed. 

Preparation — Position — Landmarks — Incision. — As  for  an  abdominal 
section  performed  in  the  special  locality  indicated. 

Operation. — Having  brought  the  site  of  intussusception  into  the  field  of 


OPERATION    FOR    INTUSSUSCEPTION. 


931 


Fig.  681. — The  Jessett-Barker  Opera- 
tion for  Intussusception: — I. — The  in- 
tussuscipiens  incised,  exposing  the  intussuscep- 
tum.     (Redrawn  from  unplaced  source.) 


Fig.  682. — The  Jessett-Barker  Opera- 
tion for  Intussusception: — II. — The  exci- 
sion of  the  intussusceptum.  (Redrawn  from 
unplaced  source.) 


Fig.  683. — The  Jessett-Barker  Opera- 
tion for  Intussusception: — III. — The  su- 
turing of  the  two  walls  of  the  intussusceptum. 
(Redrawn  from  unplaced  source.) 


Fig.  684. — The  Jessett-Barker  Opera- 
tion for  Intussusception: — IV. — The  su- 
turing of  the  intussusceptum  to  the  intussus- 
cipiens,  and  the  closure  by  suture  of  the  win- 
dow in  the  intussuscipiens.  (Redrawn  from 
unplaced  source.) 


932  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

operation  the  intussuscipiens  and  intussusceptum  are  sutured  together  by  a 
continuous  or  interrupted  seromuscular  suture  at  their  line  of  invagination, 
including  the  mesentery  (Fig.  681).  Through  the  antimesenteric  aspect  of 
the  intussuscipiens  a  longitudinal  incision,  5  cm.  (2  inches)  in  length,  is  made 
into  the  lumen  of  the  intestine.  Through  this  opening  the  invaginated  portion 
of  the  intestine  is  drawn  out  (Fig.  682).  It  is  then  divided  transversely  a 
short  distance  above  the  line  of  invagination.  The  free  edges  of  the  two 
concentric  ends  of  intestine  are  now  sutured  together  by  means  of  an  overhand 
continuous  suture — which  both  controls  hemorrhage  and  unites  the  serosae 
of  the  severed  ends  (Fig.  683).  Sometimes  it  is  easier  to  deliver  the  intussus- 
ceptum  if  the  transverse  section  be  made  first.  The  stump  of  sutured  intestinal 
ends  is  now  dropped  back  into  the  lumen  of  the  intussuscipiens — after  which 
the  longitudinal  incision  in  the  intussuscipiens  is  closed  by  a  line  of  continuous 
interrupted  sutures — reinforced,  if  necessary,  by  a  row  of  Lembert  stitches, 
interrupted  or  continuous  (Fig.  684). 

Comment. — (i)  As  the  transverse  section  of  the  invaginated  portion  is 
being  made,  the  free  ends  are  clamped  and  held  in  the  field  until  the  sutures 
are  placed.  (2)  If  the  invaginated  portion  of  intestine  cannot  be  detached 
readily,  efforts  should  be  made  to  free  it  by  manipulation  or  by  the  passage  of 
a  long  probe  or  sound  between  the  walls  of  the  two  pieces  of  intestine.  Failing 
in  this,  the  transverse  section  may  still  be  made,  leaving  the  invaginated  bowel 
to  be  passed — or  the  entire  involved  intestinal  area  may  be  excised. 


COLOPEXY. 

BRYANT'S  METH<  )D. 

Description. — In  this  operation  some  part  of  the  colon  is  elevated  and 
attached  to  the  abdominal  wall  by  suturing.  Colopexy  of  the  transverse 
colon  to  the  anterior  abdominal  wall  is  done  in  some  cases  of  Enteroptosis. 
Colopexy  of  the  sigmoid  flexure  of  the  colon  to  the  antero-lateral  abdominal 
wall  is  sometimes  done  for  Prolapsus  Recti.  This  latter  operation  will  be 
here  considered. 

Preparation — Position. — As  for  median  abdominal  section. 

Landmarks. — Outer  part  of  Poupart's  ligament. 

Incision. — About  7.5  cm.  (3  inches) — parallel  with  and  about  2.5  cm. 
(1  inch)  above  the  outer  part  of  Poupart's  ligament — being  extended  upward 
if  more  room  be  necessary. 

Operation. — (1)  The  above  incision  is  carried  clown  to  and  through  the 
peritoneum — clamping  and  tying  all  bleeding  vessels  as  encountered.  (2) 
After  having  opened  the  abdominal  cavity,  the  parietal  peritoneum  is  separated 
from  the  edges  of  the  abdominal  wound  for  about  2.5  cm.  (1  inch)  on  each 
side,  the  width  of  separation  being  somewhat  greater  above  than  below — 
the  separated  peritoneum  thus  forming  two  flaps.  (3)  The  rectum  is  now 
pulled  well  upward,  reducing  all  prolapse — and,  at  the  same  time,  any  adjacent 
laxity  of  the  colon  is  pulled  down.  While  the  rectum  is  being  drawn  firmly 
upward,  the  parietal  peritoneal  flaps  are  sutured  to  the  serous  and  muscular 
coats  of  the  rectum  by  quilting  and  continuous  silk  sutures.  (4)  About  half 
a  dozen  silk  sutures  are  then  passed  in  the  following  order — through  all  the 
layers  of  the  edges  of  the  abdominal  wound — through  the  peritoneal  flap  of 
that  side — then  through  the  serous  and  muscular  coats  of  the  intestine,  passing 


RECTOPEXY.  933 

behind  the  longitudinal  band — out  through  the  peritoneal  flap  of  the  opposite 
side — and  then  through  all  the  tissues  of  the  corresponding  edge  of  the  ab- 
dominal wound.  These  deep  sutures  are  then  drawn  tight  and  tied — thus 
bringing  the  longitudinal  band  and  a  part  of  the  intestinal  wall  into  contact 
with  the  abdominal  wall — and  approximating  the  borders  of  the  wound  so 
that  they  grasp  the  longitudinal  band  and  part  of  the  wall  of  the  gut — and, 
at  the  same  time,  closing  the  abdominal  wound. 


RECTOPEXY. 

VERNEUIL'S  METHOD. 

Description. — Rectopexy,  or  Proctopexy,  consists  in  the  suturing  of  the 
prolapsed  rectum  back  to  its  posterior  bed. 

Preparation. — Bowels  emptied;  perineum  shaved;  prolapse  replaced. 

Position. — Patient  in  lithotomy  position;  Surgeon  seated  in  front  of 
perineum;  Assistant  to  one  side. 

Landmarks. — Anus;  tip  of  coccyx;  ischial  tuberosities. 

Incision. — Two  straight  incisions  of  about  2.5  cm.  (1  inch)  in  length 
are  made  directly  outward  from  the  mid-lateral  aspect  of  the  anal  orifice 
(at  right  angles  to  the  median  perineal  line).  Two  other  incisions  are,  later, 
made  from  the  tip  of  the  coccyx  to  the  outer  ends  of  the  two  lateral  incisions. 

Operation. — (1)  Deepen  the  lateral  incisions  through  the  skin  and  ex- 
ternal sphincter.  (2)  Deepen  the  posterior  incisions  through  skin,  fascia, 
and  external  sphincter,  raising  a  triangular  flap  attached  at  its  base  to  the 
tissues  of  the  posterior  aspect  of  the  anal  orifice — and  displace  this  flap  for- 
ward, and  hold  it  out  of  the  way  by  retractors  or  skin  sutures.  (3)  Detach 
the  posterior  wall  of  the  rectum,  by  blunt  dissection,  from  the  anus  to  the 
tip  of  the  coccyx,  and  for  the  width  of  5  to  6.5  cm.  (2  to  2 J  inches).  (4) 
Pass  four  rather  stout  silk  sutures  transversely  through  the  posterior  wall 
of  the  rectum,  going  through  its  outer  coats,  for  as  nearly  the  whole  width 
of  the  posterior  aspect  of  the  rectum  as  possible,  leaving  both  ends  of  the 
sutures  free.  These  sutures  are  parallel,  the  highest  being  opposite  the 
tip  of  the  coccyx,  the  lowest  about  1.5  cm.  (f  inch)  from  the  anus,  and  the 
others  equidistant  between.  (5)  Pass  a  Reverdin  needle  (or  other  needle  with 
eye  at  point)  from  the  skin  without  to  the  denuded  surface  within — the  punc- 
tures being  made  about  4  cm.  (ih  inches)  from  the  median  line  on  each  side, 
and  above  the  particular  thread  to  be  drawn  through — the  uppermost  sutures 
coming  out  through  the  skin  on  a  level  with  the  sacro-coccygeal  articulation, 
and  the  lowermost  opposite  the  tip  of  the  coccyx.  Each  end  of  each  suture  is 
then  threaded  through  the  eye  of  the  needle,  in  turn,  and  thus  drawn  through 
the  thickness  of  the  posterior  pelvic  wall.  (6)  The  free  ends  of  these  sutures 
are  then  tied  together  over  a  firm  pad  of  gauze  (to  avoid  burying  into  and 
cutting  the  skin) — either  the.  opposite  ends  of  each  suture  being  tied  trans- 
versely together — or  the  ends  of  the  first  and  second,  and  of  the  third  and 
fourth,  tied  together  in  a  vertical  line  on  either  side.  Rather  strong  traction 
is  made  during  suturing — to  approximate  and  retain  the  posterior  aspect  of 
the  denuded  rectum  in  contact  with  the  anterior  aspect  of  the  denuded  pelvic 
wall.  (7)  Suture  the  triangular  flap  back  into  place—  narrowing,  at  the  same 
time,  the  anus,  by  suturing  the  inner  ends  of  the  lateral  incisions  somewhat 
further  inward  than  normal — freshening  the  margins  of  the  anus  sufficiently 


934  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

for  the  purpose   (the  original  incisions  may  be  planned  with  reference  to 
narrowing  the  anus). 

Comment. — The  same  object  maybe  accomplished  by  Tuttle's  somewhat 
similar  operation; — and  also  by  Peter's  operation  of  opening  the  abdomen, 
narrowing  the  barrel  of  the  rectum  by  invaginating  a  vertical  strip  of  its 
anterior  wall  by  Lemberts,  and  then  stitching  the  rectum  to  the  abdominal 
wall; — as  well  as  by  other  procedures. 


INTERNAL  RECTOTOMY. 

Description. — Rectotomy,  or  Proctotomy,  consists  in  the  division  of  the 
rectum  for  constriction,  obstruction,  or  the  removal  of  a  foreign  body.  In 
Internal  Rectotomy  the  rectum  is  divided  from  within — and  is  generally  done 
for  stricture  of  its  lower  part. 

Preparation. — Bowels  emptied;  anal  region  shaved;  and,  at  time  of 
operation,  gauze  packing  of  rectum  above,  with  end  of  gauze,  or  attached 
silk  ligature,  held  ready  for  withdrawal. 

Position. — Patient  in  lithotomy  position;  Surgeon  sits  opposite  peri- 
neum;  Assistant  to  one  side. 

Landmarks. — Anus;  known  course  of  rectum. 

Operation. — Insert  an  anal  speculum,  which,  when  opened,  will  expose 
the  site  of  stricture — introduce  a  straight,  narrow  bistoury  through  the  specu- 
lum and  divide  the  strictured  site  in  the  posterior  median  line  until  healthy 
tissue  is  reached,  cutting  backward  from  above  downward — cutting  through 
sphincters  if  necessary.  Any  vessels  which  bleed  markedly  are  tied.  The 
wound  is  packed — and  the  gauze  withdrawn.  Some  form  of  dilator  is  worn 
for  a  time  after  the  operation. 


EXTERNAL  RECTOTOMY. 

Description. — In  the  operation  of  External  or  Posterior  Rectotomy,  or 
Proctotomy,  the  rectum  is  opened  from  without  and  from  behind — generally 
for  the  removal  of  foreign  bodies,  tumors,  or  the  division  of  strictures — and 
usually  gives  a  fuller  and  higher  exposure  than  Internal  Rectotomy. 

Preparation — Position. — As  for  Internal  Rectotomy. 

Landmarks. — Anus;  tip  of  coccyx;  known  course  of  rectum. 

Incision. — An  external  incision  is  made  from  the  tip  of  the  coccyx  (or 
from  somewhat  below  it,  according  to  circumstances)  down  the  median  line 
to  and  through  the  anus. 

Operation. — (i)  The  above  incision  is  first  made  through  the  superficial 
parts — and  all  bleeding  controlled.  (2)  A  finger  is  then  placed  in  the  rectum, 
or  a  special  guide,  and  upon  this  the  whole  thickness  of  the  posterior  pelvic 
wall,  from  tip  of  coccyx  to  anus,  is  divided.  (3)  Having  completed  the 
division  of  the  rectum  and  accomplished  the  special  object,  the  wound  is 
treated  as  indicated.  In  cases  where  the  operation  has  been  for  the  removal 
of  foreign  body,  the  walls  of  the  rectum  are  to  be  carefully  brought  together 
by  suture  (chromic  gut) — and  then  the  tissues  between  the  rectum  and  the 
skin,  including  the  latter,  are  brought  together  by  sdk  sutures.  Where  the 
operation  has  been  performed  for  stricture,  the  walls  of  the  rectum  are,  of 


EXCISION    OF    THE    RECTUM    BY    THE    SACRAL    ROUTE.  935 

course,  not  reunited — a  light  packing  is  placed  between  these  to  prevent 
their  reunion — and  then  the  tissues  intervening  between  the  intestinal  wall 
and  the  skin,  including  the  latter,  are  sutured  with  silk — leaving  a  tem- 
porarv  opening  below  that  no  accumulation  of  discharge  within  the  extra- 
intestinal tissues  may  take  place. 


EXCISION  OF  THE  RECTUM  IN  GENERAL. 

Rectectomy,  or  Proctectomy,  consists  in  the  excision  of  the  rectum,  in 
whole  or  in  part.  It  is  generally  resorted  to  for  malignant  disease,  in  cases 
where  there  is  little  or  no  involvement  of  neighboring  viscera  or  lymphatic 
glands.  The  operation  may  be  done  through  the  perineum — through  the 
sacrum — through  the  vagina — by  the  abdomen — or  by  the  combined  abdomi- 
nal and  perineal  routes.     Proctectomy  may  be  partial  or  complete. 

Partial  Proctectomv  by  the  perineal  route  is  generally  confined  to  cases 
in  which  the  malignant  growth  is  within  10  cm.  (4  inches)  of  the  anus — and, 
in  women,  in  which  the  anterior  rectal  wall  is  not  involved  higher  up  than 
7.5  cm.  (3  inches).  With  some  the  indication  for  the  perineal  route  is  a 
growth  within  5  cm.  (2  inches)  of  the  anus.  Moderately  high  growths  are  ap- 
proached by  the  sacral  route.  Very  high  involvements  may  be  approached 
by  the  combined  perineal  and  abdominal  routes. 

If  uninvolved,  the  sphincters  should  be  preserved — provided  their  nerve- 
supplv,  which  reaches  them  from  their  lateral  aspects,  can  be  retained  intact — ■ 
and  subsequently  the  proximal  end  of  the  rectum  should  be  attached  to  the 
distal  end  containing  the  sphincters. 

The  division  of  the  sacrum  as  high  as  the  lower  border  of  the  third  sacral 
foramen  may  be  done  without  serious  injury  to,  or  serious  functional  impair- 
ment of,  neighboring  structures.  But  division  as  high  as  the  third  sacral 
foramen  has  been  followed  by  paralysis  of  the  bladder. 

A  wide  removal  of  circumanal  and  circumrectal  tissues  is  indicated  in  all 
malignant  involvement.  If  involved,  the  prostate  gland,  part  of  the  bladder, 
or  the  rectovaginal  septum,  should  be  removed. 


EXCISION  OF  THE  RECTUM  BY  THE  SACRAL  ROUTE 

BV  PARTIAL  EXCISION  OF  SACRUM  —  KRASKE'S  OPERATION. 

Description. — Kraske,  having  incised  through  the  soft  tissues  vertically 
downward  from  the  second  sacral  spine  to  the  anus  and  bared  the  coccyx 
and  left  lower  part  of  the  sacrum,  excised  the  coccyx — entirely  divided  the 
sacrosciatic  ligaments  and  completely  excised  the  left  lower  portion  of  the 
sacrum  along  a  line  curving  from  the  left  margin  of  the  sacrum  (on  a  level 
with  the  third  sacral  foramen)  along  the  lower  border  of  the  third  sacral 
foramen  to  the  left  inferior  corner  of  the  sacrum — and  thus  exposed  and 
excised  the  rectum. 

This  operation  subsequently  became  the  basis  of  various  modifications. 
Hochenegg,  Bardenheuer,  and  others  have  extended  the  line  of  excision  trans- 
versely across  the  entire  sacrum  on  a  level  with  the  lower  border  of  the  third 
sacral  foramen.  Heinecke,  Rehn,  Rydygier,  and  others  converted  the  partial 
excision  into  an  osteoplastic  resection  of  the  sacrum  and  coccyx — by  a  para- 
sacral incision  just  outside  of,  and  parallel  with,  the  left  border  of  the  sacrum 


936 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


and  coccyx,  followed  by  a  transverse  division  of  the  sacrum  just  below  the 
third  sacral  foramen — the  flap  thus  formed  being  temporarily  turned  aside 
to  the  right,  hinging  upon  its  partly  broken  and  partly  bent  tissues — and 
being  subsequently  replaced  in  position. 

Preparation. — (i)  A  preliminary  left  inguinal  colostomy  is  done  by 
many  surgeons  some  daws  in  advance — insuring  greater  cleanliness  of  the 
part  during  operation  and  the  avoidance  of  fecal  soiling  for  some  days  after- 
ward. It  is  desirable  in  the  majority  of  cases.  Previous  purgation  and 
irrigation  of  the  lower  bowel  for  two  or  three  days  immediately  preceding 
operation.  (2)  At  the  time  of  operation,  high  irrigation  and  swabbing  out 
of  the  bowel — and  often  rectal  packing  placed  high  up,  above  the  site  of 
disease.  Bladder  emptied.  Perineum  shaved.  The  sphincter  ani  is  para- 
lyzed by  digital  distention. 

Position. — Patient  is  held  in  the  knee-chest  position  by  means  of  upright 

supports  at  end  of  table, 
being  suspended  from 
these  from  just  below 
the  hip-joints,  while  the 
chest  is  supported  by 
a  cushion.  The  right 
latero-prone,  or  the 
exaggerated  lithotomy, 
position  may  also  be 
used. 

Landmarks. — Anus ; 
coccyx;  sacral  spines; 
posterior  superior  and 
inferior  iliac  spines; 
known  course  of  rec- 
tum. 

Incision.  —  In  the 
mid-line — from  the  sec- 
ond sacral  spine  to  the 
posterior  margin  of  the 
anus.     (See  Fig.  685.) 

Operation. —  (1) 
The  above  incision 
passes  directly  to  the 
bone  over  sacrum  and 
coccyx —  hemorrhage 
being  controlled  by 
clamp  forceps.  (2)  The  overlying  soft  parts  are  retracted  outward  to  the  left, 
exposing  the  left  side  of  the  sacrum  and  coccyx,  and  from  the  right  side  of  the 
coccyx.  (3)  The  gluteus  maximus  and  sacrosciatic  ligaments  are  detached 
from  both  sides  of  the  coccyx  and  from  the  left  side  of  the  sacrum.  The 
coccygei  and  part  of  the  left  piriformis  are  also  detached.  If  it  be  intended 
to  remove  the  anus,  the  external  sphincter  and  levator  ani  are  also  removed. 
(4)  Pass  a  periosteal  elevator  beneath  the  sacrum  (in  contact  with  its  anterior 
surface)  and  detach  the  soft  parts  from  the  hollow  of  the  bone,  and  the  sacra 
media  vessels  and  venous  plexus  along  with  them.  (5)  The  coccyx  and  as  much 
of  the  sacrum  as  considered  necessary  are  now  removed.  (See  Fig.  686.)  To 
accomplish  this  the  soft  parts  are  strongly  retracted  to  the  left  and  the  sacrum 
is  divided  with  chisel  and  mallet,  or  by  very  strong  bone-cutting  pliers,  or 


Fig.  685. — Excision  of  Rectum  by  the  Kraske  Opera- 
tion : — Subject  in  knee-chest  position.  Skin-incision  shown  in 
median  heavy  line,  from  second  sacral  spine  to  posterior  margin 
of  anus.  Bone-section  shown  in  dotted  line  crossing  transversely 
just  below  third  sacral  foramina.  Position  of  rectum  shown  in 
dotted  outline.  The  above  line  is  the  modification  of  Hochenegg 
and  Bardenheuer. 


EXCISION  OF  THE  RECTUM  BY  THE  SACRAL  ROUTE. 


937 


by  Gigli  saw — passing,  generally,  from  the  left  edge  of  the  sacrum  on  a  level 
with  a  point  just  below  the  left  third  posterior  sacral  foramen,  curving  inward 
and  downward  directly  through  the  left  fourth  posterior  sacral  foramen  to 
the  left  lower  corner  of  the  sacrum — thus  neither  harming  the  anterior  division 
of  the  third  sacral  nerve,  nor  opening  the  sacral  canal.  The  hemorrhage, 
which  is  chiefly   from  the  lateral  sacral,   middle  sacral,   and  hemorrhoidal 


Fit;.  686. —Excision  of  Rectum  by  Sacral  Route— Kraske  Operation  :— A,  Gluteus  maxi- 
mus  ;  B,  Great  sacrosciatic  ligament  ;  C,  Lesser  sacrosciatic  ligament  ;  D,  Pyriformis  ;  E.Coccygeus; 
F,  Levator  ani  ;  G,  External  sphincter;  H,  Sciatic  artery;  1.  Internal  pudic  artery;  J,  Branches  of 
internal  pudic  artery  and  pudic  nerve;  K,  Coccyx  ;  L,  Fourth  sacral  foramen  ;  M,  Gigli  saw  dividing 
sacrum  just  below  third  sacral  foramina. 


arteries,  and  anterior  and  posterior  venous  plexus,  and  the  bone,  is  controlled 
by  pressure  until  the  bone  is  removed — and  subsequently  by  catch-forceps 
and  ligature.  (6)  Having  thus  exposed  the  pelvic  cavity,  incise  the  tissues 
in  the  middle  line  down  to  and  through  the  levatores  ani,  until  the  rectum 
is  reached.     (7)  The  external  sphincter  and  anus  are  generally  left,  if  the 


938 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


site  of  involvement  be  as  much  as  2.5  cm.  (1  inch)  above  the  former.  (8) 
The  rectum  is  now  "shelled  out"  by  blunt  dissection.  This  "shelling  out" 
can  be  readily  carried  out  behind  and  on  the  sides.  The  size  of  the  rectum 
may  prevent  the  passage  of  the  finger  completely  around  it — and  the  attach- 
ments of  the  peritoneum  and  mesorectum  will  prevent  its  being  drawn  down- 
ward very  far.  (See  Fig.  687.)  (9)  Having  thus  isolated  the  rectum,  it 
should  be  divided  transversely  at  least  2.5  cm.   (1  inch)  below  the  lowest 


Fig. 687.— Excision  of  Rectum  by  Sacral  Route  (Kraske  Operation) — Part  of  Sacrum 
and  Coccyx  Removed  and  Divided  Rectum  Turned  Down  : — Unlettered  structures  are  same 
as  in  Fig.  439.  A,  Section  of  sacrum  below  third  sacral  foramina  ;  B,  Peritoneum;  C,  Vesiculse  semi- 
nales  ;  D,  Vasa  deferentia  ;  E,  Recto-vesical  layer  of  pelvic  fascia  ;  F,  Upper  end  of  severed  rectum  ; 
G,  Lower  end  of  divided  rectum  retracted  downward  ;  H,  Cancerous  growth  of  rectum  ;  1,1.  Middle 
sacral  artery  and  branches;  J,  J,  Superior  hemorrhoidal  arteries;  K,  Middle  hemorrhoidal  artery  (and 
same  on  opposite  side;. 


margin  of  disease.  In  order  to  retain  command  of  the  upper  end,  just  prior 
to  dividing  the  rectum  a  stout  circular  ligature  may  be  thrown  around  it 
just  beneath  the  involved  area — or,  simultaneously  with  the  division,  sutures 
may  be  placed  through  the  cut  walls  of  the  upper  end.  (10)  The  separation 
of  the  rectum  is  now  continued  by  blunt  dissection,  guided,  in  the  male, 
by  a  sound  in  the  bladder,  while  separating  the  rectum  from  the  prostate 


EXCISION  OF  THE  RECTUM  BY  THE  SACRAL  ROUTE.  939 

and  bladder — and,  in  the  female,  by  an  assistant's  finger  in  the  vagina,  in 
separating  the  rectum  from  the  vagina — controlling  hemorrhage  by  pressure. 
(11)  When  the  peritoneal  reflection  upon  the  anterior  aspect  of  the  rectum 
is  reached,  if  it  do  not  extend  too  high  it  may  be  found  possible  to  protrude 
this  reflection  upward  with  the  finger  and  thus  not  have  to  open  the  peri- 
toneum. If  the  growth  extend  above  the  reflection,  the  peritoneum  must  be 
opened,  and  is,  accordingly,  freely  incised.  (12)  The  mesorectum  and  pre- 
sacral areolar  tissue  now  alone  hold  the  rectum — and  these  are  separated 
and  loosened  upward  by  blunt  dissection,  while  the  bowel  is  gently  drawn 
downward.  (13)  Having  freed  the  rectal  surfaces  for  about  2.5  to  5  cm. 
(1  to  2  inches)  above  the  growth  and  clamped  it  at  this  site,  and  having 
packed  off  the  neighboring  regions  with  gauze,  it  is  divided  at  least  2.5  cm. 
(1  inch)  above  the  disease — dividing  the  mesorectum  and  presacral  areolar 
tissues  on  the  same  level.  All  bleeding  is  now  controlled  by  clamp  forceps 
and  ligature.  (14)  If  the  peritoneum  have  been  opened  during  operation,  a 
small  wound  of  the  structure  is  to  be  at  once  sutured,  with  or  without  drainage, 
as  indicated — a  large  rent  may  be  partly  sutured  and  partly  packed  with 
gauze,  or  entirelv  packed.  (15)  Having  completed  the  excision  of  the  dis 
eased  portion  of  rectum,  controlled  hemorrhage,  and  repaired  any  damage 
done  the  peritoneum,  the  ends  of  the  gut  are  to  be  treated  according  to  the 
circumstances  of  the  case  and  the  special  views  of  the  operator.  Considerable 
difference  of  opinion  exists  as  to  the  management  of  the  ends  of  the  intestine — 
some  of  the  views  being  here  summarized: — (A)  If  the  Sphincters  and  Anus 
Have  Been  Retained; — (a)  Direct  suturing  of  the  divided  ends  may  be  done. 
Kraske  sutures  the  anterior  and  lateral  portions  by  a  double  tier  of  sutures, 
one  through  the  mucous  membrane  only,  and  one  through  all  the  coats — 
while  he  inverts  the  posterior  portion  by  a  single  tier  not  passing  through 
the  mucous  membrane,  (b)  The  ends  may  be  united  by  a  Murphy  button. 
(c)  Moulouguet  carefully  removes  the  mucous  membrane  of  the  lower  portion 
of  the  rectum  (avoiding  injury  to  the  external  sphincter) — and  draws  through 
this  lower  portion  the  upper  end  and  sutures  its  borders  to  the  border  of 
the  anus,  controlled  by  its  sphincter.  (B)  If  the  Sphincters  and  Anus  be 
Sacrificed; — (a)  The  upper  end  of  the  divided  rectum  is  sutured  into  the 
upper  posterior  angle  of  the  wound,  (b)  Gersuny  twists  the  upper  end 
of  the  rectum  upon  its  long  axis  (to  give  some  difficult}-  to  the  fecal  passage) 
if  it  be  long  enough,  and  sutures  it  into  the  skin,  (c)  \\itzel  draws  the 
upper  end  of  the  rectum  through  a  short  incision  just  above  the  free  border 
of  the  gluteus  maximus  and  sutures  its  edge  to  the  skin  (to  gain  some  muscular 
control). 

Comment. — (1)  The  coccyx  alone  should  be  first  removed — as  that  may 
furnish  sufficient  room.  (2)  The  superior  hemorrhoidal  vessels  (bifurcating 
from  the  inferior  mesenteric  artery  in  the  median  line  between  the  layers 
of  the  mesorectum)  run  very  near  the  muscular  layer  of  the  intestine,  and 
by  cutting  in  the  loose  areolar  tissue  just  under  the  peritoneum  these  vessels 
are  avoided  and  the  upper  rectum  easily  freed  from  the  wall  of  the  pelvis. 
The  high  division  of  these  vessels  is  apt  to  be  followed  by  necrosis  of  the 
gut.  (3)  In  the  male,  with  empty  bladder,  the  rectovesical  peritoneal  re- 
flection is  generally  about  7.5  cm.  (3  inches)  above  the  anus.  A  full  bladder 
raises  the  reflection  about  2.5  cm.  (1  inch).  The  tip  of  the  coccyx  is  below 
the  level  of  this  reflection.  (4)  The  peritoneum  nearly  entirely  surrounds 
the  rectum  at  the  level  of  the  third  sacral  foramen,  a  distinct  mesorectum 
existing — loose  areolar  tissue  connecting  the  intestine  to  the  sacrum  and 
coccyx  where  the  peritoneum  is  absent.     (5)  A  truss  and  pad  are  worn 


94o 


OPERATIONS  UPON  THE  AI!I)OMIN<  >-I'ELVIC  REGION. 


where  a  sacral  anus  is  made.  (6)  Keen  performs  a  preliminary  inguinal 
colostomy,  which  is  permanent — and  closes  the  lower  opening  entirely.  (7) 
Fig.  687  represents  the  complete  transverse  division  of  the  sacrum. 


EXCISION  OF  THE  RECTUM  BY  THE  SACRAL  ROUTE. 

BY  THE  REHN-RYDYGIER  OSTEOPLASTIC  FLAP  METHOD. 

Description. — See  the  description  given  under  Kraske's  excision  of  the 
rectum  by  the  sacral  route. 

Preparation — Position — Landmarks. — Same  as  in  Kraske's  operation, 
above  given. 

Incision. — (1)  An  oblique  parasacral  incision  is  first  made,  beginning 
opposite  the  center  of  the  sacrum,  passing  along  just  to  the  outer  side  of 

the  left  border  of  the  sacrum 
and  coccyx  to  the  tip  of  the 
coccyx — and  thence  along  the 
mid-line  of  the  perineum 
nearly  to  the  anus.  (2)  A 
second  incision  is  then  car- 
ried transversely  across  the 
sacrum  about  4  cm.  (1^ 
inches)  above  the  sacro-coc- 
cygeal  articulation.  (See  Fig. 
688.) 

Operation. — (1)  The  ob- 
lique incision  passes  down- 
ward from  the  posterior  supe- 
rior iliac  spine  along  the 
outer  border  of  the  sacrum 
and  coccyx — the  transverse 
incision  passing  at  once  to 
the  sacral  bone.  All  bleed- 
ing vessels  in  the  lines  of  in- 
cision are  clamped.  (2)  Ex- 
pose and  divide  the  gluteus 
maximus  and  the  greater  and 
lesser  sacrosciatic  ligaments 
of  the  left  side,  along  the 
oblique  incision.  (See  Fig.  689.)  (3)  The  transverse  incision  is  further 
deepened  until  the  irregular  depressions  and  elevations  of  the  posterior 
aspect  of  the  sacrum  are  exposed  in  the  bed  of  the  transverse  wound. 
(4)  By  means  of  a  curved  elevator  and  blunt  dissector  the  soft  parts  in 
the  hollow  of  the  anterior  surface  of  the  sacrum  are  raised  from  the  bone, 
clearing  the  anterior  surface  of  the  sacrum  below  the  level  of  the  third  sacral 
foramina.  (5)  The  sacrum  is  now  divided  transversely  just  below  the  third 
sacral' foramina  by  means  of  chisel  or  saw — and  the  osteo-cutaneous  flap 
thus  freed  is  then  prized  over  to  the  right,  hinging  along  a  line  corresponding 
with  the  right  sacro-coccygeal  border — and  the  posterior  aspect  of  the  rectum 
is  thus  exposed.  All  hemorrhage  is  now  controlled  by  clamp  and  ligature 
before  proceeding.  (6)  The  subsequent  steps  of  the  operation  are  practically 
the  same  as  in  Kraske's  operation  (q.  v.).  (7)  Where  union  between  the 
two  segments  of  the  rectum  can  be  accomplished  at  the  end  of  the  operation, 


Fig.  688.— Osteoplastic  Resection  of  Rectum  by 
the  Rehn-Rydygier  Operation: — Patient  in  knee-chest 
position.  Rectum  shown  in  outline.  Skin-incision  in 
heavy  oblique  and  vertical  line.  Bone-section  in  trans- 
verse dotted  line. 


EXCISION  OF  THE  RECTUM  BY  THE  SACRAL  ROUTE. 


941 


this  is  secured  as  described  under  Kraske's  operation — followed  by  the  re- 
position of  the  bone-flap  in  place  and  the  holding  of  it  there  by  the  passage 
of  chromic  gut  sutures  through  its  periosteal  and  aponeurotic  structures — 
accompanied  by  temporary  gauze  drainage.  If  union  of  the  ends  cannot 
be  accomplished,  the  upper  end  may  be  brought  down  and  anchored  as 
low  in  the  wound  as  possible,  by  sutures,  the  wound  cavity  packed,  and 
no  attempt  made  to  suture  the  bone-flap  in  place.  Granulation  then  occurs, 
with  some  retraction  of  the  flap,  but  a  useful  result  generally  follows.  Or, 
where  the  growth  cannot  be  all  removed,  or  a  greater  gap  is  left  between 
the   segments  than   foreseen,   the  bone-flap   may  be  entirely   detached   and 


* 


Fig. 689.— Osteoplastic  Resection  of  the  Rectum— Rehn-Rydygier  Operation: — Show- 
ing flap  of  part  of  sacrum,  coccyx,  and  overlying  soft  parts  temporarily  displaced  to  right.  Unlettered 
structures  are  same  as  in  Figs.  686  and  687. 


discarded  (constituting  a  sacral  excision  of  the  lower  portion  of  the  bone) 
and  the  upper  end  of  the  gut  anchored  in  the  upper  angle  of  the  external 
wound — which  is  then  closed  throughout  the  balance  of  its  extent,  except 
at  the  site-  where  drainage  is  established. 

Comment. — The  osteoplastic  method  of  exposing  the  rectum  is  preferable 
where  it  is  possible — but  if  the  flap  of  bone  be  in  the  way  of  the  operation 
itself,  or  in  the  way  of  the  subsequent  management  of  the  case,  it  should 
be  removed — and  the  operation  converted  into  a  partial  excision.  The  tem- 
porary bony  resection  preserves  the  posterior  support  of  the  levatores  ani. 


942 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


It  probably  does  not  furnish  quite  as  much  room  as  the  method  by  partial 
excision;  the  bone-flap  may  necrose;  there  is  no  room  for  a  sacral  anus, 
where  this  is  indicated,  except  by  total  or  partial  removal  of  the  bone-flap. 


EXCISION  OF  THE  LOWER  PART  OF  THE  RECTUM  BY  THE 
PERINEAL  ROUTE. 

Description. — The  excision  of  the  lower  portion  of  the  rectum  by  the 
perineal  route  is  usually  confined  to  cases  in  which  the  cause  of  removal  is 
within  finger's  reach  of  the  anus. 

Preparation.-— Purgation;  irrigation  of  the  lower  bowel;  rectal  packing; 
bladder  emptied;  perineum  shaved. 

Position. — Patient  in  exaggerated  lithotomy  position,  or  in  Sims'  posi- 
tion.    Surgeon  standing,  or  sitting,  in  front  of  perineum. 


Fig- 69c. —Excision  of  Lower  Rectum  by  Perineal  Route  :— Line  of  incision. 


Landmarks. — Anus;  tip  of  coccyx;  and,  later,  position  of  bladder,  pros- 
tate, vagina,  and  rectum. 

Incision. — Two  lateral  oval  incisions  are  made — almost,  but  not  quite, 
meeting  in  front  of  the  anus — being  continued  backward  around  the  sides 
of  the  anus  in  the  ilio-rectal  fossae  to  meet  behind  the  anus — and  prolonged 
thence  in  the  mid-line  to  the  tip  of  the  coccyx.     (See  Fig.  690.) 

Operation. — (1)  The  incision  passes  directly  into  the  ilio-rectal  fossae — 
and  is  followed  by  blunt  dissection  (with  finger  and  blunt  dissector)  of  the 
lower  end  of  the  rectum  up  to  the  levatores  ani — the  bleeding  being  controlled 
by  catch-forceps  and  gauze-mops  upon  sponge-holders  pressed  into  the 
wound.  (See  Fig.  691.)  (2)  In  the  male,  guided  by  the  sound  in  the  bladder, 
the  rectum  is  carefully  separated  from  the  bladder,  prostate,  and  urethra, 
to  which  it  is  rather  closely  adherent.  The  index-finger  of  an  assistant 
in  the  rectum,  with  thumb  toward  bladder,  aids  the  surgeon  in  this  separation, 


EXCISION  OF  RECTUM  BY  PERINEAL  ROUTE. 


943 


(3)  In  the  female,  an  assistant's  index  in  the  vagina  aids  the  operator  in 
separating  the  rectum  from  that  organ.  (4)  Guard  against  opening  the 
reflection  of  peritoneum — and,  if  opened,  suture  at  once,  if  small — and  pack 
with  gauze,  if  the  opening  be  large.  (5)  The  levatores  ani  are  now  divided — - 
and  the  rectum  thus  freed  everywhere  but  above.  All  bleeding  vessels  are 
clamped  or  ligated  before  beginning  the  freeing  of  the  rectum.  (6)  During 
gentle  downward  traction  of  the  bowel  it  is  further  freed  by  blunt  dissection 
and  scissors.     Having  clamped  the  bowel  above  (to  retain  control  and  also 


Fig.  69 1. — Excision  of  Lower  Rectum  by  Perineal  Route  : — A,  Anus;  B,  Coccyx;  C, 
Margin  of  wound,  showing  transverse  perineal  vessels  anteriorly,  and  infei  ior  hemorrhoidal  vessels 
posteriorly;  D,  External  sphincter;  E,  Levator  ani ;  F,  Rectum  being  treed  by  blunt  dissector  (G) 
and  by  traction  with  ringer  (H)— (cancerous  growth  is  shown  at  roughened  portion  of  rectum). 


to  avoid  soiling),  it  is  divided  transversely  about  2.5  cm.  (1  inch)  above  and 
below  the  growth.  Where  possible,  the  sphincters  and  anus  should  be  pre- 
served. (7)  All  hemorrhage  having  been  controlled,  the  question  of  the 
management  of  the  ends  of  the  intestine  must  be  decided: — (a)  Where  the 
Sphincters  and  Anus  are  Left; — The  upper  end  is  brought  down  and  sutured 
to  the  lower  by  one  of  the  methods  of  entero-enterostomy;  (b)  Where  the 


944  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Sphincters  and  Anus  are  Removed; — The  upper  end  may  be  displaced  back- 
ward and  sutured  between  the  levatores  ani  in  the  position  of  a  subcoccvgeal 
anus — the  wound  in  front  being  closed  by  deep  and  superficial  sutures,  the 
deep  sutures  including  the  levatores  ani  so  as  to  form  a  sphincteric  anus. 


OPERATION  FOR  THE  CURE  OF  HEMORRHOIDS  BY  LIGATION 
AND  EXCISION. 

ALLINGHAM'S  METHOD. 

Description. — Consists  in  the  isolation  and  freeing  of  the  pile  by  dis- 
section, until  its  true  pedicle  is  reached — around  which  pedicle  a  ligature 
is  placed  and  the  pile  cut  off  below  it.  This  form  of  operation  is  especially 
indicated  in  isolated  piles,  and  particularly  those  of  columnar  outline. 

Preparation. — Purgation;  rectal  irrigation;  circumanal  region  shaved; 
dilatation  of  anus  immediately  preceding  excision. 

Position. — Patient  in  lithotomy  position  at  end  of  table;  Surgeon  seated 
opposite  perineum;  Assistant  to  surgeon's  side.  Patient  may  lie  upon  side, 
with  knees  drawn  up. 

Landmarks. — Anus;  hemorrhoidal  tumors. 

Operation. — (i)  For  the  purpose  of  dilating  the  anal  orifice,  both  thumbs, 
lubricated,  are  inserted  into  the  bowel,  knuckle  to  knuckle — and,  grasping 
the  ischial  tuberosities  on  each  side  with  the  fingers,  the  surgeon  carefully 
and  slowly  separates  the  thumbs  to  the  desired  extent,  consuming  about 
two  minutes  in  the  process.  (2)  Having  thoroughly  dilated  the  anal  orifice, 
the  interior  of  the  lower  rectum  is  examined  with  the  index-finger,  and  the 
number,  nature,  and  position  of  the  hemorrhoids  determined.  (3)  Beginning 
with  those  upon  the  lower,  posterior  aspect  (that  bleeding  may  not  obscure 
the  operation),  each  pile  is  seized  with  toothed  forceps  and  drawn  downward 
and  away  from  its  attachment,  putting  this  attachment  upon  gentle  stretch. 
(4)  While  the  pile  is  thus  held,  a  pair  of  blunt-pointed  scissors  (straight  or 
curved,  as  more  convenient)  is  made  to  dissect  the  pile  up  from  the  sub- 
cutaneous tissue  by  limited  snips,  beginning  below  at  the  line  of  muco- 
cutaneous junction  and  proceeding  upward  in  the  long  axis  of  the  bowel, 
until  a  point  is  reached  where  the  pile  is  attached  by  the  normal  mucous 
membrane  and  by  its  blood-vessels,  which  now  form  its  pedicle.  Up  to 
this  stage  but  few  vessels  have  been  encountered  and  but  little  bleeding 
occurs.  (5)  While  the  pile  is  thus  held  by  an  assistant,  a  friction-knot  of 
chromic  gut  is  thrown  around  the  pedicle  of  the  pile  and  pushed  as  high 
up  as  possible — this  friction-knot  is  drawn  tight  and  a  second  knot  is  added. 
(6)  The  hemorrhoid  is  then  cut  off,  with  scissors  or  knife,  just  far  enough 
below  the  ligature  to  insure  its  retention.  This  procedure  is  repeated  upon 
as  many  piles  as  are  present.     (See  Fig.  692,  A  and  B.) 

Comment. — (1)  Piles  are  classed  as  "External,"  below  the  pressure  of 
the  external  sphincter; — "Internal,"  above  the  pressure  of  the  external 
sphincter; — "  Interno-external, "  partly  above  and  partly  below  the  grasp 
of  the  external  sphincter.  (2)  The  vessels  which  supply  hemorrhoids  come 
from  above  and  run  just  under  the  mucous  membrane,  entering  the  upper 
portion  of  the  pile — which  facts  have  a  direct  bearing  upon  the  manner  of 
partially  separating  hemorrhoids  preparatory  to  ligation  or  excision.  (3) 
Where  closelv  placed  piles  form  more  or  less  of  a  circle  around  the  anus, 
they  are  separated  by  incisions  made  through  the  mucous  membrane,  and 
then    each    pile    is  ligated    separately,  as  above    described.     (4)   It  is    par- 


OPERATION   FOR   HEMORRHOIDS  BY  LIGATION. 


945 


ticularlv  important  to  include  no  part  of  the  skin  within  the  grasp  of  the 
ligature,  as  much  and  prolonged  pain,  from  the  inclusion  of  nerve  filaments, 
may  follow.  Such  inclusion  is  impossible  if  the  ligature  be  not  applied 
until  the  pile  is  freed  up  to  its  natural  pedicle  (5)  It  is  well  to  suture  up 
with  fine  catgut  the  furrows  in  the  submucous  tissue  left  by  the  snips  of 
the  scissors  in  dissecting  the  hemorrhoid  from  its  bed.     (See  Fig.  692,  C.) 


Fig.  692.— Operation  for  Hemorrhoids  by  Ligation  and  Excision  :— A,  Hemorrhoid  ex- 
cised from  its  bed  and  ligature  thrown  around  its  pedicle  ;  B,  Tract  left  to  granulate  after  the  ordinary 
operation  of  removal  by  ligation  and  excision;  C,  Former  tract,  left  after  ligation  and  excision, 
sutured  so  as  to  approximate  edges  and  promote  primary  union. 


OPERATION  FOR  THE  CURE  OF  HEMORRHOIDS  BY  EXCISION. 

WHITEHEAD'S  OPERATION. 

Description. — Consists  in  the  excision  of  the  pile-bearing  segment  of 
mucous  membrane,  together  with  its  piles — followed  by  the  immediate  suturing 
of  the  divided  mucous  membrane  above  to  the  skin  below.  This  form  of 
operation  is  especially  indicated  in  those  cases  of  hemorrhoids  where  a  circle 
of  large  and  irregular  piles  more  or  less  completely  surrounds  the  anal  orifice. 

Preparation — Position— Landmarks. — As  in  the  operation  by  ligation 
above  described. 

Operation. — (1)  Having  dilated  the  anal  orifice,  as  described  under  the 
ligature  operation,  the  pile-bearing  segment  of  mucous  membrane  is  seized 
with  forceps  and  put  upon  gentle  stretch.  (See  Fig.  693.)  (2)  While  thus 
held,  and  beginning  at  the  lowest  portion  of  the  circle  and  proceeding,  pari 
passu,  up  the  two  sides,  the  mucous  membrane  is  divided  with  scissors  exactly 
along  the  muco-cutaneous  line — passing  entirely  around  the  circumference  of 
60 


946 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


the  anal  opening  and  accurately  following  in  and  out  along  every  irregularity 
of  the  skin.  (3)  Working  by  rapid  dissection  along  the  submucous  plane 
with  the  closed  end  of  blunt  scissors,  the  external  sphincter  is  first  exposed 
and  then  the  beginning  of  the  internal  sphincter — and  the  mucous  mem- 
brane, with  the  attached  hemorrhoids,  separated  from  their  bed  of  sub- 
mucous tissue,  are  drawn  down  below  the  skin  margin — all  restraining  points 
of  connective  tissue  being  divided.  (4)  The  mucous  membrane  just  above 
the  hemorrhoids  is  now  cut  transversely,  a  small  extent  at  a  time — and  the 
limited  part  of  the  mucous  membrane  thus  freed  above  is  immediately 
stitched  witli  silk  to  the  free  border  of  skin  below,  which  has  been  divided 
along  the  muco-cutaneous  line  of  the  primary  incision.  Following  this, 
another  area  of  mucous  membrane  is  cut  free  above — and  at  once  sutured 


Fig. 693—  Whitehead's  Operation  for  Hemorrhoids: — A,  Pile-bearing  segment  of  mucous 
membrane  being  dissected  away  with  scissors,  while  held  upon  the  stretch  with  forceps  ;  B,  Sutures 
approximating  mucous  membrane  above,  to  skin  below. 

to  the  skin  below — and  thus  on  around  the  circle — until  the  circumference 
of  pile-bearing  mucous  membrane  is  removed. 

Comment. — All  bleeding  vessels  are  controlled,  by  Whitehead,  by  torsion 
during  these  steps.  The  chief  hemorrhage  tends  to  come  from  the  vessels 
divided  in  the  transverse  division  of  the  mucous  membrane  and  pedicle  of 
the  pile  above — and  this  bleeding  is  largely  controlled  by  the  immediate 
suturing  of  the  free  border  of  the  mucous  membrane  to  the  free  margin  of 
the  skin.  There  is  no  reason  why  fine  catgut  ligatures  should  not  be  used 
where  considered  necessarv. 


OPERATION  FOR  THE  CURE  OF  HEMORRHOIDS  BY  THE  CLAMP  AND 

ACTUAL  CAUTERY. 

Description. — Consists  in  the  cauterizing,  at  red  heat,  of  the  hemor- 
rhoidal  growth — while  held  in  the   grasp   of  special   clamp-forceps.     This 


OPERATION  FOR  FISTULA-IN-ANO  BY  INCISION.  947 

form  of  operation  may  be  applied  to  piles  in  general — but  is  more  especially 
indicated  in  simple  venous  piles  of  medium  size. 

Preparation — Position — Landmarks. — As  in  the  ligature  method. 

Operation. — (1)  Having  dilated  the  anus,  each  pile  in  turn,  or  a  cluster 
of  piles,  is  seized  with  toothed  forceps  and  drawn  downward  and  away  from 
its  attachment.  (2)  Divide  the  muco-cutaneous  border,  if  there  be  one,  with 
blunt-pointed  scissors  or  knife  (that  nerve-filaments  may  not  be  included 
in  the  grasp  of  the  clamp).  (3)  Apply  the  clamp,  with  the  pile  still  under 
gentle  traction,  to  the  base  of  the  tumor,  and  in  the  axis  of  the  gut — the 
clamp  resting  in  the  cut  groove  at  the  muco-cutaneous  border,  if  the  pile 
be  one  having  a  cutaneous  part.  The  blades  are  then  screwed  together 
sufficiently  firmly  to  thoroughly  compress  the  parts.  (4)  With  a  pair  of 
curved  scissors,  cut  away  the  excess  of  hemorrhoid  which  projects  above  the 
clamp.  Then,  with  a  Paquelin  01  other  cautery  at  red  heat,  slowly  and 
thoroughly  cauterize  the  stump  of  the  pile.  As  the  clamp  is  loosened,  follow 
down  the  escaping  pile-stump  with  the  point  of  the  cautery — seeing  that  all 
hemorrhage  is  controlled.  If  necessary  to  make  the  hemostasis  complete,  the 
stump  may  be  again  clamped  and  again  cauterized.  This  process  is  repeated 
until  all  the  piles  or  clusters  have  been  cauterized. 

Comment. — Where  the  piles  are  in  the  form  of  a  more  or  less  complete 
circle  surrounding  the  anus,  they  should  be  divided  into  segments  or  groups 
by  incision  of  the  mucous  membrane  prior  to  clamping  and  cauterizing. 
Avoid  burning  the  skin — or  detaching  the  eschars,  thereby  favoring  hemor- 
rhage. 


OPERATION  FOR  THE  CURE  OF  FISTULA-IN-ANO  BY  INCISION. 

Description. — Consists  in  the  laying  open  of  the  fistulous  tract  upon  a 
grooved  director — followed  by  the  curettage  of  the  sinus-walls — and  light 
gauze  packing  of  the  raw  bed  to  promote  healing  from  the  bottom  and  ob- 
literation of  the  fistula, — or  excision  of  tract  with  suture  of  its  bed. 

Preparation. — Purgation;  rectal  irrigation;  shaving  of  circumanal  re- 
gion; dilatation  of  the  sphincter  just  before  operation,  in  the  more  compli- 
cated cases. 

Position. — Patient  in  the  lithotomy  position,  with  nates  over  the  end 
of  the  table;  surgeon  sitting  opposite  the  perineum. 

Landmarks. — Anus;  rectum;  course  of  fistula  and  position  of  openings 
determined  in  advance,  if  possible. 

Operation. — (1)  A  grooved  director  is  passed  through  the  sinus,  from  its 
skin  opening — made  to  traverse  its  length  and  emerge  through  its  internal 
opening  within  the  bowel — and  the  end  of  the  director  is  then  caused  to 
project  through  the  anus  by  directing  its  tip  with  the  left  index-finger  within 
the  rectum,  while  its  handle  is  depressed  with  the  right  hand.  The  external 
and  internal  openings  of  the  fistula  are  then  in  plain  view — with  the  grooved 
director  passing  through  its  entire  length.  (See  Fig.  698,  A.)  (2)  Upon  the 
grooved  director  a  narrow,  pointed  knife  is  passed  (or  a  probe-pointed  bis- 
toury may  be  used)  with  its  cutting-edge  directed  outward — thus  incising 
the  fistula  throughout  its  entire  course — freeing  the  grooved  director  and 
allowing  the  parts  to  recede  into  their  normal  positions.  (3)  The  lips  of 
the  wound  and  of  the  sinus  are  then  separated  by  the  operator's  left  thumb 
and  index — and,  while  thus  exposed,  the  entire  extent  of  the  fistula  should 
be  scraped  with  a  curette,  so  as  to  remove  its  old  wall — and  then  Lightly 
packed  with  gauze  and  allowed  to  heal  from  the    bottom.     A  T-bandage 


948 


OPERATIONS  I  TON  THE  ABDOMINO-PELVIC  REGION. 


keeps  the  dressing  in  place.     The  bowels  are  usually  kept  constipated  for 
a  few  days. 

Comment. — (i)  Fistuke-in-ano  are  generally  one  of  three  types; — "Com- 
plete"— "Incomplete  Internal" — "Incomplete  External."  In  addition,  fis- 
tulas may  have  several  openings; — and  they  may  have  irregular  forms,  as, 
for  example,  the  "horseshoe"  type.  (See  Figs.  694  to  697.)  (2)  If  the 
grooved  director  does  not  pass  readily,  a  probe  may  first  find  the  way — and 
the  director  passed  along  this — and  the  probe  then  withdrawn.  (3)  If  the 
grooved  director,  or  probe,  cannot  be  made  to  find  an  internal  communication 
with  the  bowel,  but  nevertheless  comes  very  near  the  mucous  membrane, 
it  may  be  forced  the  remaining  distance,  provided  this  distance  be  short. 
(4)  If  the  end  of  the  director  cannot  be  brought  out  through  the  anus,  a 
narrow,   probe-pointed  bistoury   may  be  passed  along  it  and  the  director 


Figs.  694—697. — Forms  of  Fistul^e-in-ano  : — A,  Rectum  in  vertical  section;  a,  Incomplete  external 
fistula  ;  6,  Incomplete  internal  fistula  ;  c,  Complete  fistula  ;  d.  Irregular  complete  fistula.  B,  Surface 
view  of  fistulous  tracts,  showing  various  irregular  forms  of  fistula;  and  diverticula — their  external 
openings  being  marked  by  a  star. 


withdrawn — and  then  the  end  of  the  probe-pointed  bistoury  is  pressed  against 
the  surgeon's  left  index-finger  (or  a  special  piece  of  wood)  introduced  within 
the  rectum — and  finger  and  knife  simultaneously  withdrawn — the  knife  cutting 
the  intervening  soft  parts  through  in  its  withdrawal.  Or  one  blade  of  a 
pair  of  scissors  may  be  passed  along  the  director  and  the  sinus  thus  laid  open. 
(5)  In  incomplete  internal  fistula1,  the  internal  opening  is  found  through  a 
speculum — a  bent  probe  passed  along  the  sinus — and  an  external  opening 
made  where  thus  indicated — after  which  the  operation  is  completed  as  in  a 
complete  fistula.  (6)  In  incomplete  external  fistula,  if  the  inner  end  be  very 
near  the  mucous  membrane,  a  director  is  protruded  through  the  sinus  into 
the  bowel,  forcing  its  way  through  the  thin  barrier — after  which  the  operation 
is  completed  as  in  the  complete  fistula.     If,  on  the  other  hand,  the  inner 


OPERATION  FOR  FISTULA- IN- ANO  BY   INCISION. 


949 


opening  be  not  connected  with  or  near  the  bowel,  the  entire  tract  must  be 
laid  open  from  without.  (7)  If  the  fistula  extend  high  up  along  the  bowel, 
judgment  must  be  exercised  as  to  what  extent  cutting  is  necessary,  and  to 
what  extent  dilatation  and  scraping  will  suffice.  (8)  In  "horseshoe"  fistuke 
(an  external  opening  on  each  side  of  the  anus  leading  to  a  single  internal 
opening,  generally  upon  the  posterior  rectal  wall)  the  bowel  function  is  less 


Fig. 698.— Operation  for  Cure  of  Fistula-in-ano  by  Incision  and  Excision: — A,  Bistoury 
in  act  of  dividing  fistula  upon  grooved  director;  B,  Fistulous  tract  being  excised  by  curved  scissors, 
while  steadied  with  forceps  ;  C,  Suturing  of  bed  of  sinus  alter  its  excision  ;  D,  Ligature  attached  to 
gauze  tampon  in  rectum,  t<>  control  contents. 


apt  to  be  interfered  with  if  the  sphincter  be  cut  on  one  side  only  (and  at 
right  angles  to  the  anal  orifice)  and  the  opposite  part  of  the  fistula  be  dilated, 
scraped,  and  drained  from  the  first  side.  (9)  Search  should  always  be  made 
for  secondary  fistula?  running  off  from  the  main  one,  and  these  likewise  laid 
open  and  curetted — or  dilated  and  scraped.  (10)  The  internal  sphincter 
should  not  be  divided  if  it  can  be  helped.     If  it  be  necessary  to  incise  the 


95©  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

internal  sphincter,  the  division  should  be  at  right  angles  to  its  fibers  at  the 
site  of  section  (that  repair  may  be  more  complete,  and  subsequent  functioning). 
And  it  is  preferable  not  to  divide  the  internal  sphincter  in  more  than  one 
place  at  a  time  (for  the  same  reasons),  (n)  Whatever  hemorrhage  occurs, 
which  is  generally  slight,  is  ordinarily  controlled  by  gauze  packing — but  gut- 
ligaturing  may  be  used  where  necessary.  (12)  In  appropriate  cases  the  entire 
fistulous  tract  may  be  dissected  out — and  the  raw  edges  thus  left  be  brought 
together  by  superficial  and  deep  chromic  gut  sutures — thus  at  once  obliterating 
the  site  of  sinus  and  inviting  primary  union.  This  method  is  preferable  to 
simple  incision  wherever  applicable.     (See  Fig.  698,  B  and  C.) 


VI.  THE   STOMACH. 

SURGICAL  ANATOMY. 

Description. — Lies  in  epigastric  and  left  hypochondriac  regions — being 
about  five-sixths  to  left  and  one-sixth  to  right  of  median  line; — lying  under 
the  liver  and  diaphragm, — above  the  jejunum,  ileum,  and  transverse  colon 
(also  upon  the  transverse  mesocolon,  which  intervenes  between  it  and  pan- 
creas, abdominal  vessels  and  solar  plexus), — and  between  gall-bladder  on 
right  and  spleen  on  left. 

Relations. — Anteriorly  and  superiorly:  diaphragm;  thoracic  wall  (an- 
terior portions  seventh,  eighth,  and  ninth  ribs);  left  and  quadrate  lobes  of 
liver;  anterior  abdominal  wall;  lesser  omentum.  Posteriorly  and  infe- 
riorly :  diaphragm;  crura  of  diaphragm;  aorta  and  inferior  vena  cava; 
first  lumbar  vertebra;  cceliac  axis;  lesser  peritoneal  sac;  splenic  flexure  of 
colon ;  transverse  colon ;  transverse  mesocolon  (superior  layer) ;  spleen  (gastric 
surface);  left  kidney  and  suprarenal  capsule;  pancreas;  splenic  vessels;  duo- 
denum (fourth,  or  ascending  portion) ;  solar  plexus.  Right  end  :  transverse 
colon;  inferior  surface  of  liver.     Left  end  :  spleen;  diaphragm. 

Position  of  Cardiac  End  (Fundus). — Reaches  up  to  the  left  sixth  chon- 
dro-sternal  articulation,  or  fifth  rib  in  mammary  line,  and  to  cupola  of  dia- 
phragm;— slightly  above  and  behind  the  heart  apex; — and  3  to  5  cm.  (ij 
to  2  inches)  higher  than  the  cardiac  orifice  of  the  stomach. 

Position  of  Cardiac  Orifice. — Opposite  left  seventh  chondro-sternal 
articulation,  about  2.5  cm.  (1  inch)  from  sternum; — also  on  level  with  ninth 
dorsal  spine  (left  side  of  eleventh  dorsal  vertebra).  Lies  from  2  to  3  cm. 
(f  to  1  j  inches)  below  the  esophageal  opening,  and  about  7.5  cm.  (3  inches) 
from  the  left  extremity  of  the  stomach, — and  n  cm.  (4  J  inches)  from  the 
anterior  abdominal  wall. 

Position  of  Pylorus. — On  level  with  bony  ends  of  seventh  ribs  (which 
are  5  to  7.5  cm.,  or  2  to  3  inches,  below  the  sterno-xiphoid  joint),  lying  to 
right  of  median  line  and  nearer  the  surface  than  the  cardiac  end; — also  on 
level  with  twelfth  dorsal  spine  (upper  border  of  first  lumbar  vertebra). 

Fixation  Points  and  Ligaments  of  Stomach. — Bound  to  diaphragm  by 
esophagus; — bound  to  vertebral  column  by  duodenum ; — ligamentum  phrenico- 
gastricum  connects  cardia  to  diaphragm; — gastro-hepatic  omentum  (lesser 
omentum)  connects  lesser  curvature  to  liver; — ligamentum  hepato-duodenale 
connects  pylorus  and  duodenum  to  liver; — gastro-splenic  omentum  binds 
greater  end  of  stomach  to  spleen; — great  omentum  binds  the  stomach  only 
when  itself  is  bound. 


SURGICAL  CONSIDERATIONS  IN  STOMACH  OPERATIONS.  951 

Peritoneal  Coverings. — Everywhere — except  along  the  upper  and  lower 
curvatures,  and  upon  the  triangular  areas  at  either  end. 

Arteries. — Gastric;  pyloric  and  right  gastro-epiploic  branches  of  hepatic; 
left  gastro-epiploic  and  vasa  brevia  of  splenic. 

Veins. — Coronary  and  pyloric,  emptying  into  portal  vein;  right  gastro- 
epiploic, emptying  into  superior  mesenteric;  left  gastro-epiploic,  emptying 
into  splenic. 

Nerves. — Right  vagus  (posterior  surface) ;  left  vagus  (anterior  surface) ; 
solar  plexus  of  sympathetic  system. 

Lymphatic  Glands.— Along  greater  and  lesser  curvatures — and  at 
pyloric  and  cardiac  ends. 

SURFACE  FORM  AND  LANDMARKS. 

Stomach  when  empty — lies  far  back  in  the  abdominal  cavity,  beneath 
left  lobe  of  liver  and  in  front  of  pancreas. 

In  moderate  distention — Cardiac  end  lies  beneath  left  seventh  chondro- 
sternal  articulation,  about  2.5  cm.  (1  inch)  beyond  the  sternum.  Pyloric 
end  lies  opposite  a  point  near  end  of  eighth  right  chondro-costal  articulation. 

Borders  (curvatures)  of  stomach  are  represented  approximately  by  curves 
of  the  characteristic  contour  between  the  points  just  given — the  greater 
curvature  reaching  at  first  to  the  left,  then  downward  to  the  infracostal  line. 
The  lesser  curvature  crosses  the  vertebral  column  on  a  level  with  the  first 
lumbar  vertebra.  The  greater  curvature  crosses  the  epigastrium  on  a  line 
connecting  the  ninth  and  tenth  costal  cartilages — which  is  about  two  finger- 
breadths  above  the  umbilicus. 

Gastric  fossa — a  triangular  area  of  about  40  square  centimeters  (15J 
inches)  of  the  anterior  wall  of  the  stomach  where  it  lies  in  direct  contact 
with  the  abdominal  wall — bounded,  below,  by  the  transverse  colon;  above 
and  to  left,  by  seventh,  eighth,  and  ninth  costal  cartilages;  and  above  and 
to  right,  by  the  anterior  border  of  the  liver. 

GENERAL  SURGICAL  CONSIDERATIONS  IN  OPERATIONS  UPON 
THE  STOMACH. 

Stomach  may  be  recognized  by  its  relation  to  the  inferior  surface  of  the 
liver — by  its  continuity  with  the  anterior  layer  of  the  gastro-hepatic  omentum — 
L7  its  thick  and  stiff  wall,  as  detenrJned  by  pinching  it  up  between  the  fingers — 
by  the  direction  of  its  vessels — and  by  its  pinkish-w?.-  ;e  color  and  absolute 
opacity.  The  stomach  and  transverse  colon  have  been  mistaken  for  each 
other.  The  transverse  colon  should  be  displaced  downward  and  the  liver 
upward — revealing  the  stomach  between  them.  If  not  otherwise  recognizable, 
follow  back  the  under  surface  of  the  liver  to  the  portal  fissure,  with  the  index- 
finger — thence  downward  along  the  gastro-hepatic  omentum  to  the  stomach. 

Anterior  gastric  wall  lies  in  the  greater  peritoneal  cavity — and  its  posterior 
wall  in  the  lesser  cavity. 

Superior  wall  of  the  transverse  colon  lies  in  the  lesser  peritoneal  cavity — ■ 
and  its  inferior  wall  in  the  greater  cavity. 

Mesentery  descends  downward  and  forward  from  under  the  back  part 
of  the  transverse  mesocolon.  The  omentum  major  descends  from  the  greater 
curvature  of  the  stomach  and  inferior  aspect  of  the  transverse  colon — and 
mav  contain  a  cavity  and  be  continuous  with  the  omentum  minor  above 
the  transverse  colon — but  its  component  layers  are  more  generally  united. 
The  omentum  can  be  more  conveniently  displaced  upward  and  to  the  left. 


952  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

Note. — Other  general  surgical  considerations  will  be  mentioned  under 
special  classes  of  gastric  operations. 

INSTRUMENTS. 

Scalpels;  straight  and  blunt-pointed  bistouries;  scissors,  curved  and 
straight;  dissecting  and  toothed  forceps;  tenacula;  artery-clamp  forceps; 
various  retractors;  large  gauze  pads;  broad  spatula?;  intestinal  clamps;  stomach 
clamps;  Murphy  button;  sponge-holders;  volsella;  stomach-tube;  rubber 
tubing  (for  gastrostomies);  needles,  curved  and  straight;  needle-holders; 
sutures,  silk  and  gut;  ligatures,  silk  and  gut;  ligature-carrier,  wound-hooks. 

INTRODUCTION  OF  STOMACH-TUBE. 

Description. — The  passage  of  a  hollow  tube  down  the  esophagus  and 
into  the  stomach — for  the  purpose  of  removing  fluid  from,  or  injecting  fluid 
into,  the  stomach. 

Position. — Patient  sits  upright  in  chair  or  in  bed — head  thrown  backward 
(preferably  steadied  by  an  assistant) — mouth  gagged  (preferably,  but  not 
necessarily) — napkin  placed  over  tongue  to  enable  it  to  be  more  easily  grasped; 
— Surgeon  stands  in  front. 

Operation. — The  surgeon  depresses  the  base  of  the  tongue  with  the  left 
index-finger,  and,  at  the  same  time,  draws  it  forward — this  finger  thus  also 
guarding  the  larynx.  The  tube,  previously  warmed  and  lubricated,  and 
held  in  the  fingers  of  the  right  hand,  is  guided  along  until  it  impinges  upon 
the  posterior  wall  of  the  pharynx,  when  it  is  directed  downward.  The  esopha- 
gus once  entered,  the  tube  is  gently  pressed  further  downward,  aided  by 
the  act  of  swallowing,  until  it  has  entered  the  stomach. 

Comment. — In  the  average  adult,  the  distance  from  the  upper  incisor 
teeth  to  the  superior  end  of  the  esophagus  is  given  as  14  cm.  (5J  inches); — 
from  the  same  point  to  the  arch  of  the  aorta,  as  23  cm.  (9  inches) ; — and  from 
the  same  point  to  the  diaphragmatic  opening,  as  37  cm.  (14 J  inches).  Pouches 
and  diverticula  of  the  esophagus  are  to  be  avoided. 

GASTROTOMY 

BY  MEDIAN  INCISION. 

Description. — Consists  in  the  temporary  opening  of  the  stomach  by 
incision,  followed  by  its  closure  at  the  same  operation.  Generally  resorted 
to  for  removal  of  foreign  bodies,  for  exploration,  or  for  treatment  of  surgical 
conditions  of  the  stomach,  pylorus,  or  esophagus  (such  as  gastric  ulcer, 
dilatation  of  the  esophageal  or  pyloric  orifice,  dilatation  of  the  esophagus, 
etc.).  The  opening  may  be  made  in  the  median  line,  or  below  and  parallel 
with  the  left  costal  arch.  As  far  as  possible,  transverse  division  of  muscles 
and  injury  to  nerves  should  be  avoided. 

Preparation. — Stomach  washed  out. 

Position. — Patient  supine;  Surgeon  to  patient's  right,  cutting  from  above 
downward;  Assistant  opposite. 

Landmarks. — Linea  alba;  xiphoid  cartilage;  umbilicus. 

Incision. — In  the  median  line — its  center  being  about  opposite  the  space 
between  the  eighth  and  ninth  costal  cartilages — and  extending  to  or  toward 
the  tip  of  the  xiphoid  cartilage  above,  and  to  or  toward  the  umbilicus  below, 
as  far  as  the  circumstances  of  the  case  require — generally  being  from  5  to  10 
cm.  (2  to  4  inches)  long.     (Fig.  699,  A.) 


GASTROSTOMY. 


953 


Operation. — (i)  The  steps  of  the  operation,  up  to  entering  the  peri- 
toneal cavity,  are  exactly  similar  to  those  for  median  abdominal  section  (see 
page  631).  (2)  The  edges  of  the  abdominal  wound  are  now  well  retracted 
and  the  stomach  sought — the  steps  for  its  recognition  being  given  under  Gen- 
eral Surgical  Considerations.  While  searching  for  the  stomach,  which  is 
often  not  easily  located,  temporary  silk  sutures,  or  traction-ligatures,  may  be 


Fig.  699. — Incisions  for  Exposing  Stomach,  Liver,  Gall-bladder,  and  Spleen: — A, 
Median,  for  stomach,  liver,  or  spleen;  B,  Oblique  subcostal,  for  stomach;  C,  Vertical  over  outer 
third  of  left  rectus,  for  stomach;  D,  Vertical  subcostal  in  left  linea  semilunaris,  for  spleen;  E, 
Oblique  subcostal,  for  spleen;  F,  Oblique  subcostal,  for  liver  and  gall-bladder;  G,  Vertical 
subcostal  in  right  linea  semilunaris,  for  liver  and  gall-bladder.     (Diagram  modified  from  Deaver.) 

placed  through  the  entire  thickness  of  each  abdominal  lip — partly  to  serve 
as  retractors,  and  partly  to  prevent  the  separation  of  the  peritoneum  from 
the  abdominal  wall.  (3)  Having  located  the  stomach,  that  portion  of  its 
anterior  wall  into  which  the  incision  is  to  be  made  must  be  isolated  and 
drawn  out  of  the  wound  by  means  of  the  fingers  or  special  traction-forceps, 
the  general  peritoneal  cavity  being  packed  off  with  gauze.  The  site  of  the 
opening  into  the  stomach  will  depend  largely  upon  the  site  of  the  foreign 
body,  or  upon  the  special  object  of  the  operation.  (4)  An  assistant  grasps 
the  anterior  stomach-wall  toward  either  side  of  the  retracted  abdominal 
wound,  between  his  thumbs  and  fingers,  steadying  and  spreading  out  that 
surface — or   temporary   silk    traction-sutures    may   be   passed,    with    curved 


954  OPERATIONS  UPON  THE  ABDOMI NO-PELVIC  REGION. 

needle,  into  the  stomach-wall,  without  entering  its  cavity — thus  exposing 
an  area  of  about  5  to  7.5  cm.  (2  to  3  inches)  of  the  anterior  stomach-wall. 
(5)  This  area  having  been  put  upon  the  stretch,  an  opening  of  about  3.7  to 
5  cm.  (i|  to  2  inches)  is  made  in  the  vertical  axis  of  the  stomach,  parallel 
with  the  blood-vessels — or  it  may  be  made  parallel  with  the  long  axis,  avoiding 
large  vessels.  This  opening  may  be  made  by  a  quick,  controlled  stab  of  a 
narrow,  sharp  bistoury,  penetrating  all  the  coats,  and  then  enlarging  with 
blunt-pointed  bistoury — or  it  can  be  more  deliberately  made  by  a  pair  of 
scissors,  picking  up  a  fold  of  stomach-wall  and  cutting  through  at  right  angles 
to  the  fold.  (6)  Two  temporary  traction-sutures  are  at  once  placed  in  the 
opposite  lips  of  the  stomach  wound,  to  hold  them  in  control,  and  to  enable 
the  interior  of  the  stomach  to  be  exposed  by  retraction  of  its  walls.  The 
stomach  opening  may  be  enlarged  if  necessary.  Clamp  and  twist  all  bleeding 
vessels,  carefully  isolating  and  ligating  with  gut  any  requiring  ligature.  If 
indicated,  the  stomach  may  be  washed  out,  thoroughly  protecting  the  abdom- 
inal cavity  from  soiling.  (7)  The  object  of  the  operation  is  now  accom- 
plished. The  stomach-wall  is  then  sutured  in  the  manner  described  under 
Gastrorrhaphy,  page  955, — with  a  tier  of  sutures  through  the  mucous  coat, 
and  an  overlying  tier  of  Lemberts  through  the  outer  coats — using,  preferably, 
fine  chromic  gut.  The  stomach  is  then  dropped  back  into  place  and  the 
abdomen  closed  in  the  usual  fashion. 

Comment. — Where  the  cardiac  end  of  the  stomach  is  the  special  site 
sought,  it  is  more  conveniently  reached  by  an  oblique  subcostal  incision  (q.  v.). 
The  above  incision  is  the  best  for  the  pyloric  end,  and  for  all  other  portions 
of  the  stomach  except  the  cardiac  end — and  for  general  exploration  and  most 
foreign  bodies. 

GASTROTOMY 

BY  OBLIQUE  SUBCOSTAL  INCISION. 

Description. — The  stomach  is  opened  by  an  incision  parallel  with  and 
below  the  left  costal  arch — which  more  conveniently  exposes  the  cardiac  end 
of  the  stomach  and  the  cardiac  orifice  of  the  esophagus. 

Preparation — Position. — As  for  Median  Gastrotomy. 

Landmarks. — Xiphoid  cartilage;  left  costal  arch. 

Incision. — Begins  near  the  tip  of  the  xiphoid  cartilage  and  extends 
thence  downward  and  outward,  parallel  with  and  about  2,5  to  3,7  cm.  (1  to 
1 J  inches)  to  the  inner  side  of  the  left  costal  arch,  ending  about  opposite  the 
anterior  end  of  the  ninth  rib, — generally  extending  for  a  distance  of  5  to  7.5 
cm.  (2  to  3  inches),  varying  with  the  thickness  of  the  abdominal  wall  and  other 
circumstances.     (Fig.  699,  B.) 

Operation. — (1)  Incise  through  skin  and  fascia,  clamping  all  bleeding 
vessels.  The  incision  will  pass  through  the  fibers  of  the  external  oblique  at 
about  a  right  angle  to  its  fibers, — will  pass  between  the  fibers  of  the  internal 
oblique, — and  will  divide  those  of  the  transversalis  transversely  to  their 
course, — but  will  pass  more  or  less  parallel  with  the  seventh  and  eighth  nerves, 
which,  if  possible,  should  be  recognized  and  drawn  aside.  (2)  The  peri- 
toneum is  opened  in  the  line  of  the  original  incision — the  stomach  is  recog- 
nized— isolated — and  drawn  into  the  wound,  the  general  peritoneal  cavity 
being  well  oacked  off — and  its  anterior  wall  is  opened  in  the  same  general 
way  as  described  in  Median  Gastrotomy,  and  in  the  special  site  selected. 
(3)  The  object  of  the  operation  having  been  accomplished,  the  stomach-wall 
and  the  abdominal  wound  are  closed  in  the  manner  just  described. 


GASTRORRHAPHY. 


955 


Comment. — (i)  The  above  operation  is  very  similar  to  that  of  Gastros- 
tomy by  the  same  incision.  (2)  Large,  irregular,  impacted  bodies  are  some- 
times removed  by  incisions  made  directly  over  them  and  giving  access  by  the 
nearest  route. 

GASTRORRHAPHY. 

Description. — Suturing  of  the  stomach-wall.  Generally  resorted  to 
for  wounds,  closure  after  operations,  ulcers,  etc.  (Sometimes  gastrorrhaphy 
is  unadvisedly  used  synonymously  with  gastroplication.) 

Preparation — Position — Landmarks — Incision. — As  for  gastrotomy 
bv  median  incision. 

Operation. — (1)  The  peritoneal  cavity  having  been  opened,  hemorrhage 
controlled,  and  the  wound   retracted,  the  stomach  is  exposed  and  brought 


Fig. 700.— Gastrorrhaphy  : — A,  Line  of  overhand  continuous  suturing  through  all  coats;  B,  Inter- 
rupted Lemhert  sutures  through  outer  coats. 


forward.  (2)  The  area  being  packed  off  with  gauze,  the  site  of  the  operation 
is  conveniently  held  by  an  assistant.  (3)  The  mucous  membrane  is  first 
sutured  with  continuous  sutures  of  fine  silk  or  gut — by  means  of  a  curved 
needle  held  in  a  holder  in  the  right  hand,  while  picking  up  the  mucous  mem- 
brane with  forceps  in  the  left.  (4)  A  second  line  of  interrupted  Lemberl 
sutures  of  fine  chromic  gut  is  now  applied,  passing  through  the  serous  and 
muscular  coats  of  both  lips  of  the  wound,  and  thus  bringing  serous  surfaces 
into  contact.  (5)  The  stomach  is  then  returned  to  its  place — and  the  abdo- 
men sutured  as  usual. 

Comment. — (1)  Chromic  gut  may  be  used  throughout.     (2)  The  first 


956  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

tier  of  sutures  may  consist  of  an  overhand  stitching  through  the  entire  thick- 
ness of  all  the  coats,  applied  continuously — followed  by  interrupted  Lembert 
sutures  passing  through  the  serous  and  muscular  coats  and  burying  in  the 
first  tier.  (Fig.  700.)  (3)  Sometimes  three  tiers  are  applied — a  continuous 
stitch  through  the  mucous  coat — an  interrupted  or  continuous  through 
the  muscular — and  an  interrupted  through  the  serous.  (4)  In  cases  of 
suturing  for  gastric  ulcer — (a)  the  edges  (in  simple  cases)  are  merely  in- 
vaginated  by  sutures,  first  of  the  mucous  membrane,  then  of  the  serous 
and  muscular  coats; — (b)  Or  the  ulcer  may  be  excised  (in  hard,  thick 
walls,  or  in  large  ulcers)  elliptically,  the  edges  of  the  ellipse  being  united 
by  the  two  tiers  just  described.  (5)  All  lines  of  gastric  suturing  may  be  rein- 
forced bv  omental  grafts  sutured  over  the  suture-line. 


GASTROSTOMY  IN  GENERAL. 

Description. — Bv  gastrostomy  is  meant  the  establishment  of  a  more  or 
less  permanent  fistulous  opening  in  some  part  of  the  anterior  wall  of  the 
stomach,  for  the  purpose  of  alimentation  or  surgical  treatment — the  stomach 
generallv  being  attached  by  suture  to  the  anterior  abdominal  wall  just  pre- 
ceding or  following  the  incision  of  its  wall.  The  operation  of  Gastrostomy 
may  be  done  in  one  or  in  two  stages.  Where  haste  is  a  consideration,  the 
opening  must  be  made  into  the  stomach  as  soon  as  the  latter  is  attached  to 
the  abdominal  wall.  Where  haste  is  unnecessary,  the  stomach  is  first  attached 
to  the  opening  in  the  anterior  abdominal  wall — from  three  to  five  days  given 
for  union  to  take  place,  shutting  off  the  peritoneal  cavity — and  then  the 
stomach  is  opened.  In  such  cases  as  those  in  which  the  operation  is  done 
for  inoperable  cancer,  the  gastrostomy  is  meant  to  be  permanent.  Where 
the  operation  is  done  for  temporary  cause,  the  fistula  is  expected  to  subse- 
quentlv  heal  of  its  own  accord  (which  is  generally  the  case),  or  a  special  opera- 
tion is  done  later  for  its  closure. 

Preparation  of  Patient. — The  stomach  is  washed  out;  the  site  of  opera- 
tion is  shaved;  the  bowels  are  emptied. 

Position  during  Operation. — Supine,  at  the  side  of  table,  with  abdominal 
parietes  relaxed  by  slight  elevation  of  the  shoulders  and  slight  flexion  of  the 
hips;  Surgeon  to  right  in  operating  in  median  line,  and  to  left  in  the  sub- 
costal operation;  Assistant  opposite. 

Division  of  Abdominal  Parietes. — Muscles  should  be  divided  in  their 
cleavage  line,  in  so  far  as  this  is  possible — and  the  abdominal  nerves  should 
be  spared,  as  far  as  practicable.  A  disadvantage  of  all  oblique  incisions 
parallel  with  and  just  below  the  left  costal  arch  is  the  difficulty  of  making 
an  intramuscular  separation  of  the  fibers.  Considerable  differences  of 
statement  exist  among  the  writings  of  surgeons  as  to  the  placing  of  the  skin 
incision,  and  as  to  the  manner  of  dividing,  dealing  with,  and  suturing  the 
subjacent  structures  in  the  descriptions  of  even  the  same  operation  of 
Gastrostomy. 

Form  of  Artificial  Canal. — As  to  regurgitation  of  stomach  contents, 
the  longer,  more  indirect,  and  more  valvular  the  canal  between  the  stomach 
and  abdominal  openings,  the  greater  the  control  over  the  gastric  contents. 
Immediatelv  after  operation,  rubber  tubes  for  feeding  are  passed  down  the 
artificial  fistula — but  after  the  first  few  days  these  tubes  are  introduced  only 
at  times  of  feeding — while  in  some  cases  the  tubes  must  be  constantly  worn, 
only  being  removed  for  cleansing. 


SSABANAJEW-FRANCK'S  GASTROSTOMY.  957 

Comparison  of  Methods. — Ssabanajew-Franck's  method,  performed 
through  the  separated  fibers  of  the  rectus,  is  probably  the  best  for  a  permanent 
fistula,  especially  in  a  lax  stomach.  Kader's  method  is  probably  the  best  for 
small  or  adherent  stomachs.  MarwedeFs  method  is  probably  the  best 
for  the  rapidity  of  healing  of  the  fistula.  And  Howse's  method  is  probably 
the  most  quickly  done. 


GASTROSTOMY 

BY  SSABANAJEW-FRANCK'S  METHOD. 

Description. — A  cone  of  stomach  is  drawn  through  the  separated  left 
rectus  muscle — carried  beneath  a  bridge-work  of  skin — and  its  apex  made  to 
open  upon  the  cutaneous  surface  just  above  the  left  costal  arch.  The  stomach 
is  exposed  through  an  oblique  skin  incision  approximately  parallel  with  the 
left  costal  arch — with  a  vertical  separation  of  the  fibers  of  the  outer  part  of 
the  left  rectus  muscle — which,  at  the  end  of  the  operation,  are  sutured  about 
the  base  of  the  cone. 

Preparation — Position. — See  General  Surgical  Considerations. 

Landmarks. — Median  line;  linea  semilunaris;  left  costal  arch. 

Incisions. — Primary  incision — oblique,  about  6  to  8  cm.  (2^  to  3  inches) 
in  length,  is  made  over  the  outer  third  of  the  left  rectus  muscle,  beginning 
near  the  median  line  and 'passing  downward  and  outward  somewhat  more 
vertically  than  transversely,  though  approximately  parallel  with  and  about 
2.5  to  4  cm.  (1  to  ih  inches)  from  the  left  costal  arch.  Secondary  incision 
(made  later  in  the  operation) — about  2  cm.  (f  inch)  in  length,  is  made 
through  the  skin  and  fascia  about  2.5  cm.  (1  inch)  above  the  costal  cartilages 
and  approximately  parallel  with  the  original  incision. 

Operation. — (1)  Incise  skin  and  fascia  in  the  above  line — clamping 
bleeding  vessels — and  retracting  the  lips  of  the  wound.  (2)  Expose  the 
rectus  muscle — divide  the  anterior  layer  of  the  rectal  sheath — separate  the 
fibers  of  the  outer  part  of  the  rectus  muscle  vertically  by  blunt  dissection  in 
their  cleavage  line — divide  the  posterior  layer  of  the  sheath, — and  divide 
the  transversalis  fascia,  subperitoneal  areolar  tissue,  and  peritoneum — pre- 
serving, throughout,  the  integrity  of  the  muscles  and  nerves  as  much  as  possi- 
ble, and  retracting  the  structures  as  divided.  (Figs.  701  and  702.)  (3)  Draw 
a  long  cone  of  the  anterior  wall  of  the  stomach  through  the  abdominal  wound, 
by  means  of  a  silk  traction-ligature  passing  through  the  serous  and  muscular 
coats — the  apex  of  the  cone  being  represented  by  a  part  of  the  stomach-wall 
nearer  the  greater  than  the  lesser  curvature,  and  nearer  the  cardiac  than  the 
pyloric  end — calculating  that  sufficient  length  of  cone  be  drawn  out  to  pass, 
without  tension,  under  a  bridge-work  of  skin  about  5  cm.  (2  inches)  wide. 
(4)  The  serous  coat  of  the  stomach  forming  the  base  of  the  cone,  is  now 
sutured  to  the  peritoneal  and  fascial  edges  of  the  wound  by  four  gut  sutures. 
The  serous  and  muscular  coats  of  the  stomach  are  then  attached  throughout 
to  the  posterior  layer  of  the  rectal  sheath  by  interrupted  or  continuous  gut 
sutures  (preferably  chromic),  avoiding  the  danger  of  constriction.  (5)  The 
secondary  incision  is  now  made  through  the  skin  and  fascia  in  the  site  indi- 
cated (see  Incisions) — passing  only  into  the  connective  tissue  plane.  (6) 
By  blunt  dissection  from  the  larger  to  the  smaller  wound,  the  two  are  con- 
nected and  the  intervening  bridge-work  of  skin  thus  undermined  along  the 
fascial  plane.  (7)  A  pair  of  forceps  is  passed  through  the  smaller  opening 
into  the  larger — grasps  the  silk  traction  ligature  and  draws  the  cone  of  the 


958 


OPERATIONS  UPON  THE   AI!I)OMIX()-PKLVIC  REGION. 


stomach  into  the  smaller,  upper  wound,  over  the  edge  of  the  lower  costal 
cartilages — where  it  is  held  in  place  by  four  silk  sutures.  These  four  sutures 
are  passed  through  all  the  coats  of  the  stomach,  on  the  one  side,  and  through 
the  skin  and  fascia,  on  the  other — if  the  apex  of  the  cone  is  to  be  opened  at 
once.  But  if  the  opening  is  to  be  deferred,  the  sutures  pass  through  only 
the  serous  and  muscular  coats  of  the  stomach.  The  small  incision  is  now 
sutured  at  either  end,  leaving  a  sufficient  opening  in  the  center  for  the  passage 
of  the  cone.  (8)  The  separated  edges  of  the  rectus  and  its  sheath  are  now 
sutured  with  interrupted  chromic  gut,  from  either  end  toward  the  center, 
leaving  a  sufficient  opening  to  guard  against  dangerous  constriction  of  the 
base  of  the  cone,  while,  at  the  same  time,  approaching  the  base  nearly  enough 
to  form  a  muscular  circle  about  it.  (9)  The  skin  wound  is  then  closed 
throughout  with  subcuticular  silkworm-gut  sutures — or  other  form  of  suturing. 


Figs.  701  and  702.— Gastrostomy,  Ssabanajew-Franck's  Method  : — I.  Cone  of  stomach  drawn 
out  of  abdominal  wound,  over  costal  arch,  and  through  opening  in  skin  : — A,  Stomach-cone  ;  B,  Pos- 
terior layer  of  rectal  sheath,  together  with  subserous  and  transversalis  fasciae  and  peritoneum  sutured 
to  serous  and  muscular  coats  of  stomach  around  base  of  cone;  C,  Sutures  carried  through  anterior 
rectal  sheath  and  rectus  ready  to  approximate  rectus  muscle  around  cone  of  stomach.  II.  Com- 
pletion of  wound-suturing  : — D,  Sutures  through  rectus  and  anterior  rectal  sheath  tightened,  so 
as  to  embrace  stomach-cone  ;  E,  Sutures  through  skin  and  fascia  ;  F,  Apex  of  cone  incised  and  sutured 
into  skin. 


(10)  The  apex  of  the  cone  is  incised  at  once,  in  cases  of  emergency — otherwise 
the  opening  is  deferred  for  two  or  three  days. 

Comment. — (1)  In  the  original  Ssabanajew-Franck  operation,  the  inci- 
sion was  carried  more  obliquely  and  more  nearly  parallel  with  the  costal 
arches — and  with  less  regard  for  the  preservation  of  muscles  and  nerves  by 
intramuscular  separation.  (2)  Surgeons  differ  as  to  the  direction  of  incising 
the  posterior  layer  of  the  rectal  sheath  and  the  subjacent  structures.  (3) 
This  operation  requires  a  very  lax  stomach,  capable  of  furnishing  a  rather 
long  cone.  The  resulting  fistula  is  more  apt  to  be  difficult  to  close  than  is 
the  case  in  some  of  the  other  methods  of  Gastrostomy.  (4)  The  efficiency 
of  the  operation  depends  upon  the  valve-like  nature  of  the  opening  over  the 
edge  of  the  costal  cartilages — the  length  of  the  cone — the  muscular  action 


WITZEL'S  GASTROSTOMY.  959 

of  the  rectus — the  double  change  of  direction  of  the  gastric  fistula  (at  first 
passing  through  the  rectus,  and  then  coming  out  at  the  skin  wound) — and 
upon  the  obliquity  of  the  fistulous  canal.  (5)  The  deferring  of  making  the 
opening  into  the  stomach  until  all  the  cone-burying  sutures  are  placed  and 
tied,  prevents  regurgitation  and  soiling  of  the  wound  in  cases  in  which 
the  stomach  must  be  opened  at  once. 

Other   Gastrostomies    Resembling   Ssabanajew-Franck's    Method    in 

General  Principle. — 

Albert's  Gastrostomy. — Similar  in  all  important  essentials  to  Ssabana- 
jew-Franck's operation,  with  the  following  exceptions; — (1)  The  primary 
incision  begins  2.5  cm.  (1  inch)  below  the  margin  of  the  ribs  and  passes 
almost  vertically  downward  over  the  outer  part  of  the  rectus  muscle  (tending 
to  be  more  vertical  than  oblique  as  in  Ssabanajew-Franck's).  (2)  The  sec- 
ondary incision  is  made  more  directly  over  (than  to  one  side  of)  the  primary 
incision,  and  is  placed  somewhat  nearer  the  costal  margin.  (3)  The  stom- 
ach is  bent  more  nearly  directly  upward — rather  than  upward  and  outward. 

Hahn's  Modification  of  Ssabanajew-Franck's  Gastrostomy. — Re- 
sembles, in  general  principle,  Ssabanajew-Franck's  method — the  chief  differ- 
ence being  that  the  cone  of  stomach  is  brought  directly  up  through  the  eighth 
intercostal  space.  (1)  The  primary  incision  (Fenger's  incision)  is  about 
7.5  cm.  (3  inches)  long — placed  to  the  left  of  the  left  rectus  muscle — 2.5  cm. 
(1  inch)  from,  and  parallel  with,  the  left  costal  arch.  The  secondary  incision 
is  made  later — at  the  anterior  end  of  the  eighth  left  intercostal  space,  parallel 
with  the  ribs — and  about  2.5  cm.  (1  inch)  long.  (2)  Incise  skin  and  fascia 
in  line  of  primary  incision — incise  external  oblique  at  right  angle  to  fibers — 
separate  internal  oblique  in  cleavage  line — divide  transversalis  transversely 
to  cleavage  line — and  transversalis  fascia,  subserous  areolar  tissue,  and 
peritoneum  in  same  line — draw  out  long  cone  of  stomach,  as  in  Ssabanajew- 
Franck's  operation — suture  serous  coat  of  stomach  to  parietal  peritoneum 
and  fascial  edges  of  abdominal  wound — make  secondary  incision  in  given 
line — closed,  pointed  forceps  are  passed  through  the  anterior  end  of  the  left 
eighth  intercostal  space  and  made  to  work  their  way  through  the  intervening 
tissues,  hugging  the  posterior  aspect  of  the  costal  cartilages  and  guided  by 
the  finger  in  the  abdominal  wound — the  silk  traction-suture  is  grasped  by  the 
forceps  and  the  cone  of  stomach  drawn  through  the  eighth  intercostal  space — 
the  operation  being  completed  as  in  the  regular  Ssabanajew-Franck's  method. 
The  danger  of  injuring  the  pleural  cavity  and  the  costal  cartilages,  together 
with  the  fact  of  there  being  no  special  advantage  over  the  regular  operation, 
are  to  be  considered  in  undertaking  this  modification. 


GASTROSTOMY 

BY  WITZEL'S  METHOD. 

Description. — The  stomach  is  approached  by  an  oblique  incision  below 
the  left  costal  arch,  passing  through  skin  and  fascia — with  vertical  separation 
of  the  anterior  rectal  sheath  and  fibers  in  their  cleavage  line — division  of  the 
posterior  layer  of  the  rectal  sheath — and  vertical  division  of  the  peritoneum. 
A  rubber  tube  is  then  buried  in  a  long,  oblique  canal  in  the  anterior  stomach- 
wall,  formed  by  a  process  of  suturing — following  which,  the  stomach-wall  is 
sutured  to  the  parietal  peritoneum  and  edges  of  the  posterior  layer  of  the  rectal 
sheath — and  the  abdominal  wound  closed  over  all. 


960 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


Preparation — Position. — See  General  Surgical  Considerations. 

Landmarks. — Median  line;  linea  semilunaris;  left  costal  arch. 

Incision. — Oblique,  parallel  with  and  2.5  to  4  cm.  (1  to  ij  inches)  from 
the  left  costal  arch — beginning  near  the  median  line  and  passing  downward 
and  outward  for  about  7.5  cm.  (3  inches). 

Operation. — (i)  Incise  skin  and  fascia  in  above  line — clamp  vessels — 
and  retract  lips  of  wound.  (2)  Expose  the  rectus  muscle — divide  the  ante- 
rior layer  of  its  sheath — and  separate  the  fibers  of  the  rectus  muscle  vertically, 
in  their  cleavage  line,  by  blunt  dissection.  (Figs.  703-705.)  (3)  Divide 
the  posterior  layer  of  the  rectal  sheath.  (4)  Divide  the  transversalis  fascia, 
subserous  areolar  tissue,  and  peritoneum  vertically.  (5)  Retract  the  parts 
well — -and  draw  the  portion  of  the  anterior  stomach-wall  which  is  to  be  dealt 
with  well  into  the  wound.  (6)  A  velvet-eyed  rubber  tube  is  now  laid  against 
the  anterior  wall  of  the  stomach,  generally  in  such  a  position  as  to  correspond 
with  the  outer  wound,  with  the  blunt  end  of  the  tube  toward  the  cardiac  end 


Fig.  703. — Gasi  rostomy,  Witzel's  Method  : — I.  Cone  of  stomach  drawn  through  separated 
rectal  fibers — showing  Lembert  sutures  placed  ready  to  bury  tube,  which  is  about  to  enter  stomach 
through  incision  in  its  wall. 


of  the  stomach  and  the  opposite  end  directed  toward  the  lesser  curvature. 
About  5  to  7.5  cm.  (2  to  3  inches)  of  this  tube  is  now  buried  in  the  anterior 
stomach-wall  by  Lembert  gut  sutures,  placed  about  5  mm.  (f^  inch)  apart, 
and  extending  at  least  1.3  cm.  (£  inch)  beyond  the  point  at  which  the  tube  is 
to  enter  the  stomach,  and  so  placed  as  to  avoid  the  larger  vessels.  All  the 
sutures  are  now  tied,  thus  burying  in  the  tube — except  the  three  or  four  at 
the  lower  end  of  the  tube.  (7)  The  stomach-wall  is  then  held  in  such  a  way 
as  to  render  the  site  of  entrance  of  the  tube  into  the  stomach  prominent,  and, 
at  the  same  time,  so  as  to  separate  the  opposite  (posterior)  stomach-wall — - 
and  with  a  narrow,  sharp-pointed  bistoury,  a  quick,  controlled  stab  is  made 
through  all  the  layers  of  the  anterior  stomach-wall,  guarding  against  wounding 
the  opposite  (posterior)  wall — the  opening  being  made  just  beneath  the  tip 
of  the  tube,  which  is  temporarily  withdrawn  about  6  mm.  (J  inch)  for  that 
purpose  and  just  before  the  stab  is  made.     Immediately  upon  the  completion 


WITZEL'S  GASTROSTOMY. 


961 


of  the  stab-wound,  which  should  be  a  little  less  in  extent  than  the  caliber  of 
the  tube,  the  end  of  the  tube  is  thrust  through  the  opening  and  into  the  cavity 
of  the  stomach — and  the  already  placed  sutures,  which  were  temporarily 
left  untied  at  the  lower  end  of  the  tube,  are  at  once  tied — thereby  preventing 
any  regurgitation  of  the  stomach  contents.  (8)  The  stomach  is  now  allowed 
to  fall  back  into  the  abdominal  cavity  sufficiently  to  leave  only  the  site  of  the 
anterior  stomach-wall  represented  by  the  buried  tube  in  contact  with  the  edges 
of  the  abdominal  wound — and  even  this  area  is  so  adjusted  as  to  cause  the 
site  of  the  buried  tube  to  be  surrounded  by  the  edges  of  the  abdominal  wound 
in  the  form  of  as  narrow  an  ellipse  as  possible.  (9)  The  serous  and  muscular 
coats  of  the  stomach  are  now  united  by  interrupted  gut  sutures  to  the  parietal 


v 


n 


m 


Figs.  704  and  705.— Gastrostomy,  Witzel's  Method  :— II.  Manntr  of  placing  sutures  ;  A,  Tube 
buried  in  by  two  parallel  folds  of  stomach-wall  united  by  tying  of  interrupted  Lemberts  shown  in  I  ; 
B.  Interrupted  sutures  passing  through  serous  and  muscular  coats  of  stomach,  and  through  parietal 
peritoneum,  posterior  rectal  sheath,  and  lower  plane  of  rectus  ;  C,  Interrupted  sutures  through  skin, 
fascia,  anterior  rectal  sheath,  and  major  part  of  rectus.  III.  Final  position  of  tube— seen  emerging 
from  completely  sutured  wound. 


peritoneum  and  lower  lip  of  wound  along  this  narrow  ellipse.  (10)  The 
edges  of  the  abdominal  wound  are  then  united — first  with  chromic  gut  inter- 
rupted sutures  passing  through  the  entire  thickness  of  the  opposite  lips  of  the 
separated  rectus  muscle,  together  with  the  edges  of  its  sheath,  but  not  in- 
volving the  already  sutured  peritoneum, — followed  by  interrupted  or  con- 
tinuous silk  suturing  of  the  skin  and  fascia — or  subcuticular  suturing.  Or  skin, 
fascia,  and  rectus  may  be  sutured  in  one  tier.  The  rubber  tube  will  emerge 
between  the  two  or  three  upper  sutures.  (11)  The  rubber  tubing  is  held  in 
position  by  a  silk  suture  passing  through  the  outer  part  of  its  wall  and  attached 
to  the  skin.  The  tube  is  left  in  for  three  or  four  days — and  then  inserted  only 
for  feeding. 
61 


962 


OPERATIONS  UPON  THE  ABDOMIXO-PELVIC  REGION. 


Comment. — (1)  The  site  of  incision  sometimes  differs  from  that  above 
given — and  the  fibers  of  the  rectus  are  sometimes  cut  instead  of  separated — 
but  all  muscular  structures  should  be  separated,  and  nerves  retracted,  as 
far  as  these  may  be  done.  (2)  Fenger's  incision  is  sometimes  used — about 
7.5  cm.  (3  inches)  in  length  and  placed  to  the  left  of  the  rectus,  and  2.5  cm. 
(1  inch)  from  and  parallel  with  the  left  costal  arch.  (3)  Before  the  stomach 
is  dropped  back  into  the  abdomen,  three  gut  sutures  may  be  inserted  through 
its  serous  and  muscular  coats,  each  threaded  with  a  needle  at  either  end — 
and  after  the  stomach  has  receded  into  its  normal  position,  these  needles 
are  made  to  pierce  the  edges  of  the  abdominal  wound,  from  within — and 
the  stomach  thus  drawn  up  to  the  edges  of  the  abdominal  opening.  (4) 
By  postponing  the  opening  into  the  stomach  until  all  the  sutures  are  placed 
and  most  are  tied,  the  leakage  is  minimized.  (5)  Regurgitation  is  prevented 
by  the  constriction  of  the  separated  fibers  of  the  rectus — by  the  long,  oblique 
canal — and  by  the  short  artificial  cone  created  by  the  manner  of  suturing, 
and  which  projects  into  the  stomach.  (6)  Operators  differ  as  to  the  direction 
in  which  they  divide  the  layers  of  the  rectal  sheath  and  subjacent  structures. 


GASTROSTOMY 

BY  MARWEDEL'S  METHOD. 

Description. — This  operation  resembles  Witzel's  in  most  of  its  essentials — 
except  that  the  tube  is  buried  between  the  mucous  coat,  on  the  one  hand, 
and  the  serous  and  muscular  coats,  on  the  other — and  that  the  parietal  peri- 


Fig.  706.— Gastrostomy,  Marwedel's  Method  :— I.  Anchoring  of  stomach  and  splitting  of 
stomach-wall ;  A,  Parietal  peritoneum  sutured  into  lower  part  of  lips  of  abdominal  wound  ;  B, 
Stomach  sutured  to  parietal  peritoneum  and  lower  plane  of  abdominal  wound  ;  D,  Sutures  through 
serous  and  muscular  coats  of  stomach  ;  D,  Tube  about  to  be  buried  in  stomach-wall. 


toneum  is  sutured  to  the  skin  before  the  stomach-wall  is  attached  to  the 
edges  of  the  abdominal  incision. 

Preparation — Position. — See  General  Surgical  Considerations. 

Landmarks. — As  in  Witzel's  operation. 


MARWEDEL'S  GASTROSTOMY.  963 

Incision. — Oblique  incision  about  6  to  7.5  cm.  (2%  to  3  inches)  in  length — 
made  over  the  left  rectus  muscle — beginning  near  the  median  line  and  passing 
downward  and  outward  somewhat  more  vertically  than  horizontally,  though 
approximately  parallel  with  and  about  2.5  cm.  to  4  cm.  (1  to  ih  inches) 
from  the  left  costal  arch. 

Operation. — (1)  Incise  skin  and  fascia — clamp  bleeding  vessels — and 
retract  the  lips  of  the  wound.  (2)  Expose  the  rectus  muscle — divide  the 
anterior  layer  of  the  rectal  sheath  vertically,  nearer  its  outer  part — separate 
the  fibers  of  the  rectus  vertically  in  their  line  of  cleavage,  by  blunt  dissection — 
divide  the  posterior  layer  of  the  rectal  sheath  vertically — and  the  transversalis 
fascia,  subserous  areolar  tissue,  and  peritoneum  in  the  same  line.  (3)  The 
parietal  peritoneum  is  now  drawn  out  and  sutured  with  interrupted  gut  to 
the  skin  at  the  margin  of  the  abdominal  wound.  (See  Comment.)  (4)  The 
anterior  stomach-wall  is  then  drawn  out  and  sutured  to  the  parietal  peritoneum 


Fig.  707.— Gastrostomy,  Marwedel's  Method: — II.  Burying  of  tube  and  closure  of  wound; 
A,  Sutures  uniting  peritoneum  to  lower  plane  of  abdominal  wound;  B,  Sutures  uniting  stomach  to 
peritoneum  and  lower  plane  of  wound;  C,  Sutures  burying  tube  between  mucous  coat  below,  and 
serous  and  muscular  above;  D,  Sutures  through  skin,  fascia,  anterior  rectal  sheath,  and  upper  part 
of  rectus. 

at  the  margins  of  the  abdominal  wound,  in  the  form  of  a  narrow  ellipse. 
(Fig.  706.)  (5)  For  a  distance  of  about  5  cm.  (2  inches)  and  about  parallel 
with  the  line  of  skin  incision,  the  serous  and  muscular  coats  are  incised, 
carefully  guarding  against  cutting  through  the  mucous  coat.  The  serous  and 
muscular  coats  are  then  dissected  from  the  mucosa  to  either  side  for  a  short 
distance.  A  rubber  tube  is  now  laid  between  the  split  coats  of  the  stomach, 
which  are  then  sutured  over  it  with  fine  gut.  (Fig.  707.)  The  sutures  at  the 
lower  end  extend  1.2  cm.  (h  inch)  beyond  the  intended  opening  and  are 
placed  but  not  tied.  When  all  the  rest  are  tied,  an  opening  is  made  through 
the  mucous  coat  in  the  same  manner  as  in  Ssabanajew-Franck's  operation — 
immediately  following  which,  the  tube  is  thrust  into  the  stomach  and  the 
lower  sutures  at  once  tied.  (6)  The  margins  of  the  abdominal  wound  are 
then  sutured  together  with  interrupted  silk  or  silkworm-gut. 


964 


OPERATIONS  UPON  THE  AP.DOMIXO-PELVIC  REGION. 


Comment. — (1)  It  would  seem  better  to  attach  the  parietal  peritoneum  to 
the  lower  edge  of  the  abdominal  wound  (rather  than  to  the  skin) — and  the 
stomach  to  the  peritoneum  thus  attached — then  the  edges  of  the  split  rectus 
can  be  brought  into  direct  contact,  in  finally  closing  the  abdominal  cavity. 
(2)  Fenger's  oblique  subcostal  incision  is  often  used — about  7.5  cm.  (3  inches) 
in  length,  placed  to  the  left  of  the  rectus  and  about  2.5  cm.  (1  inch)  below 
and  parallel  with  the  left  costal  arch.  The  operation  may  also  be  done  in 
the  median  line.  (3)  The  tube  may  be  buried  in  the  stomach-wall  before 
the  latter  is  sutured  to  the  edges  of  the  abdominal  wound — which  is  some- 
times more  convenient.  (4)  Surgeons  differ  considerably  upon  the  incision 
and  subsequent  steps  of  the  operation. 


GASTROSTOMY 

PA*   KADER'S   METHOD. 

Description. — This  is  a  modification  of  Witzel's  operation,  and  consists 
in  the  insertion  of  a  tube  into  the  stomach  at  a  right  angle  to  its  surface — 
and,  by  means  of  two  tiers  of  Lembert  interrupted  sutures,  two  parallel 
folds  are  made  in  the  anterior  stomach-wall,  thus  invaginating  the  stomach- 
wall  and  burying  in  the  tube.  The  stomach  is  reached  through  the  vertically 
separated  fibers  of  the  rectus. 


Fig.  708. — Gastrostomy,  Kader's  Method  : — I.  Burying  tube  perpendicularly  within  stomach  ; 
A,  Lower  tier  of  sutures  approximating  lower  ridges  of  stomach- wall ;  B,  Upper  tier  of  sutures  approxi- 
mating upper  ridges  of  stomach-wall.  Both  tiers  are  partly  tied.  Note — Through  error,  the  abdominal 
incision  is  represented  oblique — but  should  be  vertical,  as  shown  in  II,  Fig.  710. 


Preparation — Position. — See  General  Surgical  Considerations. 

Landmarks. — Linea  alba;  linea  semilunaris;  left  costal  arch. 

Incision. — Vertical  incision  over  the  left  rectus  muscle,  beginning  about 
2.5  cm.  (1  inch)  below  the  costal  cartilages  and  extending  downward  6  to 
7-5  cm-  Olto  3  inches).     (Fig.  699,  C.) 

Operation. — (i)  Incise  skin  and  fascia  in  the  above  line — clamp  bleeding 


KADER'S  GASTROSTOMY. 


96S 


vessels — retract  margins  of  the  wound,  exposing  the  sheath  of  the  rectus. 
(2)  Divide  the  outer  sheath  of  the  rectus  vertically.  Separate  the  fibers 
of  the  rectus  by  blunt  dissection  in  their  cleavage  line.  (3)  Divide  vertically 
the  posterior  sheath  of  the  rectus,  transversalis  fascia,  subserous  areolar 
tissue,  and  peritoneum.  (4)  Isolate  and  draw  into  the  wound  a  fold  of 
the  anterior  stomach-wall — packing  off  the  peritoneal  cavity  with  gauze. 
(Fig.  708.)  (5)  Having  selected  an  appropriate  site,  and  while  the  stomach  is 
properly  held  by  an  assistant  so  as  to  avoid  injury  to  the  opposite  (posterior) 
wall,  an  opening  somewhat  smaller  than  the  caliber  of  the  tube  is  made  by 
a  quick,  controlled  stab  with  a  narrow,  sharp-pointed  bistoury.  Having  seen 
that  no  serious  hemorrhage  follows  the  stab  wound,  a  rubber  tube  is  imme- 
diately inserted  into  the  stomach  cavity  through  this  opening  and  sutured 
to  the  edge  of  the  stomach  wound  with  two  gut  sutures  passing  into  but  not 
through  the  wall  of  the  tube.     (61  While  the  tube  is  held  perpendicular  to 


>- 


A* 


Fig.  709. 


-Gastrostomy,    Kader's   Method: — Burying   the   tube  by   two  or   more   tiers   of 
purse-string  sutures.     (Redrawn  from  Fowler.) 


the  stomach-wall  at  its  point  of  entrance,  two  chromic  gut  Lembert  sutures, 
about  1.2  cm.  (h  inch)  apart,  are  so  passed  through  the  serous  and  muscular 
coats  of  the  stomach,  on  either  side  of  the  tube,  as  to  raise  a  fold  or  pleat 
of  stomach-wall  about  7.5  cm.  (3  inches)  long  and  1.2  cm.  (£  inch)  high. 
These  deep  occlusion  sutures  are  then  tied — the  included  tissues  infolding 
into  the  stomach  in  the  form  of  a  funnel-shaped  projection.  A  second  tier, 
superficial  occlusion  sutures,  is  similarly  placed,  at  the  same  distances  apart, 
above  the  first,  which  are,  in  turn,  thus  buried  in  by  the  second,  forming 


966 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


a  second  fold.  The  sutures  of  the  second  tier  are  temporarily  left  long, 
to  aid  in  the  subsequent  manipulation  of  the  stomach.  (7)  The  tube  may  be 
buried  by  means  of  two  or  more  tiers  of  purse-string  sutures  (Fig.  709).  (8) 
The  general  peritoneal  cavity  is  shut  off  by  stitching  the  serous  and  muscular 
coats  of  the  stomach,  on  the  one  hand,  to  the  parietal  peritoneum  and  edges  of 
the  divided  posterior  sheath  of  the  rectus;  on  the  other— holding  the  stomach 
by  means  of  the  temporarily  left  occlusion  sutures.  (Fig.  710.)  (9)  The 
separated  edges  of  the  rectus  are  sutured  with  interrupted  chromic  gut  sutures 
—and  the  anterior  sheath  of  the  rectus  with  a  similar  separate  line  of  sutures— 
both  being  closely  approximated  to  the  tube.  The  skin  is  closed  by  inter- 
rupted silkworm-gut  sutures. 

Comment.— (1)  This  operation  is  more  generally  applicable  than  Witzel's, 
of  which  it  is  a  modification,  because  of  requiring  less  amount  of  movable 
stomach-wall— and   because  it   may  be  used   through   any   kind   of  incision 


Fig.  710— Gastrostomy,  Kader's  Method: — II.  Anchoring  of  stomach  and  closure  of  wound; 

A,  Suture  uniting  serous  and  muscular  coats  of  stomach  to  parietal  peritoneum  and  margins  of  wound  ; 

B,  Sutures  passing  through  skin,  fascia,  anterior  rectal  sheath,  and  rectus ;  C,  Tier  of  sutures  burying 
in  tube. 


exposing  the  stomach.  (2)  The  folds  or  pleats  are  made  transverse  when 
the  opening  is  to  be  temporary-^-and  perpendicular  when  the  opening  is  to 
be  permanent.  (3)  Where  the  stomach  is  so  small,  or  so  bound  down,  as 
to  make  it  impossible  to  bring  it  well  into  the  wound,  the  pleating  may  be 
made  and  the  tube  buried  with  the  stomach  in  sit  a.  (4)  The  efficiency  of 
the  method  depends  chiefly  upon  the  valvular  invagination  of  the  stomach- 
wall.  The  sides  of  the  infolded  funnel  soon  become  adherent,  leaving  only 
the  tubular  tract  patulous.  (5)  As  in  most  Gastrostomies,  surgeons  vary  as 
to  the  exact  placing  of  the  external  incision  and  the  manner  of  dividing, 
dealing  with,  and  suturing  the  subjacent  layers.  (6)  A  somewhat  similar 
method  (Abbe  and  Stamm)  consists  in  thrusting  a  tube,  through  a  previously 
made  opening,  perpendicularly  into  the  anterior  stomach-wall — then  sur- 
rounding it  by  a  circular  purse-string  suture  about  1.2  cm.  (J  inch)  from  the 
catheter,   which  is  then   tied,  gut  being  used — then  a  second  purse-string 


GASTROENTEROSTOMY    IN    GENERAL. 


967 


suture  about   2.5   cm.   (1  inch)  from  the  first,  which  is  tied  similarly — and 
a  third — the  stomach  being  attached  to  the  abdominal  wall  as  above. 

Note. — Other  forms  of  Gastrostomy  might  be  mentioned — some  repre- 
senting older,  some  more  modern  methods — such  as  Howse's;  Greig  Smith's 
modification  of  Howse's;  E.  J.  Senn's;  Andrew's;  Yon  Hacker's;  and  others' 
— but  those  above  described  in  detail  sufficiently  cover  the  best  modern 
methods. 


GASTROENTEROSTOMY  IN  GENERAL. 

By  Gastroenterostomy  is  meant  the  establishment  of  an  anastomotic 
opening  between  the  stomach  and  some  part  of  the  small  intestine — the 
name  of  the  operation  being  further  designated  by  the  part  of  the  intestine 


Fig.  711. — Diagram  Representing  Gastroenterostomies  : — A,  Anterior  gastroenterostomy 
— small  intestine  being  carried  over  omentum  and  applied  to  anterior  stomach-wall  ;  B,  Posterior 
gastroenterostomy—  small  intestine  being  carried  through  an  opening  made  in  transverse  mesocolon 
and  applied  to  posterior  stomach-wall,     i  Modified  from  Gray.) 


anastomosed — for  example,  gastro-duodenostomy,  gastrojejunostomy,  gastro- 
ileostomy.  The  object  of  the  operation  is  generally  to  obtain  the  complete 
emptying  and  rest  of  the  stomach — or  to  furnish  egress  from  it  in  cases  of 
obstinate  obstruction  at  or  near  the  pyloric  end — or  in  cases  of  excision  of 
the  intestine  near  the  pylorus. 

The  nearer  to  the  stomach  the  portion  of  intestine  anastomosed,  the 
greater  will  be  the  length  of  small  intestine  left  for  absorption.  That  portion 
of  the  stomach  between  the  pyloric  end  and  the  site  of  the  intestine  anas- 
tomosed with  the  stomach  becomes  partially  thrown  out  of  circuit  ("short- 
circuited")  in  proportion  as  it  continues  or  not  to  transmit  intestinal  contents, 
and  henceforth  performs  more  or  less  limited  function — the  bulk  of  the 
stomach  contents  traveling  by  the  new  route,  while  the  small  amount  which 
escapes  through  the  pylorus  still  goes  by  the  old  route. 

The  flow  of  the  stomach  contents  is  usually  from  the  cardiac  to  the  pyloric 
and  alone  the  greater  curvature,  nearer  which  the  anastomosis  is  generally 


968  OrERATlONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

made — and  usually  from  the  pyloric  to  cardiac  end  along  the  lesser  curvature. 
It  is  always  desirable  to  so  approximate  a  coil  of  intestine  to  the  stomach 
that  the  flow  in  both  viscera  may  be  in  a  normal  direction — which  is  generally 
accomplished  by  giving  the  coil  of  intestine  a  half-turn  just  before  making 
the  anastomosis. 

In  order  to  avoid  regurgitation  into  the  stomach  of  intestinal  contents, 
including  bile,  many  surgeons,  after  completing  the  gastroenterostomy,  per- 
form a  jejuno-jejunostomy  (between  the  proximal  and  distal  limbs  of  the 
jejunum) — the  Jaboulay-Braun  operation  (see  page  971). 

The  intestine  may  be  anastomosed  to  the  anterior  or  to  the  posterior  wall 
of  the  stomach — constituting  Anterior  or  Posterior  Gastroenterostomy.  The 
latter  operation  is  preferable — the  reasons  for  which  being  given  under  Com- 
ment upon  the  two  operations,  pages  971  and  977.     (Fig.  711.) 

ANTERIOR    GASTRO-ENTEROSTOMY 

P,V  SIMPLE  SUTURING  — WOLFLER'S  OPERATION. 

Description. — In  this  operation  some  part  of  the  small  intestine  is  carried 
up  in  front  of  the  great  omentum  and  transverse  colon  and  united  by  some 
method  of  suturing,  without  the  aid  of  one  of  the  mechanical  devices,  to 
the  anterior  wall  of  the  stomach,  nearer  its  greater  curvature.  (Fig.  711,  A.) 
The  nearest  part  of  the  small  intestine  to  the  pyloric  end  of  the  stomach 
which  is  available,  which  will  generally  be  the  jejunum,  is  the  portion  usually 
selected  for  the  anastomosis — constituting  gastrojejunostomy. 

Preparation. — The  stomach  is  washed  out;  the  site  of  the  operation  is 
shaved;  the  bowels  are  emptied  by  purgation. 

Position. — Patient  supine,  at  side  of  table,  with  abdominal  parietes 
relaxed  by  slight  elevation  of  the  shoulders  and  slight  flexion  of  the  hips; 
Surgeon  to  the  right;  Assistant  opposite. 

Landmarks. — Lineaalba;  xiphoid  cartilage;  umbilicus. 

Incision. — In  median  line,  from  just  below  xiphoid  cartilage  to  umbilicus 
— and  beyond,  if  necessary  (Fig.  699,  A). 

Operation. — (1)  Is  conducted  as  a  median  abdominal  section  up  to 
the  exposure  of  the  abdominal  cavity.  (2)  The  beginning  of  the  jejunum 
is  now  sought — and  is  most  readily  found  by  temporarily  displacing  the 
great  omentum  upward  and  to  the  left,  and  the  transverse  colon  and  meso- 
colon upward  and  to  the  right — and  by  following  down  the  under  surface 
of  the  mesocolon  to  its  base,  from  left  to  right,  as  the  finger  passes,  beneath 
the  ligament  of  Treitz,  a  loop  of  small  intestine  is  encountered,  which  is  the 
commencement  of  the  jejunum.  (Fig.  712.)  This  is  now  followed  down 
several  inches  until  a  convenient  distance  for  anastomosis,  without  tension, 
to  the  anterior  stomach-wall  is  secured — which  is  generally  about  40  to  50 
cm.  (16  to  20  inches).  (3)  This  site  of  jejunum  being  held  by  an  assistant, 
the  transverse  mesocolon  and  great  omentum  are  now  allowed'  to  drop  back 
into  place — the  jejunum  being  brought  down,  around  and  in  front  of  them — 
seeing  that  sufficient  length  of  intestine  for  this  course  is  allowed.  Then  to 
cause  the  flow  in  the  intestinal  canal  to  correspond  with  the  gastric  flow 
(from  left  to  right)  the  loop  of  jejunum  is  given  a  half-turn  (Rockwitz's 
modification)  and  is  thus  approximated  to  the  anterior  wall  of  the  stomach, 
near  its  greater  curvature.  (Fig.  713.)  It  is  important  that  this  approxima- 
tion should  be  accomplished  without  undue  twisting  and  tension  of  the 
intestine,  or  other  marked  disarrangement  of  normal  relations  of  the  parts 
concerned.     (4)  When  all  is  in  readiness  for  suturing,  the  proposed  site  of 


ANTERIOR    GASTROENTEROSTOMY. 


969 


anastomosis  of  the  anterior  stomach-wall  and  the  corresponding  portion  of 
the  jejunum  should  be  drawn  somewhat  out  of  the  abdominal  cavity  for 
the  greater  convenience  of  manipulation.  An  assistant  holds  the  antime- 
senteric  border  of  the  jejunum  in  easy  contact  with  the  lower  anterior  surface 
of  the  stomach-wall,  near  the  great  curvature — holding  the  stomach  so  as 
to  exclude,  as  much  as  possible,  an  outflow  of  its  contents  when  incised — 
the  intestines  being  squeezed  empty  and  clamped — or  each  viscus  may  be 
clamped,  as  shown  in  the  posterior  operation  (Fig.  717).  (5)  With  a  long, 
straight  needle,  threaded  with  chromic  gut,  or  silk,  a  line  of  continuous  suturing, 
passing  through  serous  and  muscular  coats  of  the  intestine,  on  the  one  hand, 
and  the  same  coats  of  the  stomach,  on  the  other,  is  carried  along  what  will 
form  the  posterior  line  of  union,  the  needle  being  inserted  at  close  intervals — 
the  suture  left  hanging  long  at  both  ends,  with  the  needle  at  one  end,  and 
knotted  at  the  other — and  the  suturing  having  extended  in  a  slightly  elliptical 


Fig.  712. — Manner  of  Locating  Beginning  of  Jejunum;  Incised  Mesocolon  Pre- 
paratory to  Posterior  Gastro-enterostomy: — A,  Great  omentum  displaced  upward  and 
to  left;  B,  Transverse  colon  and  mesocolon  displaced  upward  and  to  right;  C,  Commencement 
of  jejunum  emerging  from  beneath  ligament  of  Treitz;  D,  Incision  in  mesocolon  through  which 
jejunum  is  to  be  carried  into  the  cavity  of  the  lesser  omentum  and  approximated  to  posterior 
stomach-wall. 


direction,  beginning  and  ending  about  1.2  cm.  (^  inch)  beyond  the  ends 
of  the  future  incision  through  the  two  opposed  walls.  (6)  With  a  sharp- 
pointed  bistoury,  a  quick,  controlled  stab  is  made  into  the  stomach,  in  its 
long  axis,  and  then  into  the  intestine,  in  its  long  axis,  in  the  indicated  sites, 
and  so  planned  that  the  incisions  will  fall  immediately  opposite  each  other 
and  be  of  the  same  size — the  incisions  being  made  while  both  stomach  and 
intestine  are  so  held  by  an  assistant  as  to  present  their  proper  surfaces,  and, 
at  the  same  time,  the  opposite  wails  are  held  apart  so  as  not  to  be  also  pene- 
trated by  the  knife  stab.  One  blade  of  a  pair  of  sharp-pointed  scissors  is 
now  introduced,  and  both  incisions  lengthened  in  the  long  axes  of  both  viscera 
to  the  extent  of  about  5  to  6.5  cm.  (2  to  2 \  inches) — until  within  about  1.2 
cm.  (^  inch)  of  either  end  of  the  posterior  line  of  suturing.     These  incisions 


97° 


OPERATIONS    UPON    THE    ABDOMIXO-PELVIC    REGION. 


into  the  stomach  and  intestine,  made  immediately  opposite  each  other,  should 
be  from  5  to  8  mm.  (j  to  ^  inch)  from  the  suture-line.  Soiling  of  the  adjacent 
structures  with  the  outflow  of  stomach  and  intestinal  contents  should  be 
prevented  as  much  as  possible  with  gauze  packing.  All  bleeding  should  be 
controlled  by  clamping  and  twisting — and  is  further  controlled  by  suturing — 
and  by  gut  ligature  if  necessary.  (7)  Immediately  following  these  incisions, 
the  margins  of  the  intestinal  incision  are  united  to  the  margins  of  the  stomach 


Fig.  713. — Anterior  Gastroenterostomy  Followed  by  Jejuno-jejunostomy: — 
A,  Stomach;  B,  Duodenum;  C,  Jejunum,  after  emerging  from  ligament  of  Treitz;  D,  Coil  of 
jejunum  given  a  half-turn  and  applied  to  lower  aspect  of  anterior  stomach-wall;  E,  E,  Outer 
tier  of  continuous  Lembert  suturing;  F,  F,  Inner  tier  of  continuous  overhand  suturing  approxi- 
mating edges  of  opening  in  stomach  and  intestine;  G,  Intestinal  clamps;  H,  Entero-enterostomy 
by  Murphy  button;  I,  Transverse  colon;  J,  Omentum  folded  back  by  uplifted  jejunum. 

incision  by  continuous  suturing  with  silk  or  chromic  gut,  passed  with  a  curved 
needle  held  in  a  holder,  the  sutures  passing  through  all  the  coats  of  both 
stomach  and  intestine,  the  edges  of  the  incision  being  so  held  as  to  enable 
them  to  be  whipped  together  by  an  overhand  stitch.  (8)  The  threaded  end 
of  the  original  continuous  gut  or  silk  suture  is  now  taken  up  and  the  line 
of  suturing  continued  from  the  end  where  it  was  temporarily  discontinued, 
on  around  now  in  front  of  the  line  of  incisions  into  stomach  and  intestine, 
in  the  same  slightly  elliptical  outline  as  upon  the  posterior  aspect,  and  passing 


ANTERIOR    GASTROENTEROSTOMY    BY    MURPHY    BUTTON.         971 

about  S  to  12  mm.  (J  to  h  inch)  from  the  line  of  incision  into  the  lumina 
of  the  viscera — until  the  suturing  reaches  the  opposite  end,  when  the  free 
end  of  the  suture  is  tied  to  the  end  originally  left  long  after  knotting.  Thus 
the  inside  line  of  sutures,  chiefly  for  strength,  is  reinforced  by -this  secondary 
line  uniting  the  muscular  and  serous  coats,  and  thus  shutting  off  any  leakage 
which  might  escape  through  the  suturing  of  the  margins  alone.  The  stomach 
and  intestine  must  be  so  manipulated  during  the  various  stages  of  the  suturing 
as  to  present  the  site  to  the  surgeon  most  advantageously.  (9)  A  third  line 
of  interrupted  gut  Lemberts  may  be  now  applied,  burying  in  the  other  two, 
if  thought  necessary — but  is  rarely  needed.  (10)  The  viscera  are  now  dropped 
back  into  the  peritoneal  cavity  and  the  abdominal  wound  closed  as  usual. 
See,  under  Comment,  reference  to  intestinal  anastomosis  as  an  accompaniment 
of  gastro-enterostomv. 

Comment. — (i)  The  chief  objections  to  the  anterior  method  of  gastro- 
enterostomy are — that  the  transverse  colon  is  apt  to  be  compressed  by  the 
small  intestine  resting  and  dragging  upon  it; — that  the  two  intestinal  arms 
descending  from  the  stomach  are  apt,  by  gravity  and  traction,  to  become 
parallel,  and  a  spur-formation  thereby  occur  at  the  stomach  opening,  by 
converting  the  original  curve  at  their  point  of  meeting  into  an  angularity; — 
and  that  regurgitation  of  intestinal  contents,  including  bile,  into  the  stomach 
is  more  frequent  after  the  anterior  operation.  Therefore  various  suggestions 
have  been  made  to  overcome  the  above  disadvantages — such  as  valvular 
forms  of  anastomoses, — multiple  intestinal  anastomoses,  or  a  single  intestinal 
anastomosis,  to  carry  off  the  contents  of  the  proximal  end  of  the  intestine, 
including  bile, — and,  probably  best  of  all,  posterior  gastro-enterostomv.  (2) 
In  all  forms  of  gastro-enterostomv,  but  especially  in  the  anterior  operations, 
it  is  advisable,  after  completing  the  gastro-enterostomv  proper,  to  form  an 
intestinal  anastomosis,  a  jejuno-jejunostomy,  at  the  site  and  in  the  manner 
described  in  connection  with  the  following  operation  (page  971).  (3)  In  the 
operation  just  described,  wherever  the  continuous  suture  is  used,  it  is  well 
to  tie  it  at  several  points  (without  intermitting  the  stitch)  rather  than  at 
one  only — to  do  away  with  any  possibility  of  the  suture  acting  as  a  "draw- 
string" and  constricting  the  opening. 


ANTERIOR    GASTROENTEROSTOMY    BY    THE    MURPHY    BUTTON; 

FOLLOWED  BY  SINGLE  OR  MULTIPLE  INTESTINAL  ANASTOMOSIS  BV  THE 
JABOULAY-BRAUN  METHI  >D. 

Description. — Consists,  first,  in  performing  an  anterior  gastro-enteros- 
tomv, by  bringing  the  highest  available  part  of  the  jejunum  up  in  front  of 
the  great  omentum  and  transverse  colon  and  uniting  it  to  the  anterior  wall 
of  the  stomach,  nearer  its  greater  curvature,  by  means  of  the  Murphy  button. 
For  the  reasons  explained  under  Comment  in  the  last  operation,  the  two 
arms  of  the  loop  of  jejunum  are  then  anastomosed,  either  by  the  Murphy 
button  or  by  simple  suturing — constituting  single  intestinal  anastomosis, — 
or,  in  addition  to  the  anastomosis  thus  formed,  one  or  more  other  anasto- 
moses may  be  made  between  adjacent  coils  of  intestine,  if  the  need  for  these 
be  indicated. 

Preparation — Position — Landmarks — Incision. — As  in  the  operation 
just  described.  "* 

Operation. — (1)  All  the  steps  of  the  gastro-enterostomv  are  precisely 
similar  to  those  described  under  anterior  gastro-enterostomv  by  simple  suture, 


972 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


up  to  the  point  of  making  the  anastomosis — which,  in  the  present  case,  is 
accomplished  by  means  of  the  Murphy  button.  The  male  half  of  the  button 
is  inserted  into  a  convenient,  relatively  non-vascular  part  of  the  anterior  wall 
of  the  stomach,  near  the  greater  curvature  and  about  at  its  center.  The 
insertion  of  the  half  button  into  the  stomach  is  accomplished  exactly  as 
described  under  entero-enterostomy  by  the  Murphy  button  (page  885) — the 
incision  into  the  stomach-wall  being  in  its  long  axis,  and  all  bleeding  being 
controlled  by  twisting  or  ligature  before  proceeding.  The  female  half  of  the 
button  is  then  inserted  into  the  antimesenteric  aspect  of  the  loop  of  jejunum — 
also  in  the  same  manner  as  described  in  entero-enterostomy  by  the  Murphy 
button.  When  all  is  in  readiness,  the  two  halves  of  the  button  are  approxi- 
mated in  the  usual  manner.     If  thought  necessary,  the  button  anastomosis 


Fig.  714. — Anterior  Gastroenterostomy  by  Simple  Suturing,  followed  by  Entero- 
enterostomy  by  Gallet's  Method  of  Introducing  Weir's  Modification  of  the  Murphy 
Button: — A,  Stomach  opening;  B,  Intestinal  opening;  C,  C,  Manner  of  applying  the  buttons 
from  within  parallel  limbs  of  jejunum;  D,  Omentum  folded  back  over  a  reversed  coil  of  jejunum. 

may  be  reinforced  by  a  few  interrupted  Lemberts.  (2)  The  anastomosis 
between  the  antimesenteric  aspect  of  the  limbs  of  the  jejunum,  several  inches 
below  the  stomach,  is  now  accomplished  in  one  of  the  following  ways: — 
(a)  By  Gallet's  method  of  introducing  Weir's  modification  of  the  Murphy 
button: — When  the  incision  is  made  into  the  knuckle  of  jejunum  to  be  anas- 
tomosed to  the  anterior  stomach-wall,  and  before  that  anastomosis  is  done, 
the  male  half  of  the  button,  with  the  end  of  its  cylinder  beveled  and  sharpened, 
as  modified  by  Weir,  is  introduced  down  the  proximal  limb  of  the  jejunum, 
in  the  grasp  of  a  pair  of  forceps,  the  handle  of  the  forceps  being  steadied 
by  an  assistant, — and  the  female  button,  similarly  grasped,  is  introduced 
down  the  distal  limb  of  the  jejunum — and  while  thus  held,  the  two  halves 
of  the  button  are  approximated  and  pressed  home,  the  cutting  cylinder  of 


ANTERIOR    GASTROENTEROSTOMY    BY    MURPHY    BUTTON.         973 


the  male  button  cutting  its  way  through  intervening  intestinal  wall  of  the 
proximal  and  distal  limbs  of  the  gut  and  finding  its  way  into  the  female 
cylinder.  No  reinforcing  suture  is  necessary — though  may  be  applied  if 
desired.  The  forceps  are  now  withdrawn  from  the  opening  in  the  knuckle 
of  intestine,  and  the  anastomosis  between  stomach  and  intestine  completed. 
(Fig.  714.)  (b)  By  Hartley's  method: — the  ordinary  Murphy  buttons  are 
used — the  male  button  being  dropped  through  the  incision  at  the  knuckle 
of  intestine  into  the  proximal,  and  the  female  button  into  the  distal  limb. 
The  gastro-intestinal  anastomosis  is  then  completed — after  which  each  button 
is  grasped  and,  while  so  held  as  to  bring  their  cylinders  into  contact  with 
the  antimesenteric  aspect  of  the  jejunum,  at  the  indicated  site,  two  small 
incisions  are  made  at  right  angles  through  the  intestinal  wall,  which  has  been 
stretched  like  a  drum-head  over  the  ends  of  the  cylinders — the  surgeon  steady- 
ing one  button  with  the  fingers  of  his  left  hand,  and  an  assistant  steadying 


Fig.  715. — Anterior  Gastroenterostomy  by  Simple  Suturing,  followed  by  Entero- 
ENTEROSTOMY  by  the  Mi'rphy  Bctton: — By  means  of  buttons  dropped  into  parallel  limbs 
of  jejunum,  and  then  approximated  through  incisions  made  over  their  cylinders.  (Hartley's 
method.) 

the  other.  The  buttons  are  then  pressed  together  in  the  usual  fashion — no 
reinforcing  suturing  being  ordinarily  used.  (Fig.  715.)  (c)  The  Murphy 
buttons  may  be  used  to  make  the  intestinal  anastomosis  in  the  ordinary 
manner — as  described  in  entero-enterostomy  by  lateral  anastomosis  (page 
888).  (d)  The  intestinal  anastomosis  may  also  be  made  by  simple  suturing. 
(3)  The  stomach  and  intestines  having  been  dropped  back  into  place,  the 
abdomen  is  closed  as  in  median  abdominal  section. 

Comment. — If  it  be  thought  advisable,  in  addition,  to  anastomose  adjacent 
coils  of  intestine,  in  order  to  increase  the  freedom  of  passage  of  intestinal 
contents,  one  or  more  anastomoses  may  be  made  where  indicated — the  opera- 
tion becoming  an  entero-enterostomy  by  lateral  anastomosis,  and  one  of  the 
methods  described  under  that  head  may  be  used — the  Murphy  button  being 
the  means  usually  employed. 


974 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


POSTERIOR  GASTROENTEROSTOMY 

BY    VON    HACKER'S    METHOD. 

Description. — In  this,  the  more  commonly  performed,  operation  some 
part  of  the  small  intestine  as  near  as  possible  to  the  stomach  (generally  the 
upper  part  of  the  jejunum)  is  carried  through  an  artificial  opening  made  for 
the  purpose  in  the  transverse  mesocolon,  and  anastomosed  with  the  posterior 
wall  of  the  stomach — constituting  a  posterior  gastrojejunostomy  (Fig.  711, 
B) — after  which  the  two  limbs  of  the  jejunal  loop  are  united,  forming  a 
jejuno-jejunostomy. 

Preparation — Position — Landmarks. — As  in  the  anterior  operation. 


N 


•X 


N 


Fig.  716. — Posterior  Gastro-enterostomy: — I. — The  omentum  and  transverse  colon 
have  been  displaced  upward  and  in  front  of  the  stomach; — The  transverse  mesocolon  is  incised 
and  its  margins  sutured  to  the  posterior  stomach-wall; — A  loop  of  the  jejunum  has  been  brought 
up  into  contact  with  the  stomach; — The  lines  of  incision  are  shown  upon  the  stomach  and 
jejunum.     (Modified  from  Mayo  and  Gould.) 

Incision. — In  the  median  line — beginning  about  5  cm.  (2  inches)  below 
the  ensiform  cartilage  and  extending  below  the  umbilicus.  The  incision  is 
sometimes  made  through  the  right  rectus. 

Operation. — (1)  Expose  the  peritoneal  cavity,  as  in  median  abdominal 
section.  (2)  Lift  the  great  omentum  upward  and  to  the  left,  and  the  trans- 
verse colon  upward  and  to  the  right,  displacing  them  over  the  stomach. 
(3)  Isolate  and  draw  out  the  beginning  of  the  jejunum,  as  described  in  anterior 
gastro-enterostomy.  (4)  An  assistant,  standing  above  the  stomach  and  to 
one  side,  so  grasps  the  stomach  that  both  his  thumbs  press  its  anterior  and 


POSTERIOR    GASTROENTEROSTOMY. 


975 


his  fingers  its  posterior  surface — then  by  pronating  his  forearms,  the  posterior 
surface  is  protruded  downward  and  forward  prominently  toward  the  surgeon, 
the  transverse  mesocolon  intervening.  (5)  Separate  the  fibers  of  the  trans- 
verse mesocolon  by  blunt  dissection  in  the  direction  of  its  vessels,  in  anon- 
vascular  region,  and  opposite  the  site  of  the  future  anastomosis — thus  opening 
into  the  cavity  of  the  lesser  omentum.  (Fig.  716.)  (6)  The  assistant, 
continuing  to  press  upon  the  stomach  as  above,  causes  its  posterior  wall  to 
bulge  through  the  artificial  slit  in  the  transverse  mesocolon — until  it  presents 
in  the  cavity  of  the  great  omentum.  The  edges  of  this  slit  in  the  mesocolon 
are  immediately  sutured  to  the  stomach,  leaving  an  oval  area  of  posterior 
stomach-wall  of  sufficient  size,  the  sutures  passing  through  the  entire  thickness 
of  transverse  mesocolon  and  through  serous  and  muscular  coats  of  the  stomach. 


Fig.  717. — Posterior  Gastroenterostomy: — II. — Folds  of  stomach  and  intestine  have 
been  taken  up  by  special  clamps,  approximated,  incised — and  are  being  sutured; — The  outer 
seromuscular  and  the  inner  through-and-through  sutures  are  shown.  (Modified  from  Mayo 
and  Gould.) 

(7)  A  convenient  coil  of  jejunum,  so  selected  as  to  avoid  tension  and  kinking, 
is  now  approximated  to  the  posterior  gastric  wall — its  contents  having  been 
pushed  away  for  several  inches  on  either  side  and  kept  away  by  clamping 
the  gut — the  assistant  holding  the  stomach  likewise  keeping  its  contents  away 
from  the  site  as  far  as  possible.  The  coil  of  jejunum  should  be  so  approximated 
to  the  stomach  as  to  make  the  flow  of  contents  from  the  latter  correspond  with 
that  in  the  intestine  (Fig.  716).  While  the  need  of  giving  it  a  half-turn  is 
not  so  pressingly  necessary  as  in  the  anterior  gastro-enterostomy,  because  of 
the  more  favorable  relations  of  the  parts  at  the  site  of  the  posterior  oper- 
ation, it  is,  nevertheless,  generally  best  to  resort  to  this  manoeuvre.  The 
stomach  and  jejunum  are  very  satisfactorily  held  in  contact  for  incision 
and  suturing  by  means  of  special  clamps  applied  as  shown  in  Fig.  717.     (8) 


976  OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

Moynihan's  line  of  gastric  incision  is  oblique,  passing  from  above  and  to  the 
left,  downward  and  to  the  right,  along  an  imaginary  line  extending  between 
two  points  represented  by  the  middle  of  the  dome  and  the  lowest  point  on  the 
greater  curvature  of  the  stomach.  The  lowest  point,  which  is  variable,  is 
placed  at  from  5  to  7.5  cm.  (2  to  3  inches)  to  the  left  of  the  sphincter  of  the 
pylorus.  The  handles  of  the  gastric  clamp  will  point  to  the  patient's  right 
shoulder.  Mayo  carries  the  incision  to  the  lower  edge  of  the  stomach,  which 
requires  the  separation  of  the  greater  omentum  from  the  posterior  aspect  of 
the  stomach  to  some  extent.  The  incision  into  the  jejunum  is  made  upon 
its  antimesenteric  aspect.  (9)  While  the  jejunum  is  held  in  contact  with 
the  posterior  stomach-wall  (both  being  drawn  as  far  out  of  the  abdominal 


. 


w 


r 

J.    - 


Fig.  718. — Posterior  Gastroenterostomy  : — III. — The  jejunum  is  shown  sutured  to 
the  wall  of  the  stomach — the  latter  part  of  the  seromuscular  suture  being  placed.  (Modified 
from  Mayo  and  Gould.) 

cavity  as  feasible)  the  surfaces  are  sutured  together  exactly  as  in  Wolner's 
Anterior  Gastro-enterostomy  (page  968).  (10)  With  a  long,  straight  needle, 
threaded  with  chromic  gut  or  silk,  a  line  of  continuous  suturing,  passing 
through  serous  and  muscular  coats  of  the  intestine,  on  the  one  hand,  and  the 
same  coats  of  the  stomach,  on  the  other,  is  carried  along  what  will  form  the 
posterior  line  of  union,  the  needle  being  inserted  at  close  intervals — the  suture 
left  hanging  long  at  both  ends,  with  the  needle  at  one  end,  and  knotted  at  the 
other — and  the  suturing  having  extended  in  a  slightly  elliptical  direction, 
beginning  and  ending  about  1.2  cm.  {\  inch)  beyond  the  ends  of  the  future 
incision  through  the  two  opposed  walls  (Fig.  718).  (n)  With  a  sharp-pointed 
bistoury,  a  quick,  controlled  stab  is  made  into  the  stomach,  in  its  oblique 
axis,  and  then  into  the  intestine,  in  its  long  axis,  in  the  indicated  sites,  and 


POSTERIOR    GASTROENTEROSTOMY.  977 

so  planned  that  the  incisions  will  fall  immediately  opposite  each  other  and 
be  of  the  same  size — the  incisions  being  made  while  both  stomach  and  intestine 
are  clamped  and  are  so  held  by  an  assistant  as  to  present  their  proper  sur- 
faces, and,  at  the  same  time,  the  opposite  walls  are  held  apart  so  as  not  to  be 
also  penetrated  by  the  knife  stab.  One  blade  of  a  pair  of  sharp-pointed 
scissors  is  now  introduced,  and  both  incisions  lengthened  in  both  viscera 
to  the  extent  of  about  5  to  6.5  cm.  (2  to  2  J?  inches) — until  within  about  1.2 
cm.  (i  inch)  of  either  end  of  the  posterior  line  of  suturing.  These  incisions 
into  the  stomach  and  intestine,  made  immediately  opposite  each  other,  should 
be  from  5  to  8  mm.  (|  to  J  inch)  from  the  suture-line.  Soiling  of  the  adjacent 
structures  with  the  outflow  of  stomach  and  intestinal  contents  should  be 
prevented  as  much  as  possible  with  gauze  packing.  All  bleeding  should  be 
controlled  by  clamping  and  twisting — and  is  further  controlled  by  suturing — 
and  by  gut  ligature  if  necessary.  (12)  Immediately  following  these  incisions 
the  margins  of  the  intestinal  incision  are  united  to  the  margins  of  the  stomach 
incision  by  continuous  suturing  with  silk  or  chromic  gut,  passed  with  a  curved 
needle  held  in  a  holder,  the  sutures  passing  through  all  the  coats  of  both 
stomach  and  intestine,  the  edges  of  the  incision  being  so  held  as  to  enable 
them  to  be  whipped  together  by  an  overhand  stitch.  (13)  The  threaded  end 
of  the  original  continuous  gut  or  silk  suture  is  now  taken  up  and  the  line  of 
suturing  continued  from  the  end  where  it  was  temporarily  discontinued, 
on  around  now  in  front  of  the  line  of  incisions  into  stomach  and  intestine, 
in  the  same  slightly  elliptical  outline  as  upon  the  posterior  aspect,  and  passing 
about  8  to  12  mm.  (^  to  h  inch)  from  the  line  of  incision  into  the  lumina  of 
the  viscera — until  the  suturing  reaches  the  opposite  end,  when  the  free  end 
of  the  suture  is  tied  to  the  end  originally  left  long  after  knotting.  Thus 
the  inside  line  of  sutures,  chiefly  for  strength,  is  reinforced  by  this  secondary 
line  uniting  the  muscular  and  serous  coats,  and  thus  shutting  off  any  leakage 
which  might  escape  through  the  suturing  of  the  margins  alone.  The  stomach 
and  intestine  must  be  so  manipulated  during  the  various  stages  of  the  suturing 
as  to  present  the  site  to  the  surgeon  most  advantageously.  (14)  A  third  line 
of  interrupted  gut  Lemberts  may  be  now  applied,  burying  in  the  other  two, 
if  thought  necessary — but  is  rarely  needed.  (15)  The  viscera  are  now 
undamped  and  dropped  back  into  the  peritoneal  cavity.  After  which  the 
limbs  of  the  jejunal  loop  are  anastomosed  by  simple  suturing,  or  by  some 
form  of  mechanical  device.  See  comment  following  YYolfler's  Anterior 
Gastro-enterostomy,  page  971,  and  also  Figs.  713,  714,  and  715.  (16)  The 
abdomen  is  closed  in  the  usual  manner. 

Comment. — (1)  When  adhesions  make  the  exposure  of  the  lesser  peri- 
toneal cavity  difficult  or  impossible,  the  posterior  operation  should  be  abandoned 
and  the  anterior  adopted.  (2)  The  jejunum  should  be  suspended  by  a 
stitch  to  the  stomach  on  each  side  of  the  anastomosis,  to  prevent  kinking  and 
dragging  (Hadra).  (3)  The  portion  of  the  jejunum  about  10  to  12.5  cm. 
(4  to  5  inches)  from  the  duodenojejunal  juncture  is  used.  About  7.5  cm. 
(3  inches)  of  the  viscera  are  taken  up  in  the  clamps.  (4)  In  the  posterior 
operation,  the  opening  in  the  stomach  is  made  with  a  slight  obliquity  from 
left  to  right  and  from  above  downward — the  intestine  being  incised  in  its  long 
axis,  as  in  the  anterior  operation.  (5)  The  suturing  of  the  split  transverse 
mesocolon  to  the  stomach  lessens  the  chance  of  the  intestine  slipping  through 
the  opening — and  also  lessens  traction  of  the  transverse  mesocolon  on  the  small 
intestine.  (6)  The  application  of  the  sutures  is  somewhat  more  difficult  in  the 
posterior  operation.  In  placing  the  continuous  suture,  it  is  well  to  tie  it  at 
intervals,  without  interrupting  its  continuity — to  prevent  its  acting  as  a  draw- 


978 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


string.  There  is  also  probably  greater  danger  of  twisting  of  the  intestines 
subsequently — owing  to  the  passage  through  the  slit  in  the  mesocolon.  (7) 
While  a  single  intestinal  anastomosis  is  generally  advisable,  some  surgeons 
perform  multiple  intestinal  anastomoses — to  further  prevent  regurgitation  of 
intestinal  contents.  Some  surgeons  also  narrow  the  caliber  of  the  proximal 
portion  of  the  small  intestine,  by  Lemberts  through  the  serous  and  muscular 
coats  transversely,  thus  infolding  the  walls  as  a  rosette.  (8)  The  various 
disadvantages  of  the  anterior  operation  are,  however,  largely  overcome — and 
some  of  them  entirely  overcome.  The  direction  of  the  flow  and  the  position 
of  the  parts  are  more  natural. 


Fig.  719. — Posterior  Gastroenterostomy  by  the  Murphy  Button,  followed  by 
Entero-enterostomy : — A  and  B,  Great  omentum  and  transverse  colon  turned  upward;  C, 
Transverse  mesocolon  with  edges  of  its  incised  wall  sutured  to  posterior  stomach-wall;  D,  Pos- 
terior stomach-wall  with  a  half-button  inserted;  E,  Coil  of  jejunum,  with  a  half-button  inserted; 
F,  F,  Forceps  holding  buttons;  G,  Coil  of  jejunum,  just  beyond  ligament  of  Treitz,  given  a 
half-turn;  H,  Mesentery  of  jejunum;  I,  Entero-enterostomy  by  simple  suturing;  J,  Intestinal 
clamps. 

POSTERIOR  GASTROENTEROSTOMY 

BY  THE  MURPHY  BUTTON. 

Description. — Consists  in  anastomosing  the  jejunum  to  the  posterior 
stomach-wall  by  means  of  the  Murphy  button — the  manner  of  exposing  the 


GASTROGASTROSTOMY.  979 

parts  being  the  same  as  in  Von  Hacker's  Posterior  Gastro-enterostomy — 
and  the  manner  of  applying  the  button  being  identical  with  its  application 
in  the  operation  of  Anterior  Gastro-enterostomy  by  the  Murphy  button.  See 
pages  971  and  974.     (Also  see  Fig.  719.) 

Where  a  single  or  multiple  intestinal  anastomosis  is  done  in  connection 
with  the  operation  of  Gastro-enterostomy,  it  may  be  performed  in  one  of 
the  several  manners  mentioned  upon  page  972. 

Note. — There  are  several  other  methods  of  performing  both  Anterior  and 
Posterior  Gastro-enterostomy — but  those  above  described  are  considered 
among  the  best  modern  methods. 


GASTROGASTROSTOMY 

BY  W'oLFI.KR'S  OPERATION. 

Description. — The  operation  of  Gastrogastrostomy  consists  in  the  anasto- 
mosis of  the  two  pouches  of  an  hour-glass  contraction  of  the  stomach,  for 
the  purpose  of  making  a  common  cavity.  Wolfler's  method  of  operating 
is  probably  more  applicable  to  a  symmetrically  deformed  hour-glass  contrac- 
tion, where  the  two  pouches  are  approximately  of  the  same  size  and  the  inter- 
vening connection  fairlv  large. 


1 


Fig.  720. — The  Pouches  of  an  Hour-glass  Stomach. 

Preparation — Position. — Gastrostomy  in  General,  page  956. 

Landmarks. — As  for  median  abdominal  section. 

Incision. — In  the  median  line — from  the  tip  of  the  xiphoid  cartilage  to 
about  7.5  cm.  (3  inches)  below  the  umbilicus. 

Operation. — (i)  Having  exposed  the  abdominal  cavity,  the  deformed 
stomach  is  brought  as  well  into  the  wound  as  possible — the  portion  inter- 
vening between  the  two  pouches  being  apt  to  be  bound  down  to  the  pancreas 
and  gastro-hepatic  ligament.     (2)  Having  packed  off  the  adjacent  regions 


980 


OPERATION'S    UPON    THE    ABDOMINO-PELVIC    REGION. 


with  gauze,  the  assistant  clamps  and  hold-  first  «>ne  and  then  the  other  gastric 
pouch  conveniently  to  the  surgeon — the  clamps  including  most  of  the  anterior 
stomach-wall,  and  the  greater  curvature  and  omental  attachment,  so  as  to 
obliterate  the  pouches.  (3)  Oval  incisions  (thus  excising  elliptical  portions) 
are  made  upon  those  aspects  of  the  two  pouches  which  face  each  other — 
extending  into  their  lower  borders,  so  as  to  re-establish  a  greater  curvature. 
(Figs.  720  and  721.)  It  is  well  to  use  Kammerer's  application  of  Finney's 
gastro-duodenostomy  technic  here  (Figs.  729-733).  These  openings  are 
about  7  cm.  (2J  inches)  long  and  pass  through  all  the  coats  of  the  stomach. 
Bleeding  vessels  are  clamped  and  gut-ligatured.  The  pouches  are  so  held 
as  to  minimize  the  escape  of  intestinal  contents.  (4)  An  assistant  now 
approximates  the  two  openings,  while  a  continuous  seromuscular  suture  is 
first  applied  posteriorly,  followed  by  a  through-and-through  suture  of  the 
margins.  Then  the  outlying  line  of  sutures  through  the  serous  and  muscular 
coats,  which  had  been  applied  posteriorly  only,  is  now  continued  on  around 


Fig.  721. — Gastro-gastrostomy  for  Hour-glass    Stomach: — The  two  pouches  have  been 
clamped  and  incised,  and  are  approximated  ready  for  suturing.     ( Redrawn  from  Gould.) 


the  sides  and  in  front — thus  completing  the  double  line  of  suturing.  Similarly 
and  preferably  the  cut  margins  can  be  whipped  together  with  a  continuous 
overhand  stitch  of  all  the  coats,  followed  by  an  outlying  continuous  sero- 
muscular suture.  (5)  The  stomach  is  now  returned  to  its  position  and  the 
abdomen  closed. 

Comment. — (1)  The  openings  are  so  calculated  that  they  will  correspond 
with  the  greater  curvature  of  the  stomach — and  increase  this  when  the  two 
halves  of  the  stomach  are  united.  (2)  In  some  cases  of  non-symmetrical 
hour-glass  contraction  of  the  stomach,  the  pyloric  pouch  is  bent  over  upon 
a  vertical  axis  and  sutured  along  an  elliptical  outline  to  the  cardiac  pouch — • 
an  opening  is  then  made  in  the  pyloric  pouch,  and  through  this  an  incision  ■ 
is  made  through  the  two  walls  which  have  been  sutured  together  and  which 
now  intervene  between  the  two  pouches — the  margins  of  this  incision  through 
the  double  walls  is  then  whipped  over  with  a  button-hole  stitch — and  then 
the  original  incision  in  the  pyloric  pouch  is  closed  by  sutures — and  the  abdo- 
men, which  has  been  opened  by  an  incision  from  the  tip  of  the  xiphoid  carti- 


GASTROPLICATION.  981 

large  down  the  median  line  two-thirds  of  the  way  to  the  umbilicus,  and  thence 
rounding  outward  and  upward  to  the  left  costal  arch,  is  closed — constituting 
Watson's  operation. 

GASTROPLICATION. 
WEIR'S  MODIFICATION  OF  BIRCHER'S  operation. 

Description. — Gastroplication  consists  in  the  reduction  of  the  size  of  a 
chronically  dilated  stomach  bv  invaeinating  a  fold  of  the  stomach-wall  into 


Figs.  722  and  723. — Gastroplication  (Weir's  Modification  of  Bircher's  Operation): — I. 
A,  Sound  infolding  anterior  stomach-wall  ;  B,  B,  First  tier  of  Lembert  sutures  burying  in  sound  ;  C, 
Second  tier  of  sutures  ready  to  bury  in  sound  for  second  time,  when  latter  is  placed  upon  first  tier. 
II.  Sectional  view  of  stomach  after  the  two  tiers  have  been  tied. 


the  lumen  of  the  stomach,  with  suturing  together  of  the  walls  of  the  infolded 
portion. 

Preparation — Position — Landmarks. — As  for  median  abdominal  sec- 
tion. 

Incision. — In  the  median  line — from  below  the  ensiform  cartilage,  nearly 
or  quite  to  the  umbilicus. 

Operation. — (1)  Expose  the  abdominal  cavity  by  the  usual  steps  of  the 
median  abdominal  section — control  hemorrhage — retract  the  edges  of  the 
wound — well  expose  the  anterior  surface  of  the  stomach  and  lift  it  as  far 
forward  into  the  wound  as  possible,  separating  by  blunt  dissection  all  minor 
adhesions.     (2)   In  a  direction  parallel  with  the  long  axis  of  the  stomach, 


982 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


and  midway  between  the  greater  and  lesser  curvatures,  depression  of  the 
anterior  surface  of  the  stomach  is  made  with  a  sound,  causing  parallel  longi- 
tudinal ridges  to  form  on  either  side  of  the  sound.  (Figs.  722  and  723.) 
(3)  These  ridges  of  anterior  stomach-wall  are  now  united  with  interrupted 
silk  sutures,  passing  through  serous  and  muscular  coats  of  each  ridge,  and 
extending  for  15  to  20  cm.  (6  to  8  inches).  (4)  The  sound  is  now  withdrawn 
and  reapplied  over  the  first  line  of  sutures,  and  parallel  with  it — similarly 
depressing  them — and  similarly  causing  two  secondary  parallel  longitudinal 
folds  of  anterior  stomach-wall  to  rise  up  on  each  side  of  the  sound.  These 
secondary  folds  are  similarly  sutured.  Whether  a  third  tier  is  placed,  will 
depend  upon  the  size  of  the  stomach — the  process  being  continued,  in  some 
cases,  until  the  greater  and  lesser  curvatures  meet.  (5)  The  stomach  is  then 
allowed  to  recede  into  position — and  the  abdomen  is  closed. 

Comment.— Bircher  did  not  suture  the  two  walls  of  the  fold  together, 
but  left  a  dead  space — Weir's  suturing  of  these  folds  into  apposition  con- 
stitutes his  modification.     Chromic  gut  may  be  substituted  for  silk. 


Figs.  724  and  725.— Gastroplication  (Moynihan's  Modification  of  Bircher's 
Operation): — I. — Interrupted  plaiting  sutures  in  anterior  wall  of  stomach;  II. — Cross-section 
of  stomach,  showing  the  result  of  tightening  and  tying  these  sutures. 


GASTROLYSIS.  983 

GASTROPLICATION. 
moynihan's  modification  of  bircher's  operation. 

Description. — The  same  object  is  here  accomplished  by  a  different 
application  of  the  sutures. 

Preparation — Position — Landmarks — Incision. — As  in  the  preceding 
operation. 

Operation. — Having  exposed  the  stomach,  a  series  of  vertical  interrupted 
seromuscular  sutures  are  placed  in  its  anterior  wall — as  illustrated  in  Fig.  724. 
Each  stitch  passes  into  the  wall  of  the  stomach  several  times — and  when  these 
are  drawn  tight  and  tied,  the  wall  of  the  stomach  is  folded  into  as  many  plaits 
or  ridges  as  there  are  bites  in  each  suture — as  shown  in  Fig.  725,  the  plaitings 
projecting  into  the  interior  of  the  organ.  A  posterior  gastroenterostomy 
is  done  in  completing  the  operation. 


GASTROPEXY. 

Description. — Consists  in  the  suturing  of  a  prolapsed  or  displaced  stomach 
to  some  fixed  point  of  support.  The  condition  of  the  stomach  is  termed 
gastroptosis — and  as  this  condition  is  frequently  associated  with  a  general 
enteroptosis  (Glenard's  disease)  of  the  abdominal  viscera,  suturing  into  a 
more  fixed  position  of  other  viscera  than  simply  the  stomach  is  generally 
indicated.  The  viscera  usually  sutured  to  the  anterior  abdominal  wall  are 
the  stomach,  liver,  and  transverse  colon. 

Preparation — Position — Landmarks. — As  for  median  abdominal  sec- 
tion. 

Incision. — In  the  median  line,  from  just  below  the  xiphoid  cartilage  to 
or  below  the  umbilicus. 

Operation. — (1)  Expose  the  abdominal  cavity — control  hemorrhage — 
retract  margins  of  wound — isolate  the  stomach  and  other  displaced  organs. 
(2)  The  following  steps  have  been  resorted  to: — (a)  Treves,  in  whose  case 
the  liver  was  also  involved,  passed  three  stout  silk  sutures — one  through 
the  edge  of  the  liver  to  the  round  ligament — and  two  from  the  falciform 
ligament  and  round  ligament  to  the  fibrous  tissue  of  the  abdominal  parietes 
near  the  ensiform  cartilage,  (b)  Duret  passed  a  continuous  suture  through 
the  serous  and  muscular  coats  of  the  anterior  wall  of  the  stomach,  on  the 
one  hand,  and  through  the  undivided  parietal  peritoneum  on  a  level  with 
the  fold  around  the  round  ligament  of  the  liver,  on  the  other,  (c)  Rovsing 
placed  three  silk  ligatures  between  the  anterior  wall  of  the  stomach  and 
the  parietal  peritoneum,  (d)  Davis,  in  one  case,  sutured,  with  silk,  the  lesser 
curvature  of  the  stomach  to  the  parietal  peritoneum  near  the  xiphoid  cartilage. 
In  another  case,  he  did  the  same  operation,  together  with  gastroplication. 
(e)  Beyea  shortened  the  gastro-hepatic  omentum  with  eight  or  ten  inter- 
rupted sutures,  (f)  Depage  operated  by  lessening  the  capacity  of  the  ab- 
dominal cavity  by  removing  a  T-shaped  segment  of  the  abdominal  wall. 


GASTROLYSIS. 

Description. — Consists  in  division  of  gastric  peritoneal  adhesions  from 
neighboring  structures.  The  adhesions  are  met  incidentally,  in  the  course 
of  other  operations. 

The  region  of  adhesions  having  been  well  exposed  in  the  course  of  some 


984  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

primary  operation,  the  adhesions  are  dealt  with  according  to  their  nature: — 

(1)  Slight,  flat  adhesions  may  be  separated  by  finger  or  blunt  dissection; — 

(2)  Cord-like  or  ribbon-like  adhesions  are  divided  between  double  ligatures;— 

(3)  Extensive,  firm  adhesions  often  require  partial  excision  of  the  wall  of 
the  stomach,  or  that  of  the  neighboring  organ — with  repair  of  the  denuded 
surface,  or  excised  area,  by  suturing,  omental  grafting,  etc. 

Note. — See  the  section  upon  Peritoneal  Adhesions,  page  822. 


GASTROPLASTY. 

Description. — An  operation  for  widening  the  opening  between  the  two 
pouches  of  an  hour-glass  contraction  of  the  stomach — similar  in  principle 
and  application  to  Pyloroplasty. 

The  stomach  is  exposed  by  median  abdominal  section — after  which  the 
narrowed  portion  between  the  two  pouches  is  brought  into  the  field — and 
the  same  operation  is  there  done  which  will  be  described  below  under  Pvloro- 
plasty. 

The  contracted  portion  of  the  stomach  is  grasped  with  special  clamps 
in  the  long  axis  of  the  organ.  An  incision  into  the  lumen  is  then  made 
in  the  long  axis  of  the  clamped  portion — and  the  protruding  mucous 
membrane  excised.  While  the  anterior  stomach-wall  is  being  drawn  forward 
with  forceps,  so  as  to  prevent  leakage,  the  clamps  are  shifted — and  are  made 
to  grasp  the  opening  at  a  right  angle  to  their  first  hold.  The  margins 
of  the  opening  are  then  closed  by  a  continuous  overhand  suture  of  all  the 
coats — followed  by  a  continuous  seromuscular  suture  after  the  removal  of 
the  clamps.  The  principle  is  the  same  as  that  of  the  Heinecke-Mikulicz 
pyloroplasty  (page  984). 

PYLOROPLASTY. 

THE  HEINEKE-MIKULICZ  OPERATION. 

Description. — Consists  in  an  increasing  of  the  caliber  of  the  pyloric 
orifice  of  the  stomach,  by  means  of  a  horizontal  incision  through  its  anterior 
wall,  corresponding  with  the  site  of  stricture,  followed  by  a  vertical  suturing 
of  the  wound.     Chiefly  resorted  to  in  non-malignant  stricture  of  the  pylorus. 

Preparation — Position. — As  for  Gastrostomy. 

Landmarks. — Linea  alba — for  median  incision; — right  rectus — for  in- 
cision through  rectus. 

Incision. — (1)  Incision  is  generally  made  in  the  median  line,  beginning 
a  short  distance  below  the  xiphoid  cartilage  and  extending  nearly  to,  or 
beyond,  the  umbilicus.  (2)  A  better  approach  to  the  site  itself,  though  with 
more  injury  to  the  abdominal  wall,  is  accomplished  by  a  vertical  incision 
through  the  outer  third  of  the  right  rectus  muscle.  The  median  incision  will 
be  used  in  the  operation  which  follows. 

Operation. — (1)  The  abdominal  cavity  having  been  opened — hemor- 
rhage is  controlled — and  the  edges  of  the  wound,  especially  on  the  right 
side,  are  well  retracted.  (2) 'The  pylorus  is  isolated  (any  slight  adhesions 
being  separated  by  blunt  dissection)  and  brought  into  the  abdominal  wound 
as  well  as  possible.  Neighboring  regions  are  well  guarded  by  gauze  packing. 
(3)  Incise  longitudinally  through  the  anterior  wall  of  the  pylorus,  beginning 
over  the  gastric  aspect  and  ending  over  the  duodenal  aspect  of  the  pylorus, 


PYLOROPLASTY. 


985 


-•/-  ^H^^^ 


Fig. 


726. — Pyloroplasty  (Heinecke-Mikulicz  Operation): — I. — The  stomach  and  duodenum 
are  clamped  and  the  constricted  gastro-duodenal  junction  incised. 


Fig.  727. — Pyloroplasty  (Heinecke-Mikulicz  Operation): — II. — The  incision  which  was 
made  in  the  long  axis  of  the  gastro-duodenal  constriction  is  now  retracted  in  the  opposite  direction. 
Two  rows  of  interrupted  sutures  are  placed — through-and-through  (the  shorter)  and  sero- 
muscular (the  longer). 

and  extending  along  midway  between  the  superior  and  inferior  borders  of 
the  pylorus — through  all  the  coats.  (Fig.  726.)  The  incision,  at  first,  is 
about  2  cm.  (f  inch)  long.     The  right  index-finger  is  then  inserted  through 


986  OPERATIONS    UPON    THE   ABDOMINO-PELVIC    REGION. 

this  opening  and  passed  on  into  the  pylorus,  to  determine  the  degree  of  con- 
striction and  the  thickness  of  the  wall,  by  palpation  between  the  internal 
finger  and  external  thumb.  The  incision  is  now  continued  through  the 
strictured  portion  on  into  the  healthy  duodenum  and  stomach — and  is  gener- 
ally about  5  cm.  (2  inches)  long.  (4)  By  means  of  wound-hooks,  or  silk 
retractors,  inserted  at  the  center  of  either  side  of  each  lip,  draw  upon  the 
margins  until  the  longitudinal  wound  first  becomes  diamond-shaped,  and 
then  transverse — and  while  held  in  this  last  position  the  sutures  are  applied. 
(5)  The  mucous  membrane  may  be  first  sutured  with  continuous  silk  suturing, 
or  sutures  may  pass  through  all  the  coats.  (Figs.  727  and  728.)  Interrupted 
silk  Lembert  sutures  are  then  introduced  through  serous  and  muscular  coats. 
If  indicated,  a  third  continuous  Lembert  suture  may  be  applied.  (6)  The 
parts  are  then  thoroughly  cleaned  and  dropped  back  into  position — and  the 
abdomen  closed  in  the  usual  manner. 

Comment. — (I)  In  a  very  dense,  thick  wall,  a  small  diamond-shaped 
excision  may  be  made — to  aid  in  the  approximation  of  the  two  edges.  (2) 
Suturing  may  be  done  as  above,  but  over  an  absorbable  tube.  (3)  The  site 
of  operation  should  be  clamped  on  both  sides. 


Fig.   728.— Pyloroplasty  (Heinecke-Mikulicz   Operation): — III. — The  sutures   are   tied   and 
the  former  contracted  site  is  now  shown  to  be  of  larger  caliber  than  normal. 

DIVULSION  OF  PYLORIC  ORIFICE  OF  STOMACH. 

LORETA'S  OPERATION. 

Description. — The  cavity  of  the  stomach  having  been  entered  by  gastro- 
tomy,  the  constricted  pyloric  orifice  is  dilated  either  by  finger  or  instrument. 
Sometimes  resorted  to  in  non-malignant  stricture. 

Preparation—Position— Landmarks— Incision.— As  for  Gastrotomy 
by  median  incision. 

Operation. — (1)  Median  abdominal  section  is  done — and  the  abdominal 
walls  retracted.  (2)  The  pylorus  is  isolated  and  brought  as  well  into  the 
wound  as  possible— exactly  as  in  Pyloroplasty.     The  region  is  well  packed 


GASTRO-DUODENOSTOMY.  987 

off  with  gauze.  (3)  Incise  the  anterior  stomach-wall  vertically,  at  a  distance 
of  about  5  cm.  (2  inches)  from  the  pylorus,  and  midway  between  the  upper 
and  lower  curvatures — at  first,  to  an  extent  only  sufficient  to  admit  the  index- 
finger  snugly.  (4)  The  right  index-finger  is  immediately  inserted  through 
the  opening  and  is  made  to  slowly  work  its  way  through  the  pyloric  stricture — - 
while  the  region  is  steadied  from  without  by  the  left  hand.  Should  the 
stricture  be  found  too  tight  for  the  tip  of  the  finger,  a  dilating  instrument 
may  be  used  first — to  be  followed  by  the  finger.  When  the  stricture  is  en- 
larged sufficiently  to  accommodate  one  finger,  the  stomach  wound  is  enlarged 
with  a  blunt  bistoury,  without  withdrawing  the  first  finger,  and  the  middle 
finger  introduced  alongside  of  it.  The  fingers  in  the  stomach  wound  prevent 
any  considerable  hemorrhage — the  vertical  direction  of  the  gastric  incision 
also  aiding  in  this  respect.  Even  a  third  finger  may  be  introduced.  (5) 
The  object  having  been  accomplished — the  fingers  are  withdrawn — and  the 
hemorrhage  from  the  stomach  wound  is  controlled  by  clamping  and  twisting, 
or  by  gut-ligaturing.  (6)  The  wound  in  the  stomach  is  then  sutured  in 
the  ordinary  manner — or  as  in  Pyloroplasty.  (7)  The  abdominal  wound  is 
closed  in  the  usual  fashion. 

Comment. — (i)  Incision  into  the  stomach  may  be  parallel  with  its  length 
and  just  to  the  left  of  the  pylorus — as  in  Pyloroplasty.  (2)  Loreta  inserted 
both  index-fingers  and  stretched  in  opposite  directions.  (3)  In  Halm's 
operation,  no  opening  is  made  into  the  stomach — the  neighboring  stomach- 
wall  is  simply  invaginated  into  the  pylorus  upon  the  end  of  the  finger. 


DILATATION  OF  CARDIAC  ORIFICE  OF  STOMACH. 

See  under  Retrograde  Dilatation  of  Esophagus,  page  716. 


GASTRODUODENOSTOMY. 
finney's  operation. 

Description. — The  establishment  of  an  artificial  outlet  from  stomach  to 
duodenum.  The  operation  consists,  briefly,  in  the  making  of  an  extended 
Heinecke-Alikulicz  incision  in  the  gastro-duodenum  and  suturing  the  margins 
of  the  incision  in  a  special  manner — after  mobilizing  the  upper  portion  of 
the  duodenum.  The  technic  is  used  for  the  enlargement  of  the  pyloric  outlet 
of  the  stomach  in  non-malignant  cases. 

Preparation — Position — Landmarks — Incision. — As  for  gastrotomy 
by  median  incision  (page  952). 

Operation. — In  the  following  description  the  interpretation  of  the  opera- 
tion as  given  by  Gould  will  be  largely  followed.  Having  exposed  the  gastro- 
duodenal  region,  mobilization  of  the  upper  portion  of  the  duodenum  is  accom- 
plished. To  emote  from  Kocher: — "To  free  the  duodenum  in  this  way  it  is 
necessary  to  divide  the  parietal  peritoneum  to  the  right  of  the  descending  part 
of  the  duodenum.  The  membrane  is  divided  vertically  over  the  front  of  the 
right  kidney,  a  little  to  the  left  of  the  descending  limb  of  the  hepatic  flexure 
of  the  colon.  We  recommend  that  this  delicate  layer  of  the  parietal  peritoneum 
be  divided  with  the  knife  two  finger-breadths  to  the  right  of  and  parallel  to 
the  second  part  of  the  duodenum,  so  that  the  peritoneum  covering  the  anterior 
surface  of  the  duodenum  may  not  be  injured,  as  would  be  the  case  were  the 
peritoneum  simply  torn  through.     If  the  divided  peritoneum  adjacent  to  the 


98S 


OPERATIONS    UPON    THE    ABDOM1NO-PELVIC    REGION. 


Fig.  729. — Gastroduodenostomy — Finney's  Operation: — I. — Showing  the  approxima- 
tion of  stomach  and  duodenum  by  means  of  traction-sutures,  preparatorily  to  the  placing  of 
the  sutures. 


Fig.  730. — Gastroduodenostomy — Finney's  Operation: — II. — The  posterior  layer  of 
seromuscular  suturing  is  shown — and  the  dotted  line  indicates  the  position  of  the  incision  through 
the  walls  of  the  stomach  and  duodenum. 


GASTRO-DUODENOSTOMY.  9S9 

second  part  of  the  duodenum  be  grasped  and  pulled  forward,  the  fingers  can 
be  introduced  behind  the  duodenum  so  as  to  raise  it  from  the  vertebral  column, 
the  vena  cava,  and  the  aorta.  By  the  above  manipulations  the  second  part  of 
the  duodenum  is  rendered  so  movable  that  it  can  easily  be  brought  up  to  the 
anterior  surface  of  the  pyloric  portion  of  the  stomach  above  the  greater  curva- 
ture." After  this  freeing,  the  duodenum  and  stomach  are  clamped  in  the 
following  manner  (in  Finney's  original  description  they  were  held  in  contact 
by  traction  sutures,  Figs.  729  and  730); — a  longitudinal  fold  of  about  6  cm. 
(2J  inches)  of  the  anterior  aspect  of  the  duodenum  is  clamped,  the  inner  limb 
of  the  clamp  passing  up  to  the  pyloric  sphincter; — a  corresponding  portion  of 
the  anterior  wall  of  the  stomach  at  the  lower  portion  of  its  pyloric  aspect  is 
similarly  clamped,  the  point  of  the  outer  limb  of  the  stomach  clamp  meeting 


Fig.  731. — Gastro-duodenostomy — Finney's  Operation: — III. — The  parts  are  here 
shown  held  in  contact  by  clamps,  which  are  applied  at  the  beginning  of  the  operation.  The 
seromuscular  line  of  suturing  has  been  placed.  (This  is  the  same  stage  as  the  preceding  illus- 
tration, where,  less  desirably,  traction  sutures  are  used.) 

the  point  of  the  inner  limb  of  the  intestinal  clamp  (Fig.  731).  When  the 
clamps  are  clasped  and  brought  together,  the  gastro-duodenal  angle  is  put  upon 
the  stretch — thus  controlling  hemorrhage  and  leakage  from  this  area,  otherwise 
difficult  to  manage.  A  seromuscular  continuous  suture  is  now  carried  down 
from  the  pyloric  angle  through  the  aspects  of  stomach  and  duodenum  in 
contact — being  left  long  at  their  angle  of  separation  (Fig.  731).  A  U-shaped 
incision  is  next  made  into  the  lumen  of  stomach  and  intestine,  directly  over 
the  center  of  each  clamp,  and  continuous  with  each  other  around  the  gastro- 
duodenal  angle  (Fig.  731).  The  protruding  mucous  membrane,  especially 
that  of  the  stomach,  is  trimmed  off  even  with  the  seromuscular  margins  of  the 
openings.     The  incised   edges  of  stomach   and   intestine  are  now   sutured 


990 


OPERATIONS    UPOxN    THE    AHDOM1NO-PELVIC    REGION. 


Fig.  732. — Gastro-dcodenostomy — Finney's  Operation: — IV. — The  posterior  layer  of 
the  seromuscular  suture  is  shown — and  part  of  the  posterior  layer  of  the  through-and-through 
suturing  is  seen. 


Fig-  733- — Gastro-duodenostomy — Finney's    Operation: — V. — The  operation   completed. 


PYLORECTOMY    FOLLOWED    BY    GASTROJEJUNOSTOMY.  991 

together  with  an  overhand  running  stitch  of  all  coats — beginning  with  the 
posterior  lips  and  ending  with  the  anterior,  knotting  the  suture  where  the 
return-stitch  begins,  the  suture  ending  at  the  pyloric  angle,  where  it  began 
(Fig.  732).  If  the  parts  are  too  tense  to  enable  this  stitch  to  be  completed 
otherwise,  the  clamps  are  relaxed  before  its  last  portion  is  completed.  Finney 
uses  mattress  sutures,  placed  prior  to  incising,  to  close  in  the  anterior  lips. 
The  clamps  are  now  taken  off  and  the  continuous  seromuscular  suture,  already 
begun  upon  the  posterior  aspect,  is  now  continued  around  the  anterior  aspect 
of  the  wound  (Fig.  733). 

Comment. — The  normal  size  of  the  pyloric  outlet  should  be  calculated 
for,  or  a  slight  overcorrection,  in  planning  the  length  of  the  incision — which 
Finney  makes  about  10  cm.  (3  inches). 


PYLORECTOMY 

IN  GENERAL. 

Pylorectomy  consists  in  the  excision  of  the  pylorus,  together  with  as  much 
of  the  stomach  and  duodenum  as  may  be  necessary.  Generally  resorted  to 
in  cases  of  malignant  growth  of  the  pyloric  end  of  the  stomach.  The  operation 
is  sometimes  called  partial  gastrectomy,  especially  where  a  considerable  portion 
of  the  stomach  is  removed. 

After  all  pylorectomies  an  additional  operation  is  always  necessary,  uniting 
the  lower  intestinal  tract  with  the  stomach.  The  cut  end  of  the  duodenum 
is  the  part  generally  united  to  some  part  of  the  stomach — though  the  cut 
end  of  the  duodenum  may  be  closed  by  suture  and  the  jejunum  united. 
The  anastomosis  may  be  by  simple  suturing  or  by  some  form  of  mechanical 
device. 


PYLORECTOMY  FOLLOWED  BY  INDEPENDENT  GASTRO-JE JUNOSTOMY. 

MAYo'S    OPERATION. 

Description. — The  operation  consists  of  the  excision  of  more  or  less  of 
the  pyloric  end  of  the  stomach — followed  by  the  closure  of  the  proximal  end 
of  the  duodenum  and  the  making  of  an  independent  posterior  gastrojejunos- 
tomy. The  operation  is,  practically,  a  partial  gastrectomy — and  is  resorted 
to  for  malignant  disease  of  the  gastro-duodenum.  The  writings  of  William 
J.  Mayo  will  be  here  largely  followed. 

Preparation — Position — Landmarks. — As  for  gastrotomy  by  median 
incision,  page  952. 

Incision. — Preliminarily,  a  limited  incision  is  made  in  the  median  line, 
midway  between  ensiform  cartilage  and  umbilicus,  for  exploration — and 
nothing  more  is  done  if  the  case  be  inoperable — the  abdomen  being  closed  with 
some  insoluble  suture  to  expedite  convalescence.  Otherwise  this  incision 
is  enlarged  to  the  extent  of  10  to  12.5  cm.  (4  to  5  inches). 

Operation. — (i)  Having  opened  the  abdomen,  the  liver  is  retracted 
upward,  the  stomach  depressed,  and  the  structures  in  the  neighborhood  of  the 
pylorus  and  duodenum  exposed.  (2)  The  four  arteries  which  supply  the 
gastro-duodenum  are  controlled  early  in  the  operation,  so  as  to  minimize  the 
hemorrhage.  The  gastric  is  doubly  ligated  and  divided  about  2.5  cm.  (1  inch) 
below  the  cardiac  orifice,  where  it  passes  to  the  lesser  curvature.  The  gastro- 
hepatic  omentum  is  doubly  ligated  and  divided  as  far  as  necessary  (from  the 
site  of  ligation  of  the  gastric  artery  to  the  structures  in  the  free  border  of  the 


992 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


omentum),  the  division  being  made  close  to  the  liver  and  leaving  the  greater 
portion  of  the  structure  adherent  to  the  stomach.  The  lesser  peritoneal 
cavity  is  thus  opened  up  and  the  pyloric  end  of  the  stomach  mobilized,  together 
with  the  tumor.  The  entire  region  is  well  protected  with  gauze  packing. 
The  pyloric  artery  is  now  doubly  tied  and  ligated  near  the  pylorus — and 
the  first  part  of  the  duodenum  freed  for  3  or  4  cm.  (i|  to  ij  inches),  prepara- 
tory to  its  later  resection.  (3)  Having  entered  the  lesser  omental  cavity, 
and  guided  by  a  finger  beneath  the  pylorus,  raise  the  gastro-colic  omentum 
from  the  transverse  mesocolon  and  thus  safely  ligate  the  right  gastro-epiploic 


Fig.  734. — Pylorectomy,  followed  by  Independent  Gastrojejunostomy — Mayo's 
Operation: — I. — The  duodenum  is  doubly  clamped  and  divided  and  the  distal  end  sutured. 
The  lesser  end  of  the  stomach  is  doubly  clamped,  ready  to  be  divided.  The  gastro- hepatic  and 
gastro-colic  omenta  have  been  tied  off  and  divided,  the  division  being  beyond  the  region  of  the 
lymph-nodes,  which  are  left  attached  to  the  excised  portion.  The  ligature  of  the  gastro-duoden- 
alis  and  gastro-epiploica  sinistra  arteries,  along  the  lesser  and  greater  curvatures  of  the  stomach, 
which  are  approached  by  bringing  the  incisions  through  the  omenta  toward  the  borders  of  the 
stomach,  are  not  shown  here  (see  Fig.   735). 

artery  (or  its  parent  vessel,  the  gastro-duodenal) .  Thence  doubly  ligate  and 
divide  progressively  the  gastro-colic  omentum  distal  to  the  lymphatic  glands 
and  vessels,  up  to  the  indicated  point  on  the  greater  curvature,  where  the 
left  gastro-epiploic  vessels  are  ligated.  In  ligating  off  the  omenta  the  line  of 
ligatures  should  be  so  placed  that  the  lymph-nodes  will  be  left  with  the  part 
of  the  gastro-duodenum  to  come  away.  Avoid  tying  or  cutting  the  middle 
colic  artery  in  entering  the  lesser  omental  cavity  by  separating  it  from  the 
mesocolon — as  it  is  generally  the  entire  supply  of  the  transverse  colon.  (4) 
The  duodenum  is  divided  by  actual  cautery  between  two  clamps  (Fig.  734), 


PYLORECTOMY    FOLLOWED    BY    GASTROJEJUNOSTOMY. 


993 


leaving  a  stump  3  mm.  (|  inch)  long — through  the  end  of  which  a  running 
catgut  suture  is  placed  before  the  clamp  is  removed,  and  drawn  tight  as  the 
clamp  comes  away.  This  stump  is  then  inverted  by  a  silk  or  linen  seromuscu- 
lar purse-string  suture  placed  around  the  duodenal  stump,  2  cm.  (f  inch) 
below  its  end.  A  Kocher  stomach-clamp,  guarded  with  rubber  tubing, 
clamps  the  stomach  from  the  ligated  gastric  artery  at  Mikulicz's  point  of 
election,  obliquely  to  Hartmann's  point  of  election  at  the  greater  curvature. 
A  second  stomach-clamp  is  applied  to  the  pyloric  aspect  of  the  first  clamp, 
to  guard  against  leakage  at  the  time  of  division.  The  stomach  is  now  divided 
through  both  of  its  walls  by  means  of  the  actual  cautery,  3  mm.  (\  inch)  from 
the  holding  clamp — the  severed  part  of  the  cardiac  end  being  caught,  as 


Fig-    735- — PYLORECTOMY,    FOLLOWED    BY   INDEPENDENT  GASTROJEJUNOSTOMY  : — MAYO'S 

Operation: — II. — The  excised  portion  has  been  removed,  showing  the  corresponding  portions 
of  the  gastro-hepatic  and  gastro-colic  omenta  tied  off.  The  duodenum  is  closed.  All  of  the 
through-and-through  suturing  of  the  stomach  has  been  completed — and  most  of  the  seromus- 
cular line  of  suturing.  The  arteries  of  the  lesser  and  greater  curvatures  of  the  stomach  are  tied. 
The  outline  of  the  independent  posterior  gastro-enterostomy  is  seen  through  the  stomach. 

divided,  by  catch  forceps,  to  prevent  retraction  within  the  bite  of  the  forceps. 
The  pyloric  end  of  the  stomach,  with  tumor,  is  now  removed  (Fig.  735). 
The  severed  edges  of  the  cardiac  end  of  the  stomach  are  sutured  together, 
from  greater  to  lesser  curvature,  with  catgut  button-hole  suture  through  all 
the  coats  of  both  anterior  and  posterior  walls — "and  in  the  same  manner 
directly  back,  and  tied  at  the  starting-point,  thus  preventing  hemorrhage  as 
well  as  leakage."  On  removing  the  clamp  any  bleeding  point  is  ligated. 
A  seromuscular  suture,  of  the  right-angle  Cushing  type,  is  placed  beyond  the 
preceding  stitch,  thus  burying  it  in  and  completing  the  approximation.  It 
should  be  so  placed  as  to  avoid  tension.  (5)  Having  completely  closed  the 
ends  of  the  duodenum  and  of  the  stomach,  an  independent  gastrojejunostomy 
is  done  with  a  loop  of  the  jejunum.     The  parts  are  thus  brought  easily  into 


994  OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

apposition  and  tension  and  handling  of  traumatized  viscera  are  avoided,  as 
would  be  apt  to  be  the  case  in  the  older  forms  of  directly  uniting  the  divided 
end  of  the  duodenum  to  the  lower  portion  of  the  sutured  edges  of  the  stomach, 
or  to  its  anterior  or  posterior  wall.  The  gastrojejunostomy  is  done  in  the 
usual  manner  (page  974,  and  Figs.  716  and  717).  Either  the  posterior  or 
anterior  operation  can  be  done,  and  the  union  may  be  by  simple  suturing  or 
by  some  mechanical  device.  Mayo  prefers  posterior  gastrojejunostomy  by 
simple  suturing,  if  the  patient's  condition  be  good  and  the  operation  a  prompt 
one — and  an  anterior  gastrojejunostomy  by  the  Murphy  button  if  the  condi- 
tion be  poor.     (6)   The  abdomen  is  closed  in  the  usual  manner. 

After-treatment. — The  patient's  head  and  shoulders  are  raised  by  four 
or  five  pillows.  Rectal  alimentation  is  used.  After  twelve  hours,  hot  water 
is  given  by  mouth  in  half-ounce  doses,  increased  to  an  ounce  every  hour. 
After  thirty-six  hours,  careful  feeding  with  fluid  food  is  used. 

Comment. — (1)  Stress  is  laid  upon  the  division  of  viscera  and  omenta 
with  the  actual  cautery — as  means  of  avoiding  the  dissemination  of  cancer 
cells  throughout  the  abdomen.  (2)  Careful  gauze  packing  is  used  throughout 
— a  deeper  layer,  which  is  not  changed  from  beginning  to  end  of  operation, 
to  further  aid  in  preventing  dissemination — and  a  superficial  layer,  which  is 
being  constantly  changed.  (3)  Cigarette  drains  are  used  when  much  soiling 
has  occurred,  the  drain  coming  from  just  above  the  transverse  colon  and 
emerging  at  the  lower  angle  of  the  wound. 


PYLORECTOMY  FOLLOWED  BY  END-IN-SIDE  POSTERIOR   GASTRO- 

DUODENOSTOMY. 

kocher's  method. 

Description. — This  operation  consists  in  the  excision  of  the  pylorus, 
with  as  much  of  the  adjacent  stomach  and  duodenum  as  indicated — followed 
by  a  complete  closure,  by  invaginating  and  suturing,  of  the  pyloric  end  of 
the  stomach — and  an  approximation  of  the  cut  end  of  the  duodenum  to  the 
posterior  aspect  of  the  stomach  near  its  excised  end.  A  less  desirable  form 
of  pylorectomy  than  the  Mayo  technic. 

Preparation — Position — Landmarks. — As  for  gastrotomy  by  median 
incision. 

Incision. — About  10  to  15  cm.  (4  to  6  inches)  in  length — beginning  a 
short  distance  below  the  ensiform  cartilage,  and  extending  as  far  as  necessary 
below  the  umbilicus,  in  the  median  line. 

Operation. — (1)  Perform  ordinary  median  abdominal  section — excise  the 
umbilicus — control  hemorrhage — retract  lips  of  wound.  Bring  into  the 
wound  the  involved  parts,  lifting  them  as  far  out  of  the  abdominal  cavity 
as  possible.  (2)  Ligate  off  the  lesser  and  greater  omenta  for  an  extent  cor- 
responding to  the  area  involved  and  sever  with  scissors  from  the  stomach 
and  duodenum,  near  the  visceral  borders.  Ligate  all  bleeding  vessels  with 
gut.  Isolate  the  parts  from  which  the  omenta  have  been  separated — and 
protect,  with  gauze  packing,  the  underlying  and  adjacent  parts  from  the 
stomach  and  intestinal  contents.  (Fig.  736.)  (3)  A  clamp  is  placed  upon  the 
duodenum  just  distal  to  the  part  to  be  removed — and  a  second  clamp  about 
2.5  cm.  (1  inch)  still  distal  to  the  first,  and  parallel  with  it,  the  handles  of  the 
clamps  lying  in  opposite  directions.  Two  clamps  are  now  placed  across  the 
pyloric  end  of  the  stomach,  in  the  same  line,  on  the  cardiac  side  of  the  growth 
— one  being  placed  from  the  lesser  and  one  from  the  greater  curvatures, 


PYLORECTOMY,    KOCHER'S    OPERATION. 


995 


their  ends  overlapping.  (4)  The  duodenum  is  now  cut  through  between 
its  two  clamp — the  edges  of  the  distal  end  being  disinfected  with  1  :  1000 
bichloride,  and  turned  over  the  right  edge  of  the  wound — and  the  proximal 
end  wrapped  in  gauze  and  lifted  out  of  the  wound.  (5)  An  assistant,  using 
his  forefingers  and  thumbs  (or  first  and  second  fingers)  as  a  second  pair  of 
clamps,  seizes  the  stomach  from  above  and  below,  a  short  distance  to 
the  cardiac  side  of  the  stomach  clamps — and  compresses  the  stomach  firmly, 
gauze  being  placed  to  catch  any  leakage  from  the  stomach.  The  stomach 
is  now   cut    through   between   the   two   stomach   clamps — and    the    growth 


Fig.  736. — Pylorectomy,  followed  by  Posterior  Gastro-duodenostomy  (Kocher's 
Operation)  : — Pylorus,  with  involved  malignant  growth  tc  be  removed;  Lesser  omentum 
ligated  off;  Greater  omentum  ligated  off;  Clamps  placed  on  either  side  of  line  of  future  incision 
through  stomach;  Clamps  similarly  placed  upon  duodenum.     (Modified  from  Kocher.) 

removed — and  all  bleeding  vessels  ligated  with  gut.  (6)  The  cut  edges  of  the 
stomach  are  now  first  sutured  with  continuous  silk  suture,  passing  through 
ail  three  coats  in  an  overhand,  or  whipping  fashion — approximating  the 
anterior  and  posterior  walls.  All  projecting  mucous  membrane  is  disinfected 
with  bichloride.  This  line  of  primary  suturing  is  then  invaginated  by  a 
second  line  of  continuous  silk  Lembert  sutures  of  serous  and  muscular  coats 
— thus  burying  in  the  first  line  and  extending  a  short  distance  beyond  its  ends. 
(Fig.  737.)  (7)  The  assistant,  holding  the  stomach  in  both  hands,  so  manipu- 
lates it  as  to  direct  its  posterior  wall  to  the  front  and  to  the  right,  compressing 


996 


OPE  RATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


the  duodenum  between  the  stomach  and  right  edge  of  the  abdominal  wound 
and  thus  (losing  the  lumen  of  the  gut.  While  the  stomach  is  thus  held,  the 
posterior  aspect  of  the  duodenum  (still  in  the  grasp  of  the  forceps)  is  applied 
to  the  posterior  wall  of  the  stomach  (the  serous  surfaces  of  both  being  in 
contact).  (Fig.  737.)  (8)  A  continuous  posterior  serous  suture  of  silk  is 
now  placed  between  the  serous  and  muscular  coats  of  the  posterior  wall  of 
the  stomach  and  the  posterior  aspect  of  the  duodenum  thus  approximated, 
from  the  upper  to  the  lower  border  of  the  intestine — both  ends  of  the  suture 
being  left  long  after  knotting,  and  the  needle  threaded  to  the  lower  one. 


Fig-  737- — Pylorectomy,  followed  by  Posterior  Gastro-duodenostomy  (Kocher's 
Operatiom): — II. — Clamp  holding  stomach  forward  while  duodenum  is  being  sutured  to  its 
posterior  aspect;  Line  of  continuous  Lembert  sutures  uniting  outer  coats  of  stomach  and  duo- 
denum; Line  of  continuous  overhand  sutures  through  all  coats,  uniting  their  edges.  (Modified 
from  Kocher.) 

These  sutures  in  the  intestine  are  placed  sufficiently  far  from  its  extreme  end 
to  leave  the  circumference  of  the  extreme  end  of  the  gut  free  for  suturing  to 
the  stomach  opening.  The  hitherto  retained  forceps  are  undamped  from 
the  duodenum — (unless  a  pair  should  be  kept  on  further  down) — and  what- 
ever leakage  occurs  is  caught  upon  gauze — the  lumen  of  the  gut  is  then  disin- 
fected—and the  vessels  are  gut-ligatured.  (9)  The  posterior  stomach-wall 
is  now  incised  vertically  about  1.2  cm.  (\  inch)  from  the  posterior  serous 
suture  just  inserted,  and  for  a  distance  equal  to  the  breadth  of  the  duodenum. 
Bleeding  vessels  are  gut-ligatured.  (10)  A  continuous  silk  ligature  is  now 
passed,  upon  curved  needle  in  holder,  uniting  the  edges  of  the  cut  end  of  the 
duodenum  to  the  edges  of  the  stomach  opening,  passing  through  all  the  coats 
of  both  viscera,  around  the  entire  circumference.     This  line  of  suturing  is 


PYLORECTOMY,    BILLROTH'S    OPERATION.  997 

chiefly  for  strength.  If  preferred,  two  rows  ma}"  be  used — one  of  the  mucous 
membrane — and  one  of  the  serous  and  muscular  coats,  (n)  Taking  up 
now  the  still  threaded  end  of  the  posterior  serous  suture,  that  line  of  con- 
tinuous suturing  is  continued  around  the  anterior  aspect,  forming  the  anterior 
serous  suture,  passing  through  the  serous  and  muscular  coats  of  the  intestine 
and  stomach,  until  the  surfaces  throughout  the  entire  circumference  are 
approximated,  and  is  then  tied  to  the  opposite  free  end  of  the  suture.  (12) 
The  parts  are  then  thoroughly  cleaned  and  disinfected  and  dropped  back  into 
place.  (13)  Prior  to  the  return  of  the  parts  to  the  abdomen,  the  free  edges 
of  the  lesser  and  greater  omenta  should  be  gut-ligatured  to  the  upper  and  lower 
margins,  respectively,  of  stomach  and  intestine  at  the  site  of  operation.  (14) 
The  abdominal  wound  is  then  closed  as  in  ordinary  median  abdominal  sec- 
tion. 

Comment. — (i)  The  omenta  can  be  ligated  off  conveniently  with  Cleve- 
land's ligature-carrier,  or  an  aneurism-needle.  (2)  The  division  of  the  stomach 
and  intestines  is  usually  made  with  scissors.  (3)  A  rather  long  abdominal 
wound  may  be  needed  to  enable  sufficient  lateral  displacement  to  the  right 
to  expose  the  gastroduodenal  site  sufficiently  for  the  necessary  technique, 
upon  the  accuracy  of  the  details  of  winch  so  much  depends.  (4)  The  Mur- 
phy button  may  be  used  for  the  approximation,  after  the  excision  of  the 
growth  by  the  above  method.  (5)  A  second  pair  of  stomach  clamps  may 
be  used  instead  of  the  fingers  of  an  assistant. 


PYLORECTOMY  FOLLOWED  BY  END-TO-END  GASTROENTEROSTOMY. 

BILLROTH'*  OPERATIOX. 

Description. — Following  the  excision  of  the  pylorus,  together  with  the 
adjacent  involved  portions  of  the  stomach  and  duodenum,  the  large  opening 
left  in  the  pvloric  end  of  the  stomach  having  been  lessened  by  suturing  to  the 
size  of  the  lumen  of  the  duodenum,  the  two  viscera  are  anastomosed  by  simple 
suturing,  end  to  end.  This  operation  is  not  so  desirable  as  either  of  the 
preceding. 

Preparation — Position. — As  for  Gastrotomy. 

Landmarks. — Right  rectus  muscle. 

Incision. — Vertical,  in  the  outer  third  of  the  right  rectus,  beginning  a 
short  distance  beneath  the  costal  arch  and  extending  downward  to  or  below 
the  level  of  the  umbilicus.  Various  incisions  have  been  used; — A  median 
incision,  which  does  not  so  readily  expose  the  parts; — An  obliquely  transverse 
incision  10  to  12.5  cm.  (4  to  5  inches)  long,  having  one-third  of  its  length  to 
the  left,  and  two-thirds  to  the  right  of  the  linea  alba,  and  crossing  that  line 
obliquely  downward  from  left  to  right,  between  the  xiphoid  cartilage  and 
umbilicus,  Billroth's  original  line,  which  necessitates  much  transverse  division 
of  muscle,  though  better  exposing  the  parts. 

Operation. — (1)  Expose  the  peritoneal  cavity  in  the  usual  manner  of 
abdominal  section  by  vertical  incision  through  the  outer  third  of  the  rectus 
muscle — control  hemorrhage  and  retract  the  margins  of  the  wound.  (2) 
The  site  of  the  operation  is  carefully  located  and  packed  off  with  gauze — 
slight  adhesions  being  broken  down  by  blunt  dissection — and  the  parts  brought 
as  well  forward  into  the  wound  as  possible.  (3)  The  lesser  and  greater  omenta 
are  ligated  off  along  the  area  corresponding  with  the  parts  to  be  removed — 
by  gut-ligature  carried  by  an  aneurism-needle,  or  Cleveland  ligature-carrier — 
along  the  upper  and  lower  borders  of  the  pyloric  end  of  the  stomach  and  duo- 


OOS  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

denum.  (4)  As  soon  as  freed  from  omental  attachment,  the  contiguous  por- 
tions of  the  stomach  and  intestine  are  to  be  packed  off  with  especial  care  from 
the  general  cavity  and  adjacent  structures  with  gauze.  Two  clamps  are  now 
placed  upon  the  duodenum,  parallel  with  and  about  2  cm.  (f  inches)  apart,  on 


Fig.  73S.— Pylorectomv  (Billroth's  Operation)  : — I.  A,  Malignant  pylorus  excised;  B,  Free 
end  of  duodenum;  C,  Portion  of  stomach-opening  in  excess  being  closed  by  interrupted  sutures  of  all 
coats,  followed  by  interrupted  Lemberts  of  the  outer  coats  ;  D,  Remaining  portion  of  stomach-opening 
to  be  sutured  to  the  duodenum. 


either  side  of  the  line  to  be  incised.  Two  are  similarly  placed  upon  the  stomach 
about  2.5  cm.  (1  inch)  apart.  The  lines  of  incision  are  so  calculated  that  they 
will  be  parallel.  (5)  The  duodenum  is  first  divided  between  the  clamps,  with 
scissors.  All  leakage  is  carefully  caught  and  the  interior  of  the  free  end  of  the 
gut  cleaned.  The  stomach  is  then  similarly  dealt  with.  The  excised  portion 
is  now  removed.  The  free  ends  of  the  stomach  and  intestine  are  brought  well 
forward  and  abundant  packing  placed  posteriorly.  The  clamps  are  retained 
as  convenient  means  of  aiding  in  the  manipulation  of  the  parts.  (6)  In  order 
to  provide  a  lumen  of  stomach  at  the  pyloric  end  which  will  correspond  with 
that  of  the  duodenum,  all  that  portion  of  the  cut  edges  of  the  stomach  in  excess 
of  the  required  lumen  is  closed.  This  is  done  by  a  continuous  overhand  silk 
suture  including  all  the  coats  of  both  edges  of  the  stomach.  It  begins  at  the 
lesser  curvature  and  is  carried  downward  the  required  distance — leaving  un- 
sutured,  next  to  the  greater  curvature,  a  lumen  of  stomach  which  will  corre- 
spond in  size  with  the  opposite  lumen  of  duodenum.  A  line  of  continuous 
or  interrupted  chromic  gut  Lembert  sutures  immediately  buries  in  this  first 
line  of  silk  suturing,  passing  through  the  serous  and  muscular  coats  of  the 
stomach,  on  either  side  of  the  first  suture  line  and  thus  invaginating  it.  (Fig. 
738.)  (7)  The  free  edges  of  the  openings  in  the  duodenum  and  stomach  are 
then  approximated  by  an  assistant  who  holds  them  in  apposition  by  means  of 
the  clamps.  By  means  of  a  continuous  or  interrupted  silk  suture  including  all 
the  coats  of  intestine  and  stomach,  the  duodenum  is  sutured  to  the  remaining 
opening  in  the  stomach — the  parts  being  so  turned,  as  the  suturing  progresses, 
as  to  present  the  entire  circumference.  This  line  of  sutures  is  chiefly  for 
strength.     (8)  The  line  of  continuous  circular  suturing  just  applied  is  im- 


PARTIAL    GASTRECTOMY. 


999 


mediately  followed  by  a  second  tier  of  interrupted  silk  Lembert  sutures  passing 
through  serous  and  muscular  coats  of  both  viscera,  thereby  burying  in  by  in- 
vagination the  first  tier.  This  second  line  of  suturing  is  chiefly  for  occlusion. 
(Fig.   730.)     (9)  The  clamps  being  relaxed  and  all  parts  being  thoroughly 


Fig. 739. — Pylorectomy  (Billroth"s  Operation)  :— II.  A,  Upper  portion  of  stomach-opening 
sutured  ;  B,  Interrupted  sutures  of  all  coats  uniting  duodenum  to  lower  portion  of  stomach-opening  ; 
C,  Interrupted  Lemberts  uniting  outer  coats.     The  greater  curvature  of  stomach  is  here  restored. 

cleansed,  the  lesser  and  greater  omenta,  which  had  been  previously  ligated  and 
detached,  are  now  resutured  with  gut  to  the  upper  and  lower  borders  of  the 
attached  stomach  and  duodenum.  (10)  The  parts  are  then  dropped  back 
into  place  and  the  abdomen  closed. 

Comment. — (1)  The  above  is  the  description  of  Billroth's  operation  in  the 
main — the  line  of  incision,  the  manipulation  of  the  parts,  and  especially  the 
method  of  suturing  being  simplified.  (2)  If  indicated,  after  excision  of  the 
pyloric  end  of  the  stomach,  the  large  opening  may  be  closed  to  fit  the  duodenum 
by  being  sutured  partly  from  the  lesser  curvature  downward  and  partly  from 
the  greater  curvature  upward.  Again,  the  junction  may  be  made  continuous 
with  the  lesser  curvature — though  the  stomach  is  better  emptied  when  made 
continuous  with  the  greater  curvature.  (3)  Murphy's  button  may  be  used  in 
accomplishing  the  approximation.  Still  other  forms  of  operation  are  the 
following; — Pylorectomy  with  posterior  gastrojejunostomy  by  means  of 
Murphy's  button: — Posterior  gastrojejunostomy  at  first  sitting,  followed 
by  pylorectomy  at  second  sitting  (Czerny). 


PARTIAL  GASTRECTOMY 

(OF    THE    MEDIAN    PORTION). 

Description. — The  median  portion  of  the  stomach  is  sometimes  excised 
for  stricture  or  malignancy.  The  free  edges  of  remaining  portions  are  then 
united  end-to-end.  Any  excess  in  size,  upon  the  part  of  the  cardiac  end, 
is  provided  for  by  special  suturing. 

Preparation — Position — Landmarks — Incision. — As  for  gastrotomy  by 
median  incision. 


IOOO  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

Operation. — The  stomach  is  brought  into  the  held  as  in  the  last  operation. 
The  arteries  along  the  upper  and  lower  curvatures  of  the  stomach  are  ligated 
(Fig.  740) — the  gastric  artery  along  the  lesser  and  the  epiploic  arteries  along 
the  greater  curvature — so  planning  the  double  ligatures  as  to  leave  satisfactory 
blood  supply  to  the  severed  edges.  The  gastro-hepatic  and  gastro-colic 
omenta  are  ligated  off  in  sections,  corresponding  with  the  portion  of  the 
stomach  to  be  excised,  after  which  the  lesser  peritoneal  cavity  and  the  adjacent 
parts  are  protected  with  gauze  packing.  Double  clamps  are  now  placed  on 
each  side  of  the  area  to  be  excised,  about  2.5  cm.  (1  inch)  apart,  and  allowing 
ample  margin  of  healthy  tissue  between  the  growth  and  themselves.  The 
involved  portion  of  stomach  is  now  cut  away  with  scissors  passing  through 


Fig.  740. — Partial  Gastrectomy  (of  the  Median  Portion):— I. — The  cardiac  and 
pyloric  aspects  of  the  stomach  are  doubly  clamped,  ready  to  be  divided.  The  gastro-hepatic 
and  gastro-colic  omenta  are  ligated  and  divided.  The  arteries  of  the  lesser  and  greater  curva- 
tures are  doubly  ligated. 

all  the  coats  and  travelling  between  each  set  of  clamps — especial  care  being 
used  to  guard  the  field  from  the  inevitable  leak  which  follows  opening  up  the 
mucous  cavity  of  the  organ.  The  free  edges  of  the  incised  portions  are  now 
approximated  by  means  of  the  clamps,  and  held  in  a  convenient  position  for 
suturing  (Fig.  741).  A  continuous  silk  or  linen  overhand  suture  of  all  the 
coats  is  first  made,  and  applied  while  the  clamps  are  tilted  away  from  the 
suture-line,  knotting  the  suture  at  intervals,  to  avoid  the  purse-string  effect. 
Outside  of  these  a  second  row  of  suturing  is  placed,  of  the  seromuscular  type, 
carried  continuously  or  interruptedly,  and  consisting  of  silk  or  linen.  Where 
the  calibers  of  the  two  portions  are  about  alike,  no  great  difficulty  is  experienced 
in  adjusting  them  to  each  other.     Where  a  disparity  exists  (the  cardiac  end 


TOTAL    GASTRECTOMY, 


IOOI 


usually  being  larger  than  the  pyloric  end)  the  edges  of  the  excess  caliber  are 
made  to  overlap  on  the  line  of  the  greater  curvature  of  the  stomach — the 
smaller  caliber  being  applied  to  and  sutured  into  as  much  of  the  larger  caliber 
as  is  indicated.     The  omental  incisions  are  sutured  with  catgut. 

Comment. — The  greater  curvature  may  be  restored  (insuring  a  freer 
emptying  of  the  stomach,  probably,  by  uniting  the  parts  in  the  same  manner 
as  in  Billroth's  pylorectomy  (page  997,  and  Figs.  73S  and  739).  It  is  well 
to  leave  as  much  of  the  cardiac  end  of  the  stomach  as  possible — to  increase 


Fig.  741. — Partial  Gastrectomy  (of  the  Median  Portion): — II. — The  median  excised 
portion  of  the  stomach  has  been  removed  and  the  incised  edges  of  the  cardiac  and  pyloric  aspects 
are  approximated  by  means  of  the  clamps.  The  posterior  layer  cf  the  seromuscular  suture  has 
been  placed — its  free  end  showing.  The  posterior  layer  of  the  through-and-through  suture  has 
also  been  placed — and  one  end  left  free.  The  redundant  portion  of  the  cardiac  aspect  of  the 
stomach  is  sutured  separately,  by  through-and-through  and  seromuscular  sutures,  until  its 
caliber  corresponds  with  that  of  the  pyloric  aspect. 

the  ease  of  approximating  the  duodenum — excess  of  cardiac  end  being  sutured 
down  to  fit  the  duodenum,  as  in  gastro-duodenostomy.  (1)  Displacement 
of  the  left  lobe  of  the  liver,  temporarily,  aids  in  giving  room.  (2)  As  the 
esophagus  is  more  brittle  than  the  stomach,  it  is  well,  where  possible,  to  leave 
enough  of  the  latter  for  suturing  to  the  duodenum.  (3)  Brigham,  not  having 
sufficient  room  for  simple  suturing,  united  duodenum  and  esophagus  with 
No.  3  Murphy  button,  without  any  subsequent  suturing.  (4)  Delatour  used 
temporary  abdominal  drainage. 


TOTAL  GASTRECTOMY. 

Description. — Consists  in  the  total  removal  of  the  stomach.     Following 
the  removal  of  the  stomach,  anastomosis'is  at  once  made  between  the  esophagus 


1002  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

and  some  part  of  the  small  intestine.  When  circumstances  permit  of  suffi- 
ciently easy  approximation  of  the  cut  end  of  the  duodenum  to  the  cut  end  of  the 
esophagus,  esophago-duodenostomy  is  performed.  Where  this  is  impossible, 
the  free  end  of  the  duodenum  is  closed,  and  a  loop  of  the  jejunum  is  anasto- 
mosed with  the  esophagus,  constituting  esophago-jejunostomy. 

Preparation — Position — Landmarks. — As  for  Gastrotomy  by  median 
incision. 

Incision. — In  the  median  line,  from  the  xiphoid  cartilage  to  or  below  the 
umbilicus. 

Operation. — (£)  Expose  the  peritoneal  cavity — control  hemorrhage — re- 
tract the  wound.  (2)  The  stomach  and  duodenum  are  brought  to  view — ad- 
hesions, if  any,  being  separated  by  blunt  dissection,  or  divided  between  double 
ligatures — and  these  viscera  are  then  brought  as  well  forward  as  possible.  (3) 
The  lesser  (gastro-hepatic)  omentum  is  ligated  off  with  silk  near  the  duo- 
denum and  lesser  curvature  of  the  stomach — beginning  at  the  duodenum  and 
extending  toward  the  esophagus.  When  8  to  10  cm.  (3  or  4  inches)  have  been 
thus  ligated,  the  greater  omentum  is  similarly  ligated  off,  beginning  at  the 
duodenum  and  following  along  the  greater  curvature.  After  8  to  10  cm.  (3 
or  4  inches)  of  this  omentum  is  ligated,  the  ligaturing  is  interrupted  here  and 
resumed  along  the  lesser  omentum — and  thus  alternating  upon  the  two  omenta, 
manipulating  and  rotating  the  stomach  as  indicated,  both  omenta  are  entirely 
tied  off.  (4)  The  duodenum  is  now*  clamped  off  with  two  parallel  clamps  and 
divided  between  them — the  adjacent  regions  having  been  packed  off  with 
gauze.  Both  free  ends  are  also  well  protected  with  gauze  (the  duodenum  being 
well  cleansed) — the  clamps  being  left  in  situ.  (5)  The  gastro-splenic  omen- 
tum is  ligated  off  and  divided — and  also  the  gastro-phrenic  omentum.  (6) 
While  some  tension  is  being  exercised  upon  the  stomach  to  draw  the  esophagus 
downward,  a  clamp  is  placed  upon  the  esophagus  as  high  up  as  possible.  An- 
other esophageal  clamp  is  placed  just  below  the  site  at  which  division  is  to  be 
made.  The  esophageal  end  of  the  stomach  is  then  divided  between  the  clamps, 
the  freed  ends  being  treated  as  above  described,  the  esophageal  end  being 
particularly  cleansed  and  protected.  (7)  An  attempt  is  then  made  to  ap- 
proximate the  duodenum  and  esophagus,  and  if  the  ends  come  together 
without  too  much  tension,  they  are  at  once  united.  If  the  esophageal  end  of 
the  stomach  (especially  when  much  of  the  cardiac  end  is  left)  be  too  large,  it  is 
sutured  down  to  fit  the  duodenum  (as  described  under  Pylorectomy).  In 
Schlatter's  operation,  the  duodenum  was  sutured  to  the  esophagus  in  the  fol- 
lowing manner; — the  mucous  membrane  of  the  esophagus  was  united  to  that  of 
the  duodenum  by  continuous  silk  suture; — the  serous  and  muscular  coats  of 
each  viscus  were  then  united  by  continuous  suture;  and  both  of  these  were 
followed  by  a  row  of  Lembert  sutures.  The  clamps  are  then  removed.  (8) 
If  the  duodenum  cannot  be  made  to  easily  reach  the  esophagus,  the  duodenum 
is  closed  at  its  free  end  and  the  nearest  coil  of  jejunum  is  anastomosed  to  the 
esophagus  (esophago-jejunostomy) — followed,  if  thought  best,  by  an  anasto- 
mosis of  the  two  coils  of  jejunum  lower  down  (jejuno-jejunostomy).  (9) 
The  omenta  are  sutured  into  as  nearly  a  normal  position  as  possible.  (10) 
The  viscera  are  replaced  and  the  abdomen  closed. 

OPERATION  FOR  GASTRIC  ULCER. 

Description. — The  nature  of  the  operation  will  depend  upon  the  nature 
and  position  of  the  ulcer.  According  to  Welch,  the  most  frequent  sites  of 
gastric  ulcers  are  as  follows; — Upon  the  lesser  curvature,  36  per  cent.;  posterior 
wall,  29  per  cent.;  pylorus,  12  per  cent.;  anterior  stomach-wall,  8  per  cent.; 
cardiac  end,  6  per  cent.;   fundus,  3  per  cent.;   greater  curvature,  3  per  cent. 


OPERATION    FOR    GASTRIC    ULCER. 


1003 


According  to  Brinton,  2  per  cent,  of  those  which  occur  on  the  posterior  wall 
perforate — 85  per  cent,  of  those  on  the  anterior  wall — 40  per  cent,  of  those  on 
the  cardia — and  10  per  cent,  of  those  at  the  pylorus. 

Preparation — Position — Landmarks — Incision. — As  for  Gastrotomy  by 
median  abdominal  section. 

Operation  for  Perforated  Gastric  Ulcer. — Having  exposed  and  brought 
into  the  field,  by  median  abdominal  section,  the  stomach,  and  located  the 
ulcer,  its  treatment  will  depend  upon  the  local  conditions  found; — (a)  "Where 
the  walls  are  pliable  and  the  ulcer  small; — Invert  the  edges  of  the  ulcer  with 
interrupted  Lembert  or  Halsted  sutures,  without  excision  of  its  margins,  (b) 
"Where  the  gastric  walls  are  rigid  and  thick: — Excise  the  ulcer  elliptically — 
unite  the  mucous  membrane  bv  continuous  silk  suture — then  the  serous  and 


Fig.  742. — Excision  or  Gastric  Ulcer: — I. — The  lesser  curvature  of  the  stomach  and 
the  area  of  the  ulcer  clamped  off  by  two  clamps  compressing  anterior  and  posterior  stomach- 
walls  in  a  V-shaped  fashion. 

muscular  coats  with  interrupted  silk  sutures,  (c)  "Where  the  edges  of  the 
ulcer  cannot  be  brought  together: — One  of  the  following  methods  may  be  used; 
Patch  with  omental  graft;  Plug  with  omentum,  sewing  it  in;  Suture  to  a  neigh- 
boring structure;  Suture  to  the  abdominal  wound  and  drain;  Perform  gastro- 
enterostomy, uniting  the  incised  intestine  with  the  ulcerated  stomach-opening 
(after  excising  the  edges  of  the  latter) ;  Drain  the  ulcer  through  the  abdominal 
wound,  packing  with  gauze  to  make  sinus  between  abdominal  wound  and  ulcer. 
(d)  Where  the  question  of  possible  malignancy  may  be  associated  with  a 
gastric  ulcer,  the  entire  suspicious  area  should  be  widely  excised.  In  those 
cases  where  the  ulcer  is  situated  upon  the  lesser  curvature,  which  is  their 
most  usual  site,  the  area  is  excised  by  a  V-shaped  incision,  with  the  limbs  of 
the  V  abutting  upon  the  lesser  curvature  (Fig.  742).     The  gastric  artery  is 


ioo4 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


doubly  ligated,  and  divided  and  the  necessary  extent  of  gastro-hepatic  omentum 
is  tied  off  in  sections.  The  site  is  controlled  by  two  clamps  placed  in  a  V-shaped 
fashion — their  tips  meeting  at  the  apex  of  the  V-  The  area  is  excised  with 
scissors,  leaving  a  free  margin.  Owing  to  the  inaccessibility  of  the  posterior 
margins  these  arc  besl  sutured  with  Connell  stitches  (page  864,  Fig.  614). 
These  may  be  placed  far  enough  back  from  the  free  edges  as  to  leave  room 


*1  Swo' 


»% 


Fig.  743. — Excision  of  Gastric  Ulcer:— II.— The  margins  of  the  stomach,  left  by  the 
excision,  approximated  by  clamps — with  the  first  tier  of  suturing  (through-and-through)  shown. 

for  a  continuous  overhand  stitch  of  all  the  layers  of  both  margins  placed 
within  the  outlying  interrupted  through-and-through  Connell  stitches.  The 
anterior  edges  of  the  wound  are  closed,  first  by  an  overhand  continuous 
stitch  of  all  the  layers  (Fig.  743),  followed  by  a  continuous  seromuscular 
suture. 

Comment. — Non-perforating  ulcer  may  also  be  treated  by  excision  and 
gastrorrhaphy.    Also  see  Enterorrhaphy  for  Wounds  of  the  Intestine,  page  848. 


VII.  THE  LIVER. 


SURGICAL  ANATOMY. 

Description. — Presents  three  surfaces  (superior,  or  phrenic; — inferior,  or 
visceral; — posterior) : — two  extremities  (right  and  left) : — one  border  (anterior). 
Its  average  measurements  are  transversely,  28  cm.  (11  inches) — antero-pos- 
teriorly,  20  cm.  (8  inches) — vertically,  6  cm.  (2^  inches). 

Position. — Occupies  parts  of  right  hypochondriac,  epigastric,  and  left 
hypochondriac  regions; — situated  below  diaphragm — above  stomach,  duo- 
denum, transverse  colon,  and  small  intestine — and  in  front  of  right  false  ribs 
(tenth,  eleventh,  and  twelfth). 


SURGICAL  ANATOMY.  1005 

Fissures. — Left  longitudinal  fissure: — Anterior  part  forms  umbilical 
fissure  (for  umbilical  vein  in  fetus,  and  for  its  remains,  the  round  ligament,  in 
adult) ; — Posterior  part  forms  fissure  of  ductus  venosus.  Right  longitudinal 
fissure  : — Anterior  part,  forms  fossa  for  gall-bladder; — Posterior  part,  fossa  for 
vena  cava.  Transverse  fissure  : — Transmits  hepatic  artery,  portal  vein, 
hepatic  duct,  nerves,  lymphatics,  and  connective  tissue. 

Lobes. — Right,  Left,  Quadrate,  Caudate,  Spigelian. 

Ligaments  and  Fixations  of  Liver. — (i)  Coronary: — from  posterior 
surface  of  liver  to  diaphragm.  Formed  of  two  layers  of  reflected  parietal 
peritoneum.  (2)  Right  lateral  ligament : — from  right  lobe  of  liver  to  back 
of  diaphragm.  Lateral  continuation  of  coronary  ligament.  (3)  Left  lateral 
ligament : — from  left  lobe  of  liver  to  diaphragm  anterior  to  esophagus.  Lat- 
eral continuation  of  coronary  ligament.  Note: — Middle  portion  of  coronary 
ligament  has  its  anterior  layer  furnished  by  greater  peritoneal  sac,  its  posterior 
layer  by  lesser  sac;  Right  lateral  ligament  has  both  layers  from  greater  sac; 
Left  lateral  ligament  has  both  layers  from  greater  sac.  (4)  Longitudinal 
(broad  or  suspensory)  ligament : — Passes  antero-posteriorly  upon  upper 
and  anterior  portion  of  liver.  Posteriorly  and  superiorly  it  is  connected  with 
the  coronary  ligament.  Anteriorly  and  superiorly  it  is  connected  with  the 
posterior  sheath  of  the  right  rectus  muscle,  up  to  the  umbilicus — and  thence 
to  under  surface  of  diaphragm,  diverging  to  either  side.  Free  anterior  margin 
extends  from  interlobular  notch  to  transverse  fissure — containing  round  liga- 
ment (remains  of  fetal  umbilical  vein).  Inferiorly  it  extends  along  the  superior 
surface  of  the  liver,  from  before  backward.  Formed  by  portions  of  peritoneum 
covering  superior  surface  of  liver — one  layer  passing  over  left  lobe,  the  other 
over  right,  and  meeting  at  longitudinal  ligament.  (5)  Round  ligament : — 
Remains  of  umbilical  vein — in  free  margin  of  longitudinal  ligament,  extending 
from  left  longitudinal  fissure  to  umbilicus.  (6)  Lesser  omentum  (Gastro- 
hepatic  omentum)  : — may  be  considered  a  ligament  of  liver,  consisting  of 
following  parts; — (a)  Lig.  Hepato-gastricum — from  borders  of  transverse 
fissure  to  upper  curvature  of  stomach; — (b)  Lig.  Hepato-duodenale — that  part 
embracing  superior  curvature  of  duodenum,  and  enclosing  following  structures; 
common  bile-duct,  portal  vein,  hepatic  artery,  lymphatics  and  nerves; — (c) 
Lig.  Hepato-colicum — that  part  passing  over  duodenum  to  transverse  colon; — 
(d)  Lig.  Hepato-renale — that  part  from  inferior  surface  of  right  lobe  of  liver 
(near  gall-bladder  and  vena  cava,  and  posterior  to  foramen  of  Winslow),  to 
upper  surface  of  right  kidney; — (e)  Lig.  Cystico-duodenale — that  part  from 
gall-bladder  to  duodenum.  Xotc: — Fusion  of  upper  surface  of  liver  to  dia- 
phragm forms  a  strong  fixation  of  liver. 

Peritoneal  Covering. — Only  portions  of  liver  uncovered  by  peritoneum 
are;  transverse  fissure,  fossa  of  gall-bladder,  and  postero-superior  aspect  of 
right  lobe  (where  fused  to  diaphragm). 

Relations.— (1)  Antero-posteriorly: — diaphragm  (whole  of  right  arch 
and  part  of  left — which  separates  liver  from  right  and  left  lungs  and  peri- 
cardium);  abdominal  wall;  six  or  seven  lower  right  ribs  (seventh  to  eleventh, 
according  to  Morris) ;  fifth  to  ninth  right  costal  cartilages  (sixth  to  ninth,  ac- 
cording to  Morris).  (2)  Inferiorly: — stomach  (cardiac  and  pyloric  ends, 
lesser  curvature,  and  part  of  anterior  surface) ;  duodenum  (superior  curve  and 
descending  parts);  gall-bladder  and  cystic  duct;  portal  vessels;  right  kidney 
and  capsule;  colon  (hepatic  flexion).  (3)  Posteriorly: — diaphragm  and 
crura;  tenth  and  eleventh  dorsal  vertebrae;  tenth  and  eleventh  ribs;  esophagus; 
aorta;  vena  cava;  right  suprarenal  capsule;  thoracic  duct. 

Vessels  of  Liver. — Hepatic  artery   (of  cceliac  axis),  artery  of  supply; 


1006  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Portal  vein,  bringing  blood  from  stomach,  intestines,  pancreas,  and  spleen; 
Hepatic  veins,  emptying  blood  of  liver  into  vena  cava;  Hepatic  duct,  formed  at 
transverse  fissure. 

Lymphatics. — Deep  set;  accompany  portal  vein,  hepatic  artery,  and  duct 
and  join  superficial  set.  Superficial  set;  empty  into  (a)  mediastinal  glands; 
(b)  sometimes  into  thoracic  duct;  (c)  glands  of  small  omentum;  (d)  lumbar 
glands;  (e)  glands  of  esophagus  and  lesser  curvature  of  stomach. 

Nerves. — From  left  pneumogastric  and  cceliac  plexus. 

Structures  at  Transverse  Fissure. — (a)  Hepatic  artery,  portal  vein,  and 
numerous  nerves  enter: — (b)  Hepatic  duct  and  some  lymphatics  leave: — Note: 
the  hepatic  veins  do  not  emerge  here,  but  pass  backward  into  the  vena  cava. 

Order  of  Structures  at  Transverse  Fissure. — From  before  backward; 
hepatic  duct,  hepatic  artery,  portal  vein. 

Order  of  Structures  in  Gastro-hepatic  Omentum. — Common  bile-duct, 
to  right;  hepatic  artery,  to  left;  portal  vein,  behind  and  between  other  two. 


SURFACE  FORM  AND  LANDMARKS. 

The  liver  occupies  parts  of  right  hypochondriac,  epigastric,  and  left  hypo- 
chondriac regions — filling  all  of  right  and  part  of  left  diaphragmatic  arches — 
the  diaphragm  forming  dome  of  cavity  in  which  liver  rests  and  passing  down 
laterally  between  ribs  and  liver. 

Upper  limit  of  right  lobe — is  along  line  from  right  fifth  chondro-sternal 
articulation  extending  horizontally  outward  to  a  point  about  2.5  cm.  (1  inch) 
below  the  right  nipple — thence  downward  to  seventh  rib  at  lateral  aspect  of 
chest. 

Upper  limit  of  left  lobe — along  line  from  right  fifth  chondro-sternal  artic- 
ulation extending  across  sternum  slightly  downward  to  a  point  about  5  cm. 
(2  inches)  to  left  of  gladiolus,  on  a  level  with  left  sixth  costal  cartilage. 

Lower  limit  of  right  margin — corresponds  with  line  passing  from  behind 
forward  about  1.2  cm.  (J  inch)  below  the  lower  margin  of  the  right  thorax  to 
right  ninth  costal  cartilage — thence  obliquely  across  the  subcostal  angle  to 
left  eighth  costal  cartilage. 

Lower  limit  of  left  margin — represented  by  a  curved  line,  with  outward  con- 
vexity, from  left  eighth  costal  cartilage  to  a  point  5  cm.  (2  inches)  to  left  of 
gladiolus  and  on  a  level  with  left  sixth  costal  cartilage. 

Lower  border  of  liver  in  middle  line — about  half-way  between  xiphoid 
cartilage  and  umbilicus. 

Convex  surface  of  liver,  on  right  side — corresponds  with  seventh  to  eleventh 
ribs,  inclusive — and,  in  front,  with  ensiform  cartilage  and  sixth  to  ninth  costal 
cartilages,  inclusive. 

Heart  descends  to  left  fifth  interspace.  Right  lung  descends  to  superior 
margin  of  sixth  rib,  in  the  nipple-line. 

Note. — Authorities  differ  considerably  upon  the  relations  of  the  liver  to  the 
thoracic  wall. 

GENERAL  SURGICAL  CONSIDERATIONS. 

The  liver  may  be  approached  either  through  the  abdominal  cavity,  the 
more  usual  route — constituting  a  transperitoneal  operation; — or  through  the 
thoracic  cavity — in  which  latter  case  the  operation  may  be  either  transpleural 
or  subpleural,  while,  at  the  same  time,  intrathoracic. 

While  desirable  that  all  incisions  should  be  in  intramuscular  cleavage  lines 


THE  LIVER— GENERAL  SURGICAL  CONSIDERATIONS.  1007 

as  far  as  possible,  yet,  as  hernia  of  the  upper  abdominal  wall  is  less  frequent 
than  of  the  lower,  incisions  about  the  liver  and  gall-bladder,  therefore,  often 
violate  this  desirable  rule. 

The  two  most  general  methods  of  transperitoneal  approach  are  the  follow- 
ing:— (a)  Bv  incision  parallel  with  and  about  1.2  to  2  cm.  (h  to  f  inches)  below 
the  right  costal  arch,  with  its  center  over  the  indicated  site; — (b)  By  incision 
in  the  right  linea  semilunaris  (which  runs  down  from  the  ninth  rib  to  the  pubic 
spine) — or  further  outward,  from  the  tenth  costal  cartilage — passing  from  the 
lower  border  of  the  right  costal  arch  as  far  down  as  necessary. 

Oblique  subcostal  incision: — gives  better  approach  to  the  subhepatic  space 
— and  especially  to  the  right  end  of  the  liver.  It  may  be  extended  upward  or 
downward  obliquelv,  parallel  with  the  costal  arch.  It  will  cross  the  external 
oblique  and  transversalis  at  a  right  angle,  and  about  coincide  with  the  fibers 
of  the  internal  oblique.  It  affords  a  somewhat  better  chance  to  preserve  some 
of  the  abdominal  nerves. 

Anterior  vertical  incision: — gives  best  access  to  gall-bladder  and  ducts — 
together  with  a  very  good  exposure  of  the  liver.  A  vertical  incision  in  the  right 
linea  semilunaris — or  more  externally,  from  the  tenth  costal  cartilage — can  be 
increased  directlv  downward  to  give  room.  Its  lower  end  may  also  be  ex- 
tended transversely,  or  obliquely,  toward  the  median  line — giving  an  angular 
flap.  A  continuation  of  the  original  incision  gives  a  very  extensive  approach 
to  the  abdominal  cavity — and  even  the  pelvis.  The  simple  vertical  incision 
will  cross  the  external  and  internal  oblique  muscles  obliquely,  and  the  trans- 
versalis at  a  right  angle — and  will  cross  the  abdominal  nerves  at  a  right  angle. 

In  operating  to  expose  the  liver,  it  will  often  be  found,  when  the  liver  is 
reached,  that  its  serous  surface  is  adherent  to  the  parietal  peritoneum — and, 
therefore,  that  its  substance  can  be  entered  without  involving  the  general 
peritoneal  cavity. 

As  adjuncts  to  the  satisfactory  exposure  of  these  sites,  the  following  man- 
oeuvres are  helpful: — (a)  the  reversed  Trendelenburg  position — (b)  firm  up- 
ward traction  upon  the  liver  and  right  costal  arch — (c)  passage  of  the  left  index 
through  the  foramen  of  Winslow  and  the  left  thumb  over  the  lesser  omentum, 
thus  embracing  that  structure  between  the  digits. 

When  the  round  ligament  is  encountered  descending  to  the  umbilicus  and 
is  severed,  it  should  be  sutured  at  the  end  of  the  operation. 

Standing,  the  lower  border  of  the  liver  is  about  1.2  to  2.3  cm.  (\  to  \  inch) 
below  the  costal  cartilages; — reclining,  the  lower  border  recedes  until  about 
2.5  cm.  (1  inch)  above  the  lower  costal  cartilages.  This  change  in  position, 
and  change  during  respiration,  must,  therefore,  be  allowed  for  in  suturing  the 
liver  to  the  parietes. 

Anteriorly,  the  gastro-diaphragmatic  sinus  (between  the  lower  edge  of  the 
pleura  and  the  diaphragm)  makes  it  possible  to  reach  and  pierce  the  diaphragm 
more  easily  and  without  involving  the  pleura,  in  operating  intrathoracically, — 
therefore  the  subpleural  operation  is  more  generally  done  anteriorly  or  antero- 
laterally.  This  sinus  is  absent  posteriorly,  and  an  incision  here  would  pass 
through  the  pleura  (if  that  structure  were  not  raised  from  the  course  of  in- 
cision by  blunt  separation) — hence  the  posterior  operation  is  generally  trans- 
pleural. 

In  the  transpleural  operation,  where  the  two  layers  of  pleura?  cannot  be 
sutured  /';/  situ — the  parietal  pleura  is  incised — its  edges  are  grasped  with  for- 
ceps, or  traction-sutures  (to  keep  them  from  receding  out  of  the  way) — then 
the  visceral  peritoneum  is  incised — and  the  edges  of  the  parietal  and  visceral 
peritoneum  are  whipped  together  by  an  overhand  stitch. 


iooS 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


INSTRUMENTS  USED  IN  OPERATIONS  UPON  LIVER  AND 
GALL-BLADDER. 

Scalpels;  bistouries;  scissors,  curved  and  straight;  forceps,  dissecting  and 
toothed;  artery-clamp  forceps;  clamp-forceps  for  adhesions;  retractors,  various; 
broad  spatulae;  grooved  director;  tenaculum;  costotome;  blunt  dissector;  in- 
testinal clamps;  forceps  for  removing  calculi;  forceps  for  crushing  calculi; 
Halsted's  hammer;  lithotomy  scoop  (small) ;  lithotomy  forceps  (small) ;  needles 
for  needling  stones;  cholelithotomy  forceps  and  scoop;  sponge-holders;  gauze 
pads  with  tails;  intestinal  and  other  needles;  silk,  gut,  and  silkworm-gut;  drain- 
age-tubing, glass-drains,  gauze-drains;  exploratory  cannula  and  trocar,  or 
exploratory  needle;  intestinal  instruments;  Murphy  button  (special) ;  probe. 


EXPLORATORY  PUNCTURE  OF  LIVER. 

Description. — Resorted  to  for  withdrawal  of  fluid  for  diagnostic  pur- 
poses— generally  pus  or  hydatid.  An  operation  involving  some  danger.  The 
site  of  puncture  is  generally  determined  by  some  physical  sign,  such  as  tumor 
or  other  indication — and  the  puncture  is  made  by  the  safest  and  most  direct 
route  into  the  site. 

Preparation. — Site  asepticized. 

Position. — Such  as  to  best  expose  the  region. 

Landmarks. — Anatomical  outline  of  liver;  physical  signs. 


Fig.  744.— Relative  Relation  of  Abdominal  Viscera  on  Level  with  Lowest  Part  of 
Costal  Arch  (5  cm.,  or  2  inches,  above  umbilicus  ;  on  a  level  with  second  lumbar  vertebra)  : — A, 
Stomach;  B,  Liver;  C,  Spleen;  D,  Pancreas;  E,  E,  Kidneys;  F,  Transverse  colon.  (Modified  from 
Riidinger.) 


Operation. — The  exploration  is  usually  made  with  the  needle  of  an  ex- 
ploratory syringe.  The  depth  of  puncture  is  to  be  guarded  by  the  right  index 
on  the  barrel  of  the  needle — and  to  be  largely  determined  in  advance  by  the 
estimated  thickness  of  the  abdominal  or  thoracic  wall  and  intervening  liver 
substance  at  the  site  to  be  punctured.  If  no  physical  sign  guiding  to  the  seat 
of  exploration  exist,  puncture  may  be  made  in  several  sites: — (i)  Laterally, 


HEPATOTOMY  IN  GENERAL.  ioog 

in  the  ninth,  tenth,  or  eleventh  intercostal  space,  in  the  mid-axillary  line — the 
most  general  position — and  the  tenth  space  being  the  one  most  frequently 
used; — (2)  Anteriorly,  in  the  subcostal  angle,  over  the  known  region  of  the 
liver  (on  anatomical  grounds) — in  the  space  bounded,  above,  by  the  costal 
arches,  and,  below,  by  a  line  from  the  right  ninth  costal  cartilage  to  the  left 
eighth  costal  cartilage.  In  abnormal  cases,  the  liver  may,  of  course,  be  looked 
for  considerably  lower  than  usual; — (3)  Posteriorly,  in  the  tenth  intercostal 
space  on  the  right.  The  liver  is  in  relation,  posteriorly,  with  the  tenth  and 
eleventh  ribs — and  the  pleura  comes  down  to  the  twelfth,  or  lower — hence  the 
pleura  would  be  pierced  if  not  displaced; — (4)  Transthoracic — preferably 
subpleural — rarely  transpleural.  See  subpleural  and  transpleural  hepatotomy, 
pages  1014  and  1016; — (5)  Below  the  free  border  of  the  ribs — where  the  liver 
dulness  extends  belov; — (6)  At  any  point  from  which  liver  substance  can  be 
reached  with  minimum  risk  and  danger — the  guides  being  anatomical  and 
physical.  Upon  the  withdrawal  of  the  needle  the  puncture-wound  is  generally 
sealed  with  sterile  gauze  and  collodion.     (See  Fig.  744.) 

Comment. — (1)  Wounding  of  the  lung  should  be  avoided — and  also 
piercing  of  the  pleura  or  diaphragm,  unless  specially  indicated.  (2)  The  dia- 
phragm would  be  penetrated  by  any  puncture  above  the  lower  border  of  the 
ribs  or  costal  arch.  The  pleura  would  be  penetrated  by  any  puncture  above 
the  eighth  right  rib  in  the  nipple-line — the  ninth  right  rib  in  the  mid-axillary 
line — (the  tenth  left  rib  in  the  same  line) — and  the  twelfth  right  rib  in  the  pos- 
terior scapular  line.  The  lung  would  be  penetrated  by  any  puncture  above  the 
sixth  costo-sternal  articulation  in  front — the  sixth  right  rib  in  the  nipple-line — 
the  eighth  right  rib  at  the  mid-axillary  line — and  the  right  twelfth  rib  in  the 
scapular  line. 

HEPATOTOMY  IN  GENERAL. 

(1)  Hepatotomy  consists  in  an  incision  of  the  liver — and  is  generally  re- 
sorted to  for  abscess,  hydatid  cyst,  or  other  tumor.  The  site  of  the  incision 
is  usually  determined  in  advance — by  the  presence  of  a  tumor,  or  as  a  result  of 
an  exploratory  puncture.  (2)  The  liver  may  be  exposed  by  the  transperito- 
neal, subpleural,  or  transpleural  routes — and  each  of  these  routes  may  be  fol- 
lowed from  the  anterior,  lateral,  or  posterior  aspects  of  the  thoracico-abdom- 
inal  wall — though  each  method  of  approach  usually  has  a  site  of  preference. 
(3)  The  selection  of  the  site  and  method  of  operation  will  depend  upon  the 
location  of  the  abscess,  or  other  condition — as  to  its  accessibility,  importance 
of  contiguous  organs,  and  possibility  of  drainage.  (4)  The  choice  of  incision 
for  approaching  the  liver  transperitoneally  will  generally  lie  between  the  oblique 
subcostal  and  vertical  subcostal  incisions — each  having  its  advantages  (see 
General  Surgical  Considerations).  It  is  to  be  remembered  that  abscesses, 
hydatids,  tumors,  etc.,  often  project  downward  considerably  below  the  ribs. 
It  is  also  to  be  remembered  that,  after  incision  of  such  sacs  and  emptying  of 
their  contents,  there  is  a  tendency  for  the  portion  of  involved  liver  to  regain  its 
normal  position — and  that,  therefore,  in  calculating  to  suture  such  parts  to  the 
abdominal  wall  for  drainage,  calculation  must  be  made  that  the  stitching  will 
not  draw  the  part  too  far  out  of  its  natural  position.  (5)  Where  no  guide 
exists,  the  anterior  or  antero-lateral  subcostal  transperitoneal  route  is  generally 
chosen,  as,  in  abscess,  pus  is  usually  in  the  more  anterior  part  of  the  right  lobe. 
But  after  exposure  of  the  liver,  if,  by  exploratory  syringe,  or  otherwise,  pus  be 
found  in  a  locality  more  conveniently  reached  and  drained  from  another  ex- 
ternal incision,  the  first  incision  may  be  closed  and  a  second  made  in  the  in- 
64 


ioio  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

dicated  position.  (6)  The  different  incisions  described  in  the  following  pages 
are  given  to  cover  the  various  sites  in  which  the  liver  may  be  exposed — and 
apply  as  much  to  the  exposure  of  the  liver  for  other  purposes  as  for  incision 
of  that  viscus.  In  the  case  of  pus  or  hydatids  the  site  of  operation  will 
generally  have  been  indicated  by  a  preliminary  exploratory  puncture.  (7) 
The  operation  of  exposure  of  the  liver  may  be  done  in  one  or  in  two  stages. 
In  operating  in  one  stage,  the  liver  is  exposed  and  the  organ  is  cut  into  at  once — 
after  safeguarding  the  general  peritoneal  cavity  by  suturing  the  parietal  perito- 
neum to  the  surface  of  the  liver,  or  by  gauze  packing, — or,  in  transthoracic 
operations,  after  protecting  the  pleural  cavity  on  the  same  principles.  In 
operating  in  two  stages,  the  liver  is  first  exposed  and  the  wound  then  packed 
with  gauze  for  two  or  three  days,  until  the  peritoneal  surface  of  the  liver  adheres 
to  the  wound  (the  union  being  reinforced  and  aided  by  sutures,  in  some  cases) 
— and  then  the  organ  is  incised.  (8)  In  operating  transthoracically,  if  the 
pleura  be  wounded,  it  should  be  immediately  sutured — with  a  purse-string 
suture,  if  possible,  thus  drawing  the  edges  together.  (9)  The  subpleural 
method  is  generally  impossible  if  adhesions  exist — but  then,  also,  the  pleural 
cavity  is  apt  to  be  shut  off — so  that  it  is  not  opened  up  even  if  one  passes 
through  its  layers.  (10)  The  posterior  superior  aspect  of  the  right  lobe  of  the 
liver  is  fused  to  the  diaphragm  (there  being  no  peritoneum  here) — hence  the 
diaphragm  may  be  immediately  incised  in  this  locality,  without  waiting  for 
adhesions.  An  abscess  here  would  be  subphrenic  and  extraperitoneal,  (n) 
If  the  transpleural  method  of  approaching  the  liver  be  adopted,  the  same  prin- 
ciples should  be  adhered  to  as  in  operating  transperitoneally — either  suture  the 
two  opposed  pleurae  together  and  incise  through  them  at  once — or  press  the 
two  pleural  surfaces  into  contact  with  gauze  packing  for  two  or  three  days, 
until  adhesions  occur — and  then  incise  through  them.  (12)  It  is  preferable 
to  pass  beneath  the  pleura  rather  than  through  it — and  if  they  must  be  incised 
at  once,  it  is  preferable  to  suture  the  parietal  and  visceral  layers  together  pre- 
paratory to  going  through  them.  The  operation  of  suturing  the  pleura?,  how- 
ever, is  quite  difficult — and  the  suturing  is  apt  to  tear  away — or  allow  of  leak- 
age. (13)  In  cutting  into  the  liver  the  incisions  should  be  made  in  straight 
lines  radiating  from  the  direction  of  the  center  toward  the  periphery.  (14) 
Bleeding  from  deep  incisions  may  be  controlled  by  ligature  en  masse,  with  in- 
terlocked stitches — as  described  under  partial  excision  of  the  liver. 


ANTERIOR  SUBCOSTAL  TRANSPERITONEAL  HEPATOTOMY 

BY  ANTERIOR  OBLIQUE  INCISION  PARALLEL  WITH  COSTAL  ARCH. 

Description. — The  liver  is  exposed  along  the  right  costal  arch,  by  an  in- 
cision which  parallels  that  arch  and  is  placed  1.3  to  2  cm.  (\  to  f  inch)  below 
it.  Resorted  to  where  the  more  central  portion  of  the  anterior  aspect  of  the 
liver  and  gall-bladder  region  is  to  be  exposed. 

Preparation — Position. — As  for  abdominal  section. 

Landmarks. — Right  costal  arch. 

Incision. — Parallel  with  and  from  1.3  to  2  cm.  (\  to  f  inch)  below  the 
right  costal  arch — beginning  near  the  right  linea  semilunaris  (which  runs 
downward  from  the  ninth  rib  to  the  spine  of  the  pubis) — and  extends  as  far 
downward  and  outward,  below  the  costal  arch,  as  considered  necessary — even 
to  the  extent  of  12.5  to  15  cm.  (5  to  6  inches).     (Fig.  699,  F.) 

Operation. — (1)  Incise  skin — fascia — external  oblique  (transversely) — 
internal  oblique  (in  cleavage  line).     Superior  epigastric  artery  may  be  cut  at 


ANTERIOR  SUBCOSTAL  TRANSPERITONEAL  HEPATOTOMV.      ion 

inner  end  of  incision,  if  the  inner  end  reaches  the  outer  border  of  the  rectal 
sheath — if  so,  it  is  ligated.  The  abdominal  nerves  lie  between  the  internal 
oblique  and  transversalis,  crossing  the  line  of  incision,  and  an  attempt  should 
be  made  to  draw  them  aside  if  encountered.  The  transversalis  muscle  is  then 
divided  obliquely  to  its  fibers.  In  long  incisions,  much  division  of  muscles  and 
nerves  must  occur.  In  short  incisions,  much  displacement  in  intramuscular 
cleavage  lines  and  saving  of  nerves  may  be  accomplished  (Fig.  745).  (2) 
Divide  the  transversalis  fascia,  subperitoneal  areolar  tissue,  and  peritoneum  in 
the  original  line — and  retract  the  wound  well.  (3)  Adhesions  are  looked  for 
as  soon  as  the  abdomen  is  opened.  If  encountered,  intervening  between  the 
seat  of  pus,  or  hydatid  fluid,  and  the  abdominal  wall,  they  are  carefully  pre- 
served— that  they  may  serve  as  a  protection  to  the  general  peritoneal  cavity  in 
opening  these  collections- of  fluid.     If  the  object  be  the  exposure  of  the  liver 


Fig. 745.— Exposure  of  Liver,  and  Hepatotomy,  by  Anterior  Oblique  Subcostal  In- 
cision : — A,  External  oblique  ;  B,  Internal  oblique  ;  C,  Transversalis  ;  D,  Outer  border  of  right  rectus 
incised,  showing  superior  epigastric  vessels  between  muscle  and  posterior  sheath;  E,  Transversalis 
fascia  and  subserous  areolar  tissue;  F,  Peritoneum;  G,  Surface  of  liver;  H,  Suture  through  lip 
of  liver  wound,  peritoneum,  transversalis  fascia,  subserous  areolar  tissue,  and  transversalis  ;  I,  Same 
tightened,  approximating  lip  of  liver  wound  to  lower  plane  of  abdominal  wound. 


on  other  grounds,  the  adhesions  are  separated  by  blunt  dissection,  or  are 
divided  between  ligatures.  (4)  The  liver  having  been  exposed,  the  operation 
may  be  concluded  in  a  single  stage,  or  in  two  stages: — (A)  In  One  Stage; — 
Where  (in  pus  and  hydatid  cases)  adhesions  of  parietal  peritoneum  to  hepatic 
peritoneum  have  occurred,  the  incision  may  be  made  directly  into  the  liver 
substance.  Where  no  such  adhesions  exist,  one  of  two  courses  may  be  pur- 
sued;— (a)  The  lips  of  the  abdominal  wound  may  be  applied  to  and  pressed 
around  the  site  of  the  liver  to  be  opened,  by  the  fingers  of  an  assistant  and  by 
packing — the  tensity  of  the  abscess  wall  is  then  lessened  (to  avoid  a  gush  of  pus) 
by  the  withdrawal  of  some  of  its  contents  with  a  syringe — a  narrow  bistoury  is 
inserted  into  the  abscess  and  its  walls  incised — the  contents  are  directed  out 
without  escaping  into  the  abdomen — and  as  soon  as  the  cavity  is  partly  empty, 


1012  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

the  edges  of  the  abscess  wall,  including  Glisson's  capsule,  are  seized  with 
special  forceps  and  drawn  up  into  the  wound  and  exerted,  while  the  balance  of 
its  contents  is  emptied — the  borders  of  the  abscess  cavity  are  then  stitched  to 
the  edges  of  the  abdominal  wound  at  its  lower  plane  (that  is,  to  the  parietal 
peritoneum,  subserous  areolar  tissue,  transversalis  fascia,  and  possibly  into  the 
edge  of  the  muscle  tissue)  with  continuous  or  interrupted  silk  or  chromic  gut 
sutures — closing  in  either  end  of  the  abdominal  wound  in  the  usual  way— 
leaving  room  for  the  exit  of  tube  or  gauze  drain.  Or,  pursuing  a  second 
course — (b)  Before  opening  the  peritoneum,  and  after  recognizing  that  the 
parietal  and  hepatic  peritoneal  surfaces  are  not  adherent,  the  parietal  peri- 
toneum (by  slight  outward  separation  of  the  extraperitoneal  parts  of  both  lips 
of  the  wound)  may  be  stitched,  with  curved  needle,  to  the  hepatic  surface  over 
an  elliptical  area,  with  continuous  silk  or  chromic  gut— surrounding  and  further 
protecting  the  area  by  gauze  packing — and  then  incision  is  made  simultane- 
ouslv  through  parietal  and  visceral  peritoneum  into  the  liver — drainage  being 
established  and  the  wound  treated  as  in  (a).  (B)  In  Two  Stages; — This 
method  is  practised  only  where  no  adhesions  are  found — and  when  no  haste 
exists.  The  parietal  peritoneum  is  united  to  the  serous  surface  of  the  liver  in 
one  of  the  two  above  ways — the  gauze  packing  being  preferable  to  the  stitching 
(or  both  may  be  used  together) — the  wound  being  packed  with  gauze,  pressing 
the  serous  surfaces  together  for  two  or  three  days — after  which  the  incision  is 
made  and  the  operation  completed  as  in  (a)  above. 

Comment. — Where  the  abscess,  or  other  cavity,  is  incised  before  the  ab- 
dominal wall  is  sutured  to  the  liver,  the  suturing  of  the  margin  of  the  cavity  to 
the  abdominal  wound  is  aided  by  inserting  the  left  index-finger  into  the  cavity 
and  hooking  it  forward — thus  holding  it  in  contact  with  the  abdominal  wall 
while  the  sutures  are  being  placed  and  tied. 


EXPOSURE  OF  LIVER  BY  ANTERIOR  SUBCOSTAL  TRANS- 
PERITONEAL ROUTE 

BV  ANTERIOR  VERTICAL  INCISION"  THROUGH  RIGHT  LINEA   SEMILUNARIS. 

Description. — A  free  exposure  is  thus  given — which  may  be  lengthened 
so  as  to  give  access  to  both  peritoneal  and  pelvic  cavities.  See  General  Sur- 
gical Considerations.  The  incision  may  also  be  placed  to  the  outer  side  of  the 
right  semilunar  line. 

Preparation — Position. — As  for  abdominal  section. 

Landmarks. — Right  Linea  Semilunaris  (which  extends  from  the  ninth 
right  costal  cartilage  to  the  pubic  spine,  passing  within  7.5  cm.  [3  inches]  of  the 
umbilicus) ;  right  costal  arch. 

Incision. — Vertically  downward  in  the  right  semilunar  line,  beginning  at 
the  right  ninth  costal  cartilage  and  extending  as  far  as  necessary  (Fig.  699,  G). 

Operation. — Incise  skin — fascia — external  oblique  (obliquely)— internal 
oblique  (obliquely) — abdominal  nerves  between  internal  oblique  and  trans- 
versalis are  almost  necessarily  divided  (except  in  very  short  incisions  they  may 
sometimes  be  displaced) — transversalis  muscles  (transversely) — transversalis 
fascia,  subserous  areolar  tissue  and  peritoneum — entering  the  abdomen  in  the 
original  line.  All  hemorrhage  is  controlled — the  lips  of  the  wound  retracted— 
and  the  liver  exposed. 


INTERCOSTAL  SUBPLEURAL  EXPOSURE  OF   LIVER.  1013 


EXPOSURE  OF  LIVER  BY  LATERAL  SUBCOSTAL  TRANS- 
PERITONEAL ROUTE 

BY  LATERAL  HORIZONTALLY  CURVED  INCISION  BELOW  RIGHT  TWELFTH  RIB. 

Description.— The  general  features  of  the  operation  are  the  same  as  by 
the  anterior  oblique  subcostal  incision — the  steps  of  the  operation  differing  only 
in  so  far  as  determined  by  anatomical  circumstances.  Chiefly  applicable 
where  the  lower  lateral  aspect  of  the  liver  is  to  be  exposed. 

Preparation. — As  for  abdominal  section. 

Position. — Patient  rests  upon  opposite  side,  with  cushion  under  the  sound 
side  to  round  out  the  involved  side;  Surgeon  may  stand  behind  or  in  front  of 
patient;  Assistant  opposite. 

Landmarks. — Right  twelfth  rib,  in  the  mid-axillary  region. 

Incision. — Parallel  with  and  about  1.3  to  2  cm.  (J  to  f  inch)  below  the  right 
twelfth  rib,  with  its  center  about  opposite  the  mid-axillary  line. 

Operation. — Incise  skin — fascia — external  oblique  (obliquely) — latis- 
simus  dorsi  (transversely,  if  the  incision  extend  that  far  backward) — internal 
oblique  (obliquely) — the  nerves  between  the  internal  oblique  and  transversalis 
being  guarded  as  well  as  possible — transversalis  muscle  (in  cleavage  line) — 
transversalis  fascia,  subserous  areolar  tissue,  and  peritoneum  in  the  original 
line.  All  hemorrhage  is  controlled — the  wound  retracted — and  the  liver 
brought  into  the  field. 

Comment. — Unless  the  liver  be  enlarged,  but  small  part  of  its  lower  border 
is  accessible  through  this  incision — except  by  the  strong  upward  retraction  of 
the  twelfth  rib,  and  the  downward  retraction  of  the  lower  lip  of  the  wound. 


EXPOSURE  OF  LIVER  BY  INTERCOSTAL  SUBPLEURAL  ROUTE 

BY  INTERCOSTAL  INCISION  BELOW  LEVEL  OF  PLEURA. 

Description. — This  incision,  which  is  made  in  an  intercostal  space  below 
the  level  of  the  pleura,  rarely  gives  sufficient  room — and  is  indicated  only  in 
cases  where  abscess  or  fluid  point  here  and  adhesions  have,  in  all  probability, 
protected  surrounding  regions.  In  the  following  description  the  operation 
site  will  be  supposed  to  be  in  the  right  tenth  interspace,  in  the  mid-axillary  line. 

Preparation — Position. — As  for  intercostal  thoracotomy  (see  page  761). 

Landmarks. — Right  tenth  and  eleventh  ribs,  in  the  mid-axillary  line. 

Incision. — Midway  between  lower  border  of  the  right  tenth  and  the  upper 
border  of  the  right  eleventh  rib — in  the  mid-axillary  region. 

Operation. — The  steps  of  the  operation  are  the  same,  practically,  as  those 
for  Intercostal  Thoracotomy  (q.  v.,  page  761) — with  the  exception  that  in  the 
present  instance  the  incision  is  made  below  the  level  of  the  pleura.  As  an 
operation,  owing  to  the  small  amount  of  room  which  it  affords,  it  is  indicated 
only  in  those  cases  in  which  the  liver  is  supposed  to  be  adherent  to  the  dia- 
phragm opposite  the  site  of  incision  (either  naturally  or  by  pathological  pro- 
cess). If  during  operation  it  be  found  that  the  liver  be  not  adherent  to  the 
diaphragm,  parts  of  one  or  two  ribs  should  be  excised — and  the  operation  be 
completed  as  given  in  the  following  description. 

Comment. — The  operation  is  distinctly  inferior  to  the  following  method. 


IOI4  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


A   - 


Fig. 746.— Exposure  of  Liver  by  Subpleural  Route,  by  Partial  Excision  of  a  Rib  below 
Level  of  Pleura  : — A,  A,  Thoracic  muscles  ;  B,  B,  Anterior  and  posterior  layers  of  rib  periosteum 
retracted  after  excising  part  of  rib,  both  divided  longitudinally,  and  endothoracic  fascia  seen  upon 
under  surface  of  latter;  C,  Diaphragm  being  sutured  to  convex  surface  of  liver  and  incised  within 
area  elliptically  sutured. 


EXPOSURE  OF  LIVER  BY  SUBPLEURAL  ROUTE 

BY  PARTIAL  EXCISION  OF  ONE  OR  MORE  RIBS  BELOW  THE  LEVEL  OF  PLEURA. 

Description. — The  liver  is  here  approached  transthoracically,  but  the 
incision  being  placed  below  the  normal  level  of  the  pleura,  the  pleura  is  not, 
ordinarily,  brought  into  the  field  of  operation.  In  the  following  account,  part 
of  the  right  eleventh  rib  in  the  mid-axillary  line  will  be  removed. 

Preparation — Position. — As  for  Thoracotomy  by  the  partial  excision  of  a 
rib. 

Landmarks. — The  special  rib  nearest  the  site  to  be  exposed. 

Incision — Operation. — As  for  the  Partial  Subperiosteal  Excision  of  a 
Rib  (see  page  480) — up  to  the  point  of  the  removal  of  the  rib.  The  posterior 
layer  of  periosteum,  forming  the  bed  in  which  the  rib  has  lain,  is  then  incised 
in  its  center,  in  its  long  axis.  If  more  room  be  required  than  furnished  by  the 
partial  excision  of  one  rib,  two  or  more  ribs  are  excised  in  part  (see  page  764). 
Having  passed  through  the  thoracic  wall,  the  diaphragm  is  exposed  and  in- 
cised— in  a  line  corresponding  with  the  direction  of  its  muscle-fibers  at  the  site 
incised.  The  edges  of  the  diaphragmatic  wound  are  sutured  to  the  convex 
surface  of  the  liver,  if  not  already  adherent.  If  adhesions  be  present,  or  if 
haste  be  necessary,  the  liver  is  incised  at  once.  If  haste  be  unnecessary,  and 
no  adhesions  be  present,  the  wound,  after  the  above  suturing,  is  packed  with 
gauze  for  two  or  three  days,  until  adhesions  form — and  the  organ  then  in- 
cised (Fig.  746). 


EXPOSURE  OF  LIVER  BY  SUBPLEURAL  ROUTE 

BY  PARTIAL  EXCISION  OF  ONE  OR  MORE  RIBS  OPPOSITE  THE  PLEURA. 

Description. — Parts  of  one  or  more  ribs  are  excised  subperiosteally  above 
the  level  of  the  pleura — the  pleura  is  exposed  but  not  opened — and  is  carefully 


EXPOSURE  OE  LIVER  BY  SUBPLEURAL  ROUTE.        1015 

separated  from  the  thoracic  wall  and  diaphragm  and  displaced  upward — the 
diaphragm  being  thus  exposed  and  the  liver  entered  through  its  substance.  In 
the  following  account,  parts  of  the  seventh  and  eighth  right  ribs  in  the  antero- 
lateral aspect  of  die  chest  will  be  removed. 

Preparation — Position. — As  for  Thoracotomy. 

Landmarks. — The  rib  or  ribs  overlying  the  involved  site. 

Incision — Operation.— (1)  The  operation  is  conducted  as  a  Partial  Sub- 
periosteal Excision  of  one  or  more  Ribs  (see  page  480) — up  to  the  removal  of 
the  rib.  The  Subperiosteal  bed  of  the  rib  is  very  carefully  incised  in  the  center 
of  its  long  axis — cautiously  recognizing  but  not  incising  the  costal  pleura — 
which  is  to  be  preserved  with  the  greatest  care  from  the  smallest  cut  or  tear  (on 
account  of  the  respiratory  complications  often  arising  from  the  entrance  of  air 
into  the  pleura,  with  the  possible  collapse  of  the  lung,  and  the  possible  infection 


Fig.  747. — Exposure  of  Liver  by  Subpleural  Route,  by  Partial  Excision  of  Parts  of 
Tun  Ribs  Opposite  the  Pleura  : — A,  A,  Upper  layer  of  periosteum  and  thoracic  muscles  retracted  ; 
B,  B,  Lower  layer  of  periosteum  and  intercostal  muscles  retracted;  C,  Pleura  detached  and  retracted 
upward;  D,  Diaphragm  incised;  E,  Incised  margin  of  parietal  pleura;  F,  Convex  surface  of  liver; 
G,  Sutures  uniting  edges  of  diaphragm  and  parietal  peritoneum  to  surface  of  liver. 


of  the  pleura).  (2)  The  costal  pleura  is  carefully  detached  by  blunt  dissection, 
largely  aided  by  the  back  of  the  surgeon's  fingers — first  detaching  it  from  the 
ribs,  until  its  lowest  thin  edge  is  reached — then  from  the  upper  surface  of  the 
diaphragm — and  finally  displacing  it  upward  and  retaining  it  there  by  blunt, 
rounded  retractor,  or  gauze  packing.  Thus  the  upper  surface  of  the  diaphragm, 
as  far  inward  as  necessary,  is  freely  exposed — with  the  upper  convex  surface  of 
the  liver  immediately  below  it  (Fig.  747).  (3)  The  operation  is  now  com- 
pleted in  one  or  in  two  stages: — (a)  In  One  Stage; — The  diaphragm  is  incised 
over  the  site  of  fluid — the  edges  of  the  diaphragmatic  wound  are  slightly  sepa- 
rated— and  these  edges  are  sutured  with  chromic  gut  (by  means  of  a  curved 
needle  in  a  holder)  to  the  upper  surface  of  the  liver,  in  the  form  of  an  ellipse. 
If  adhesions  be  present  between  liver  and  diaphragm,  this  suturing  is  unneces- 
sary.    In  addition  (to  either  suturing  or  adhesions),  gauze  is  packed  around 


1016  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

the  region,  further  guarding  against  infection.  To  relieve  the  tension  part  of 
the  contents  of  the  cavity  is  first  aspirated.  The  liver  is  then  incised  and 
drained.  The  wound  is  closed  up  to  the  site  of  drainage — so  suturing  the 
parts  that  the  thoracic  cavity  is  shut  off  and  the  pleura  prevented  from  coming 
into  the  region  of  the  wound,  (b)  In  Two  Stages; — The  diaphragm  is 
sutured  as  above  to  the  liver  and  the  wound  packed — and,  after  two  or  three 
days,  when  adhesions  have  occurred,  the  liver  is  incised  and  drained — and  the 
wound  treated  with  the  same  precautions  as  just  given. 

Comment. — (i)  Parts  of  at  least  two  ribs  should  generally  be  excised — to 
give  the  necessary  room  to  meet  the  difficulties  which  are  apt  to  arise  in  the 
progress  of  the  operation.  (2)  Where,  from  the  position  of  the  opening  it  is 
possible  to  do  so,  it  is  well  to  unite  the  edges  of  the  diaphragm  to  the  edges  of 
the  thoracic  wound — thus  giving  freer  drainage  and  better  protection  of  the 
neighboring  parts  from  infection. 


EXPOSURE  OF  LIVER  BY  TRANSPLEURAL  ROUTE 

BY  PARTIAL  EXCISION  OF  ONE  OR  MORE  RIBS  OPPOSITE  THE  PLEURA. 

Description. — Following  the  subperiosteal  excision  of  parts  of  one  or 
more  ribs,  no  attempt  is  made  to  avoid  the  pleura,  but  care  is  taken  not  to  open 
it  prematurely.  After  entering  the  thoracic  cavity,  in  the  same  manner  as  in 
the  last  operation,  the  costal  and  diaphragmatic  pleurae  are  recognized — their 
surfaces  are  then  sutured  together  in  the  form  of  a  circle  or  an  ellipse — and  an 
opening  is  made  through  their  united  surfaces — at  once  if  necessary, — after 
two  or  three  days  if  haste  be  unnecessary.  Thus  an  attempt  is  made  to  pre- 
vent the  invasion  and  infection  of  their  cavity.  The  operation  is  inferior  to  the 
subpleural  method,  which  should  always  be  practised  if  possible — reserving  the 
method  just  described  for  those  cases  in  which  the  pleura  cannot  be  thus  sepa- 
rated and  pushed  above  the  seat  of  operation.  In  the  following  account  parts 
of  the  seventh  and  eighth  right  ribs  will  be  excised  in  the  antero-lateral  aspect 
of  the  chest. 

Preparation — Position — Landmarks — Incision. — As  in  the  operation 
last  described. 

Operation. — Same  as  in  the  above  operation — except  that  when  the  pleura 
is  exposed,  instead  of  detaching  and  displacing  it  upward,  the  costal  and  dia- 
phragmatic pleura?  are  sutured  together  in  an  elliptical  or  circular  outline, 
with  continuous  suture  of  silk  or  fine  chromic  gut  carried  upon  a  curved  needle 
in  a  holder — carefully  guarding  against  opening  the  pleural  cavity  in  the  pro- 
cess of  manipulation — it  being  very  difficult  to  prevent  the  tearing  out  of  the 
pleural  stitches.  The  operation  may  now  be  concluded  in  one  or  in  two 
stages: — (a)  In  One  Stage; — Through  the  center  of  the  area  thus  sutured,  the 
two  pleurae  are  incised — through  this  incision  the  diaphragm  is  exposed — the 
margins  of  the  pleurae  are  now  sutured  as  one  layer  to  the  diaphragm,  over  an 
elliptical  area,  with  continuous  suture  of  silk  or  fine  chromic  gut,  carried  upon 
a  fully  curved  needle  in  a  holder — the  surrounding  area  is  packed  off  with 
gauze,  in  addition — the  diaphragm  is  incised — and  the  edges  of  the  diaphragm 
are  stitched,  in  turn,  to  the  liver  with  chromic  gut — after  which,  the  tension  of 
the  abscess  is  partly  relieved  by  aspiration — the  liver  then  being  incised — drain- 
age established  and  the  wound  partly  closed,  (b)  In  Two  Stages; — Same  as 
in  the  single-stage  method — except  that  after  suturing  the  double  layer  of 
pleura  together,  and,  at  the  same  time,  to  the  diaphragm,  in  the  form  of  a  circle 
or  ellipse — the  area  is  packed  with  gauze  for  two  or  three  days — after  which  the 


EXPOSURE    OF    LIVER    BY    RESECTION    OF    RIGHT    COSTAL    ARCH.      1017 

operation  is  completed  as  above.  In  such  cases,  the  diaphragm  will  usually  be 
found  adherent  to  the  liver  (when  the  operation  falls  over  the  peritoneal  aspect 
of  the  liver).  If,  however,  upon  exposing  the  liver  through  the  diaphragm,  no 
adhesions  are  found,  the  margins  of  the  diaphragmatic  wound  can  be  stitched 
to  the  liver  surface — the  wound  packed  and  two  or  three  days  longer  waited, 
if  haste  be  unnecessary. 

Comment. — (i)  If  the  two  pleurae  cannot  be  sutured,  and  time  be  avail- 
able, incise  the  parietal  pleura — pack  the  wound  for  a  few  days,  until  the  two 
pleurae  have  united  around  the  margins — then  incise  the  visceral  pleura  and 
diaphragm — similarly  stitching  the  diaphragm  to  the  liver  for  a  few  days,  if 
desired.  (2)  If  the  situation  of  the  wound  make  it  possible,  it  is  well  to  suture 
the  edges  of  the  diaphragmatic  and  thoracic  wounds  together. 


EXPOSURE  OF  LIVER  BY  CHONDRO-PLASTIC  RESECTION  OF  RIGHT 

COSTAL  ARCH 

BY    ANTERIOR    OBLIQUE    SUBCOSTAL    INCISION. 

Description. — Where  the  operation  site  is  encumbered  by  the  bony  or 
cartilaginous  thoracic  wall,  the  area  may  be  more  satisfactorily  exposed  by 


Fig.  748. — Chondroplastic  Resection  of  the  Chest-wall: — I. — The  soft  parts  over- 
lying the  costal  arch  have  been  incised  and  retracted — exposing  the  cartilages  of  the  seventh, 
eighth,  ninth,  and  tenth  ribs.     (Redrawn  from  Guibe.) 


temporarily  resecting  the  right  costal  cartilage  forming  the  costo-chondral 
arch — turning  it  outward — and  back  into  place  at  the  end  of  the  operation. 
By  the  resection  of  the  right  costal  arch  and,  if  necessary,  the  temporary 
division  of  the  suspensory  ligament  of  the  liver,  the  superior  aspect  of  the 
liver  is  exposed.     The  resection  of  both  costal  arches  may  be  performed, 


I0l8  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

where  the  freest  exposure  of  the  liver,  gall-bladder,  gall-duct,  and  stomach 
regions  is  necessary. 

The  chief  danger  is  the  possibility  of  opening  the  pleural  cavity — to  avoid 
which  it  is  necessary  not  to  carry  the  division  of  the  ribs  too  high — not  higher 
than  the  seventh  interspace. 

Preparation — Position — Landmarks. — As  for  exposure  of  the  liver  by 
an  anterior  oblique  subcostal  incision. 

Incision. — An  oblique  incision  is  made — commencing  at  the  border  of  the 
ensiform  cartilage,  a  little  below  the  last  chondro-sternal  articulation — 
passing  thence  outward  and  downward,  parallel  with  but  about  2.5  cm.  ( 1  inch) 
above  the  border  of  the  costal  arch — generally  ending  at  the  tip  of  the  eleventh 
rib. 

Operation. — The  skin,  fascia,  and  overlying  muscle-fibers  are  divided — 


Fig.   749. — Choxdroplastic  Resection  or  the  Chest-wall: — II. — The  costal  margin  incised 
and  turned  forward.     (Redrawn  from  Guibe.) 

until  the  plane  of  the  costal  cartilages  is  reached.  The  cartilaginous  portion 
of  the  ribs  is  divided  with  a  bistoury,  carefully  guarding  the  underlying  soft 
parts.  The  tenth  and  ninth  cartilages  are  divided  just  to  the  inner  side  of 
the  chondro-costal  articulations.  The  eighth  cartilage  is  generally  divided 
in  three  places — externally,  just  within  the  chondro-costal  articulation — 
internally,  just  without  the  chondro-sternal  articulation — and  in  the  middle, 
through  the  band  of  union  of  the  eighth  to  the  seventh  cartilage  (when  this 
exists).  Between  the  cartilages,  the  intercostal  muscles  and  membranes  are 
incised  (Fig.  748).  The  incised  cartilaginous  margin  is  then  seized  and 
turned  downward  and  inward— separating  with  a  bistoury  the  muscular 
attachments  of  the  diaphragm  and  transversalis,  closely  hugging  the  cartilages 
in  the  act  (Fig.  749) .  As  soon  as  the  chondro-plastic  flap  has  been  sufficiently 
displaced,  the  muscular  fibers  of  the  diaphragm  or  transversalis,  which  form 
the  floor  of  the  wound,  are  incised — thus  opening  the  peritoneal  cavity.  The 
chondro-plastic  flap  is  then  well  depressed  and  the  outer  lip  of  the  wound 


PARTIAL    HEPATECTOMY.  IO19 

well  elevated— when  the  superior  surface  of  the  liver  is  exposed  by  retracting 
it  downward  and,  if  necessary,  by  temporarily  dividing  the  suspensory  liga- 
ment— and  the  inferior  aspect  and  gall-bladder  region  by  retracting  the  liver 
upward.  As  the  end  of  the  operation,  in  closing  the  wound,  the  deeper 
portion  is  sutured  by  carrying  the  suture  through  the  intercostal  spaces  and 
the  diaphragm,  on  the  outer  side,  and  through  the  transversalis  and  internal 
oblique,  on  the  inner  side — thus  bringing  together  the  soft  parts  of  the  thorax, 
and,  with  them,  the  incised  cartilages.  The  overlying  superficial  muscles 
are  then  sutured — and  the  skin  closed  as  usual.  If  considered  necessary, 
the  surfaces  of  the  severed  cartilages  may  be  sutured  through  previously 
pierced  holes.  Indeed,  the  temporarily  displaced  costal  arch  may  be  com- 
pletely severed  from  its  soft  attachments  and  discarded — though  its  retention 
is  preferable.  If  necessary,  a  drain  may  be  carried  beneath  the  replaced 
costal  arch. 

HEPATORRHAPHY. 

Description. — Suturing  of  the  liver  substance.  Generally  done  in  the 
case  of  wounds  of  the  liver-^and  in  the  approximation  of  the  cut  surfaces  after 
partial  excisions.  The  liver  may  be  exposed  by  any  of  the  above  operations, 
according  to  the  circumstances  of  the  case — preference  being  given  to  the 
simplest  route. 

Preparation — Position — Landmarks — Incision. — As  for  Hepatotomy 
(page  10 10). 

Operation. — Having  exposed  the  liver  in  one  of  the  usual  methods — and 
an  assistant  having  brought  the  involved  region  of  the  organ  well  into  the 
field — interrupted  chromic  gut  sutures,  carried  upon  a  large,  fully-curved 
Hagedorn,  or  other,  needle,  are  carried  through  the  opposed  edges  of  the 
wound.  Two  tiers  of  sutures  are,  ordinarily,  indicated — coarser  gut  carried 
more  deeply  and  further  from  the  edges — and  finer  gut  more  superficially  and 
nearer  the  edges.  The  deeper  sutures  are  first  tied — then  the  superficial, — 
after  which  the  liver  is  dropped  back  into  place — and  the  abdomen  closed—- 
unless  special  cause  for  drainage  exist.     (See  Fig.  750.) 


HEPATOPEXY. 

Description. — Operation  of  suturing  the  liver,  in  whole  or  in  part,  to  the 
abdominal  wall,  or  neighboring  structures.  Resorted  to  for  partial  or  com- 
plete hepatoptosis. 

Preparation — Position — Landmarks — Incision. — As  for  Hepatotomy 
by  anterior  oblique  subcostal  incision. 

Operation. — The  prolapsed  liver  having  been  exposed,  the  part  involved 
in  the  prolapse,  or  the  whole  liver,  if  involved  in  its  entirety,  is  brought  into 
its  normal  position — and  is  then  sutured  with  coarse  chromic  gut,  kangaroo- 
tendon,  or  silk,  to  the  posterior  surface  of  the  anterior  abdominal  wall.  It 
may  also  be  sutured  to  the  round  ligament — to  the  cartilages  of  the  ribs— or 
to  the  general  abdominal  wall.  The  sutures  are  carried  deeply  into  the  liver 
substance  with  a  lanie,  fullv  curved  needle. 


PARTIAL  HEPATECTOMY, 

Description. — Excision  of  a  limited  portion  of  the  liver  substance.     Gen- 
erallv  done  in  the  removal  of  growths. 


1020  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

Preparation  —Position— Landmarks — Incision. — As  for  Hepatotomy 
by  one  of  the  transperitoneal  routes — and  preferably  by  an  incision  parallel 
with  and  just  below  the  ribs. 

Operation. — (i)  The  abdomen  is  opened — and  the  involved  portion  of 
the  liver  is  brought  as  far  forward  into  the  wound  as  possible.  (2)  Circum- 
scribe the  growth,  or  part  to  be  removed,  by  an  elliptical  incision — the  elliptical 
outline  representing  the  base  of  a  wedge,  the  sides  of  which  come  together 
within  the  liver  beyond  the  part  to  be  removed.  The  ellipse,  where  possible,  is 
made  with  its  long  .axis  radiating  from  the  center  of  the  liver  toward  the  per- 
iphery, and  so  placed  as  to  avoid  the  chief  hepatic  vessels.  This  area  is  ex- 
cised by  cutting  down  along  the  outline  of  the  incision,  the  knife  traveling  at  a 


Fig.  750.— Partial  Hepatectomy,  followed  by  Hepatorrhaphy  : — A,  Incised  external  ob- 
lique, internal  oblique,  and  transversalis  ;  B,  Incised  outer  border  of  rectal  sheath;  C,  Costal  arch 
retracted  from  liver;  D  (lower  D),  Gauze  pad  packed  under  liver;  E,  Borders  of  liver-wound  after 
excision  of  wedge;  F,  Superficial  sutures  through  liver  substance;  D  (upper  D),  Deep  sutures. 


right  angle  to  the  surface — hemorrhage  being  controlled  by  pressure  and  by 
ligature  with  chromic  gut.  (Also  see  Comment.)  (3)  The  sides  of  the  wound 
are  then  brought  together  by  deep  and  superficial  chromic  gut  sutures — 
placed  and  tied  as  described  under  Hepatorrhaphy  (page  1019).  (4)  Unless 
drainage  be  specially  indicated,  the  liver  is  dropped  back  into  place  and  the 
abdomen  closed — particularly  if  the  surfaces  of  the  wound  be  satisfactorily 
approximated  and  hemorrhage  be  entirely  controlled  (Fig.  750). 

Comment. — (1)  If  the  area  to  be  excised  is  first  surrounded  by  a  deeply 
placed,  interlocking  chromic  gut  ligature,  hemorrhage  is  more  thoroughly  con- 
trolled. These  ligatures  are  then  drawn  tightly  enough  to  cut  through  the 
liver  substance  and  bind  the  vessels  before  these  are  cut.     (2)  Also  a  heavy 


SURGICAL    ANATOMY    OF   THE    GALL-BLADDER.  1021 

ligature  may  be  placed  through  the  liver,  surrounding  the  part  to  be  removed, 
which  is  thus  tied  off  in  sections — the  ligatures  being  tightened  and  the  part 
removed  with  the  knife  or  cautery. 

OPERATION  FOR  CIRRHOSIS  OF  THE  LIVER. 

EPIPLORRHAPHY   OR    EPIPLOPEXY — TALMA-DRTTMMOND    OPERATION. 

Description. — This  operation,  or  one  of  its  modifications,  has  been 
successfully  employed  in  some  cases  of  cirrhosis  of  the  liver.  It  is  based 
upon  the  principle  of  forming  additional  venous  communications  between  the 
systemic  and  portal  circulations  in  order  to  relieve  obstruction  in  the  over- 
burdened portal  circuit. 

Preparation — Position — Landmarks. — As  for  median  abdominal  sec- 
tion. 

Incision. — The  incision  is  made  in  or  near  the  median  line,  over  a  length 
equivalent  to  that  between  the  ensiform  cartilage  and  umbilicus.  Local 
anesthesia  generally  suffices. 

Operation. — Having  opened  the  abdominal  cavity,  all  ascitic  fluid  is 
drained  or  sponged  away.  The  liver  is  exposed  and  all  of  the  accessible  upper 
surface  which  comes  into  contact  with  the  diaphragm  is  rubbed  briskly  with 
gauze.  The  convex  surface  of  the  spleen  is  similarly  treated.  The  omentum 
is  brought  forward  and  sutured  to  the  parietal  peritoneum  of  the  anterior 
abdominal  wall,  to  both  sides  of  the  median  line  (with  or  without  frictioning 
of  their  surfaces) — which  is  readily  accomplished  by  everting  the  relaxed 
abdominal  wall  in  the  average  case  of  ascites.  The  greater  the  number  of 
adherent  points  between  peritoneum  and  omentum,  the  better.  The  abdomen 
is  closed — no  drainage  being  used  in  the  later  cases,  as  was  formerly  the  habit. 

VIII.  THE  GALL-BLADDER. 

SURGICAL  ANATOMY. 

Description  and  Position. — Bound  to  fossa  of  gall-bladder,  upon  under 
surface  of  liver,  by  connective  tissue  and  vessels,  lying  between  the  right  and 
quadrate  lobes — its  fundus  reaching  the  abdominal  wall  anteriorly — and  its 
neck  extending  to  the  transverse  fissure  posteriorly.  Its  fundus  and  inferior 
and  lateral  aspects  are  covered  with  peritoneum  reflected  from  the  liver.  It 
sometimes  has  a  mesentery.  Its  neck  points  backward  and  upward,  toward 
the  transverse  fissure  of  liver, — its  fundus  points  downward  and  forward  toward 
the  anterior  border  of  liver.  Its  length  is  from  7  to  10  cm.  (2|  to  4  inches) — 
the  width  of  its  fundus  is  from  2.5  to  3  cm.  (1  to  if\  inches) — and  it  holds 
about  20  c.c. 

Relations. — Superiorly; — fossa  of  gall-bladder; — Inferiorly; — duode- 
num (first  and  second  parts);  pyloric  end  of  stomach  (sometime-);  colon 
(hepatic  flexion  and  commencement  of  transverse  portion); — Anteriorly; — 
abdominal  wall;  ninth  costal  cartilage. 

Arteries. — Cystic,  from  right  branch  of  hepatic. 

Veins. — Cystic  (two)  emptying  into  right  branch  of  vena  porta?;  others 
emptying  into  liver. 

Lymphatics. — Run  into  a  gland  at  its  neck. 

Nerves.— Supplied  by  cceliac  plexus. 

Fixations. — Connective  tissue;  vessels;  peritoneum  reflected  over  under 
surface  of  liver;  cvsto-duodenal  ligament  (a  fold  of  peritoneum  extending  from 
neck  of  gall-bladder  to  duodenum). 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


SURFACE  FORM  AND  LANDMARKS. 

The  fundus  of  the  gall-bladder  projects  outward  beyond  the  anterior  border 
of  the  liver,  in  the  incisura  vesicalis — generally  resting  upon  the  transverse 
colon — and  coming  into  contact  with  the  anterior  abdominal  wall  close  to  the 
outer  border  of  the  right  rectus  muscle.  Authorities  differ  as  to  the  exact  point 
of  contact  with  the  abdominal  wall,  in  relation  with  the  costochondral  struc- 
tures;— according  to  Morris,  the  fundus  lies  opposite  the  cartilage  of  the  right 
ninth  or  tenth  rib; — according  to  Gray,  opposite  the  inferior  border  of  the 
right  ninth  costal  cartilage; — and  according  to  Treves,  below  the  inner  end  of 
the  right  tenth  costal  cartilage. 


GENERAL  SURGICAL  CONSIDERATIONS. 

(i)  The  gall-bladder  is  in  relation  with  the  first  and  second  portions  of  the 
duodenum,  with  the  hepatic  flexure  and  commencement  of  the  transverse  colon, 
and  sometimes  with  the  pylorus.  Therefore  the  gall-bladder  could  generally 
be  united  with  either  duodenum  or  colon — but  if  united  to  the  colon,  the  func- 
tion of  the  bile  in  the  small  intestines  would  be  lost — hence  the  duodenum  is 
the  usual  site  of  anastomosis.  (2)  In  examining  the  gall-bladder  and  ducts, 
first  pass  the  left  index  over  these  structures,  to  gain  an  idea  of  their  size  and 
contents — then  let  the  left  index  slip  through  the  foramen  of  Winslow — in 
which  position  the  left  thumb  will  grasp  the  ligamentum  hepato-duodenale 
(the  right  margin  of  the  gastro-hepatic  omentum)  and  press  it  against  the  left 
index — and  thus  the  ducts  can  be  palpated  between  thumb  and  index,  up- 
ward and  downward.  (3)  By  drawing  upon  the  gall-bladder,  the  gall-ducts 
are  rendered  more  tense  and  evident.  (4)  The  pedicle  of  the  gall-bladder 
consists  of  cystic  duct,  artery,  and  veins. 


INSTRUMENTS  USED  IN  GALL-BLADDER  OPERATIONS. 

Mentioned  under  Instruments  used  in  operations  upon  the  Liver 
(page  1008). 

CHOLECYSTOTOMY 

BY    VERTICAL    SUBCOSTAL    INCISION. 

Description. — Incision  of  gall-bladder  for  removal  of  its  contents — 
followed  by  closure  at  same  operation.  LTsually  resorted  to  in  exploratory 
operations  upon  the  healthy  gall-bladder  and  with  unobstructed  ducts.  The 
closed  gall-bladder  may  be  dropped  back  into  the  free  abdomen,  but  is  gen- 
erally anchored  to  the  abdominal  wall. 

Preparation. — As  for  a  median  abdominal  section. 

Position.— The  best  position  for  gall-bladder  and  gall-duct  work  is  that 
given  by  Elliot,  of  Boston,  in  his  own  words; — "The  patient  is  hung  by  straps 
under  the  arms  on  an  inclined  plane  at  an  angle  of  something  less  than  45 
degrees.  A  sand-bag  is  placed  under  the  back,  so  that  the  patient  is  bent 
over  it.  In  this  position  the  intestines  gravitate  to  the  lower  part  of  the 
abdomen,  so  that  when  the  liver  is  held  up  by  a  retractor,  the  air  sucks  in 
between  the  liver  and  the  intestines,  much  as  it  enters  the  pelvis  in  the  Tren- 
delenburg position."     The  only  objection  to  this  position  (which  does  not 


CHOLECYSTOSTOMY. 


1023 


outweigh  its  advantages)  is  that  when  a  simple  vertical  incision  is  used,  the 
lips  of  the  wound  tend  to  be  approximated  and  tensed  by  the  posture  of  the 
body — which,  however,  is  avoided  by  the  adoption  of  the  Mayo  Robson  inci- 
sion. 

Landmarks. — Site  of  fundus  of  gall-bladder  (opposite  lower  border  of 
right  ninth  costal  cartilage) ;  right  linea  semilunaris. 

Incisions. — The  best  incision  of  approach  is  probably  that  of  Mayo  Robson 
— which  begins  as  a  simple  vertical  incision  through  the  outer  aspect  of  the 
right  rectus  muscle,  10  or  13  cm.  (4  or  5  inches)  in  length,  from  the  costal 
arch  downward.  If  more  room  be  needed,  it  may  be  extended  upward  and 
inward  below  the  costal  arch — or  downward  in  a  straight  line  (Fig.  751,  A). 
The  oblique  subcostal  incision  of  Kocher  may  be  used  (Fig.  751,  B). 


Fig.  751. — Incisions  for  Exposing  the  Gall-bladder  and  Ducts: — A,  Mayo  Robson's 
incision;  R,  oblique  subcostal  incision.     (Modified  from  Deaver.) 


Operation. — Having  opened  the  abdomen  and  examined  the  gall-bladder, 
gall-ducts,  and  head  of  the  pancreas,  the  region  of  the  gall-bladder  is  packed 
off  with  gauze.  The  fundus  of  the  bladder  is  grasped  with  special  forceps — 
so  as  to  draw  it  forward  and  hold  it  in  the  field  during  subsequent  manipula- 
tions. If  at  all  distended,  part  of  the  contents  should  be  withdrawn  with  a 
needle — to  avoid  the  spurt  of  fluid  which  would  otherwise  be  likely  to  soil  the 


I024  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

field  when  the  overdistended  organ  is  incised.  The  fundus  is  then  incised 
with  a  knife,  or  clipped  with  scissors — and  the  traction-forceps  shifted  to 
grasp  the  lips  of  the  bladder-wound.  While  the  lips  of  the  wound  are  held 
apart,  examination  for  calculi  is  made  with  a  special  scoop  or  forceps.  When 
this  has  been  done,  the  gall-bladder  tracts  are  carefully  palpated.  Should 
any  calculi  be  found,  they  are  "milked"  forward — and  removed  through  the 
gall-bladder  wound.  In  completing  the  operation,  the  usual  course,  where 
calculi  have  been  found,  is  to  establish  a  temporary  opening  and  drainage  of 
the  gall-bladder — a  cholecystostomy  (page  1024).  In  those  cases  where  no 
cause  for  drainage  may  have  been  found  (which  is  rare  in  distinct  gall-bladder 
involvement) — in  such  cases,  for  instance,  as  where  the  bladder  is  opened  for 
exploration  and  no  diseased  condition  be  found,  the  organ  may  be  sutured  up 
and  the  abdomen  closed.  The  incised  wound  is  best  closed  by  a  layer  of  fine 
continuous  catgut  suture  through  all  the  coats  of  the  viscus — followed  by  an 
interrupted  seromuscular  Lembert  suture,  burying  in  the  first  line  of  suturing. 
The  gall-bladder  may  then  be  dropped  back  into  the  abdominal  cavity — or  be 
anchored  to  the  abdominal  wall  by  a  couple  of  catgut  seromuscular  sutures, 
where,  in  the  event  that  drainage  become  necessary,  it  will  be  easily  accessible. 
The  abdomen  is  then  closed  in  the  usual  manner. 


CHOLECYSTOSTOMY 

BV  OBLIQUE  OR  VERTICAL  Sl'BCOSTAL  INCISION. 

Description. — Incision  of  gall-bladder,  followed  by  suturing  of  the  opened 
bladder  into  the  abdominal  wound  for  a  shorter  or  longer  time.  Generally 
resorted  to  in  cases  of  gall-stones,  or  in  suppuration.  The  operation  may  be 
done  in  one  or  in  two  "stages — in  the  former  case,  the  gall-bladder  is  opened  at 
once — in  the  latter,  it  is  first  sutured  to  the  abdominal  wall  and  not  opened 
until  after  adhesions  have  formed. 

Preparation. — As  for  median  abdominal  section. 


Fig. 752. — Cholecystostomy  by  Oblique  Subcostal  Incision: — A,  External  oblique;  B,  In- 
ternal oblique;  C,  Transversalis ;  D,  Subserous  areolar  tissue  and  transversalis  fascia;  E,  Peri- 
toneum ;  F,  Gall-bladder,  its  fundus  being  drawn  out  of  abdominal  wound  ;  G,  Sutures  through  trans- 
versalis and  subserous  fasciae,  and  through  serous  and  muscular  coats  of  gall-bladder. 

Position. — As  for  vertical  subcostal  cholecystotomy,  page  1022. 
Landmarks. — Lower  border  of  tip  of  right  ninth  costal  cartilage;  costal 
arch;  right  linea  semilunaris. 


CHOLECYSTOSTOMV.  IO25 

Incision. — Oblique  or  vertical  subcostal  incision,  as  for  exposure  of  the 
liver  (see  page  1010  and  Fig.  745,  and  also  General  Surgical  Considerations 
in  Operations  upon  the  Liver,  page  1006). 

Operation. — Having  opened  the  abdomen  by  the  chosen  incision,  hem- 
orrhage is  controlled,  the  wound  is  retracted,  and  the  gall-bladder  located. 
If  any  adhesions  are  found,  these  are  separated  by  blunt  dissection,  or  tied 
off — and  the  bladder  brought  as  far  out  into  the  abdominal  wound  as  possible 
(Fig.  752).  If  much  intravesical  tension  exist,  this  should  be  lessened  pre- 
liminarily by  the  aspiration  of  part  of  the  fluid.  The  operation  may  now  be 
concluded  in  one  or  in  two  stages; — (A)  In  One  Stage: — (a)  Having  partially 
emptied  the  gall-bladder  by  aspiration,  and  after  having  packed  off  the  vicinity 
with  gauze,  the  bladder  is  seized  with  special  forceps,  a  pair  in  each  hand  of  an 
assistant — or  by  two  traction-loops  passing  through  the  serous  and  muscular 
coats — and  while  thus  held  as  far  out  of  the  wound  as  possible,  the  fundus  of 
the  bladder  is  incised  vertically  between  the  forceps  or  traction-loops,  pro- 
vision being  made  for  the  catching  of  the  fluid,  (b)  Having  opened  the  gall- 
bladder, and  while  holding  the  lips  of  the  bladder  wound  apart,  insert  a  finger, 
or  special  instrument,  and  pass  it  down  to  the  cystic  duct  to  examine  the  con- 
tents— removing  with  special  forceps  or  scoop  any  calculi  found — followed  by 
irrigation  or  cleansing  of  the  bladder,  (c)  The  cystic,  hepatic,  and  common 
ducts  are  then  carefully  palpated,  (d)  In  completing  the  operation,  the  pack- 
ing is  removed  and  the  excess  of  abdominal  wound  is  closed  in  from  either  end 
toward  the  center,  in  the  ordinary  manner,  leaving  a  sufficient  opening  mid- 
way between  the  ends,  or  in  the  most  convenient  site  for  approximating  the 
bladder.  The  margins  of  the  gall-bladder  are  now  sutured  into  the  lower 
edge  of  the  abdominal  wound  left  after  the  partial  closure  of  the  ends  of  the 
abdominal  incision — in  such  a  way  that  all  the  coats  of  the  gall-bladder  are 
sutured  to  the  lower  layers  of  the  abdominal  wound  with  fine  interrupted 
chromic  gut — so  that  serous  surfaces  are  approximated,  but  so  that  the  edges 
of  the  gall-bladder  wound  do  not  reach  to  the  skin.  Or,  where  sufficient  room 
for  manipulation  exists,  it  is  better  to  use  two  tiers  of  sutures — the  first  row  of 
fine  gut  sutures  passing  through  serous  and  part  of  muscular  coats  of  the  gall- 
bladder, on  the  one  hand,  and  through  the  parietal  peritoneum,  on  the  other, — 
followed  by  a  second  tier  suturing  all  the  coats  of  the  gall-bladder  to  the  apo- 
neurotic layer  of  the  abdominal  wound,  (e)  If  considered  necessary,  drainage 
may  be  conducted  through  the  abdominal  wound  down  to  the  cystic  duct. 
The  best  form  of  bladder  drainage  is  secured  by  means  of  a  rubber  tube, 
about  6  mm.  (3  inch)  in  diameter — 5  to  8  cm.  (2  to  3  inches)  of  which  are 
placed  within  the  gall-bladder — the  opposite  end  reaching  to  the  pelvis  for 
drainage.  The  tube  is  held  in  position  by  a  catgut  suture  passing  through 
the  rubber  tube,  on  the  one  hand,  and  through  the  serous  and  muscular  coats 
of  the  gall-bladder,  on  the  other.  The  serous  surface  of  the  gall-bladder 
is  made  to  snugly  grasp  the  rubber  tube  by  being  drawn  around  it  with  a 
seromuscular  purse-string  suture — thus  avoiding  leakage — as  shown  in 
Fig.  753-  If  the  incision  into  the  fundus  of  the  gall-bladder  be  too  large  for 
closure  by  a  purse-string  suture,  the  closure  may  be  made  by  a  seromuscular 
suture.  The  gall-bladder  may  be  allowed  to  fall  back  into  the  peritoneum — 
but  it  is  generally  better  to  anchor  it  in  contact  with  the  abdominal  wall, 
either  separately  by  a  few  interrupted  seromuscular  sutures,  or  in  the  act  of 
suturing  up  the  lower  level  of  the  abdominal  wound.  (B)  In  Two  Stages; — 
(a)  Having  closed  in  the  excess  of  abdominal  wound  from  either  end,  the 
fundus  of  the  gall-bladder  is  sutured  into  the  remaining  opened  portion  of  the 
abdominal  wound  by  interrupted  silk  or  fine  chromic  gut  sutures — passing 


1026  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

through  the  serous  and  muscular  coats  of  the  gall-bladder,  on  the  one  hand, 
and  through  the  parietal  peritoneum  and  the  lower  layers  of  the  abdominal 
wound,  on  the  other,  (b)  When  adhesions  have  formed  in  two  or  three 
days,  the  fundus  is  incised — as  in  the  single-stage  operation. 

Comment. — (A)  In  Operating  in  One  Stage; — (a)  The  gall-bladder  may 
be  tied  with  a  purse-string  around  a  glass  flanged  tube,  which  is  then  brought 
out  of  the  abdominal  wound.  Or  a  Murphy  button-tube,  with  long  cylinder, 
may  be  used.  The  tube  or  button  tied  in  sloughs  out  in  a  few  days,  by  which 
time  adhesions  have  shut  off  the  cavity,  (b)  Where  the  gall-bladder  is  small 
and  contracted,  so  as  not  to  reach  the  abdominal  wound,  the  parietal  perito- 
neum may  be  peeled  back  from  the  edges  of  the  abdominal  wound  and  sutured 
around  the  wound  in  the  fundus  of  the  gall-bladder.     (B)  In  General; — (a) 


Fig.  753- — Cholecystostomy: -—  A  rubber  drainage-tube  anchored  in  the  incised  fundus  of  the 
gall-bladder  and  about  to  be  further  buried  by  a  purse-string  suture. 

It  may  be  possible,  by  the  oblique  subcostal  incision,  to  expose  the  gall-bladder 
through  an  intermuscular  separation  of  the  external  oblique,  internal  oblique, 
and  transversalis  muscles,  in  the  triangular  space  bounded  by  the  eighth  nerve 
running  along  the  costal  arch,  the  ninth  nerve  running  transversely  inward 
from  the  level  of  the  lower  border  of  the  ninth  costal  cartilage,  and  the  linea 
semilunaris,  (b)  Adhesions  may  have  to  be  separated  before  the  gall-bladder 
can  be  brought  forward,  (c)  Avoid  stitching  the  gall-bladder  to  the  skin,  as 
such  fistulae  are  hard  to  cure,  (d)  Sometimes  stones  discovered  in  the  ducts 
can  be  milked  back  into  the  gall-bladder  and  thence  removed,  (e)  In  the 
two-stage  operation,  the  examination  of  the  interior  of  the  bladder  and  of  the 
ducts  is  not  so  satisfactory  as  in  the  single-stage  operation — nor  the  removal 
of  stones,  if  found,  so  easy. 


CHOLECYSTENTEROSTOMY 

BV  THE  MURPHY  BUTTON. 

Description. — By  Cholecystenterostomy  is  meant  the  establishment  of  a 
communication  between  the  gall-bladder  and  the  small  or  the  large  intestine. 
Preferably  the  union  is  made  with  the  duodenum  (Cholecysto-duodenostomy), 
— next,  with  the  upper  jejunum  (Cholecysto-jejunostomy), — and  if  these  be 
not  easily  brought  into  apposition  (because  of  adhesions,  or  other  conditions), 
the  junction  is  made  with  the  hepatic  flexure  of  the  colon  (Cholecysto-col- 
ostomy).  Union  may  be  accomplished  by  some  mechanical  device,  of  which 
Murphy's  special  gall-bladder  button  is  probably  the  best — or  it  may  be  ac- 
complished by  simple  suturing.  The  operation  is  indicated  in  unremovable 
obstruction  of  the  cystic  or  common  ducts,  in  chronic  cholecystitis,  and  in 
persistent  fistulae  following  cholecystostomy. 

Preparation — Position — Landmarks. —As  for  Cholecystotomy. 

Incision. — A  vertical  subcostal  incision  is  generally  to  be  preferred.     If  a 


CHOLECYSTENTEROSTOMY. 


1027 


tumor  exist,  the  incision  is  placed  over  it — if  not,  it  is  placed  in  the  right  semi- 
lunar line,  or  just  to  the  outer  side  of  it. 

Operation. — The  steps  of  the  operation  are  not  essentially  different  from 
Entero-enterostomy  by  the  Murphy  button.  (1)  The  abdomen  having  been 
opened,  the  gall-bladder  and  duodenum  are  exposed — and  trial  is  made  to  as- 
certain that  both  structures  can  be  brought  into  the  field  and  approximated 
without  too  great  tension.  The  field  is  then  packed  off  with  gauze.  If  the 
bladder  be  very  much  distended,  the  distention  is  lessened  by  partial  aspira- 
tion, that  the  contents  may  not  be  thrown  out  over  the  neighboring  parts  on 
incising  the  viscus.  (2)  The  regular  purse-string  suture  (see  Fig.  754)  is  then  in- 
troduced through  all  the  coats  of  the  gall-bladder,  calculating  to  so  place  it  upon 
the  prominent  fundus,  or  the  inferior  surface  of  the  gall-bladder,  as  to  make 
the  best  approximation  with  the  duodenum,  without  tension.  The  bladder- 
wall  is  then  incised  between  the  lines  of  the  purse-string  suture  for  a  distance 
equal  to  two-thirds  of  the  diameter  of  the  special  button.  The  male  button, 
grasped  in  the  usual  manner,  is  insinuated  into  the  opening  in  the  gall-bladder 
and  the  walls  of  that  viscus  drawn  about  the  cylinder  of  the  button  and  tied. 
(3)  The  female  button  is  similarly  introduced  into  the  free  aspect  of  the  duo- 
denum and  tied.  (4)  The  halves  of  the  button  are  pressed  together — thus 
completing  the  cholecysto-duodenostomy.  If  reinforcing  Lembert  sutures  are 
considered  necessary,  they  are  applied.  (5)  Unless  special  cause  for  drainage 
exists,  the  abdomen  is  closed  as  after  ordinary  abdominal  section. 


Fig.  754. — Cholecystenterostomy    by    the    Murphy    Button:— A,   Male    button    within    gall- 
bladder ;  B,  Female  button  within  duodenum. 


Comment. — (1)  Union  of  the  gall-bladder  to  portions  of  the  intestine  be- 
tween the  usual  site  of  anastomosis  (duodenum,  or  upper  part  of  jejunum)  and 
the  hepatic  flexure  of  the  colon,  is  more  apt  to  be  followed  by  volvulus.     (2) 


1028  OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

Prior  to  completing  the  anastomosis,  the  interior  of  the  gall-bladder  should  be 
examined  for  calculi,  and  the  ducts  palpated.  (3)  The  contents  of  the  duo- 
denum should  be  pressed  away  from  the  site  of  anastomosis  and  controlled  by 
double  clamps  during  the  operation.  (4)  If  more  convenient,  the  smaller 
female  button  may  be  placed  in  the  gall-bladder. 


CHOLECYSTENTEROSTOMY 

BY  SIMPLE  SUTURING. 

Description. — The  operation  is  the  same  as  Cholecystenterostomy  by  the 
Murphy  button,  except  that  no  artificial  device  is  used  in  accomplishing  the 
union  other  than  simple  suturing,  aided  by  special  clamps,  or  small  curved 
intestinal  clamps. 

Preparation — Position — Landmarks — Incision — Operation. — Are,  in 
the  main,  the  same  as  those  just  described.  Having  brought  the  gall-bladder 
and  intestine  (preferably  the  duodenum)  into  convenient  position  for  manipu- 
lation by  means  of  special  clamps,  the  two  viscera  are  united  in  exactly  the 
same  manner  as  in  entero-enterostomy  by  lateral  anastomosis  (see  page  862). 
A  posterior  row  of  continuous  Lembert  sutures  is  introduced  through  the 
serous  and  muscular  coats  of  the  two  viscera,  along  their  posterior  aspects, 
leaving  the  threads  long  at  both  ends.  The  two  organs  are  then  incised — 
and  the  lips  of  the  incision  whipped  together  by  an  overhand  continuous 
suture  of  all  the  coats — after  which,  the  line  of  continuous  Lembert  suturing 
is  carried  around  the  anterior  aspect  of  the  wound.  The  opening  made  in  the 
gall-bladder  and  intestine  is  from  1.2  to  2  cm.  (£  to  f  inch)  long.  The  parts 
are  returned  to  the  abdomen,  which  is  closed  in  the  usual  manner. 

Comment. — (1)  The  above  method  of  suturing  is  simpler  than  to  first 
make  the  incision  and  suture  together  the  mucous  coats  alone — followed  by 
suturing  of  muscular  and  serous  coats.  (2)  Sometimes,  though  rarely,  union  by 
simple  suturing  is  done  in  two,  or  even  in  three  stages; — (a)  In  Two  Stages; — 
The  gall-bladder  and  intestine  are  sutured  together  by  continuous  sutures  of 
serous  and  muscular  coats,  approximating  an  area  of  each  equal  to  about  2.5 
by  3.7  cm.  (1  by  i^  inches).  These  viscera  are  then  sutured  to  the  bottom  of 
the  abdominal  wound  and  the  wound  packed  for  several  days.  An  incision  is 
then  made  through  the  intestine — and  through  this  an  incision  is  made  through 
the  adherent  walls  of  gall-bladder  and  intestine.  The  incised  wound  in  the 
intestine  is  then  closed — and  the  abdominal  wound  also  closed,  (b)  In  Three 
Stages ; — The  gall-bladder  and  intestine  are  sutured  together,  as  in  the  above. 
The  gall-bladder  is  then  incised  and  its  edges  sutured  into  the  abdominal 
wound  (after  closing  the  excess  of  abdominal  wound  from  the  ends).  After 
several  days  the  adherent  wall  between  gall-bladder  and  intestine  is  incised 
through  the  fistula — which  fistula  is  then  allowed  to  close,  or  is  closed  by  a 
plastic  operation. 

CHOLECYSTO-LITHOTRITY. 

Description. — Consists  in  the  exposure  of  the  gall-bladder  and  crushing 
of  the  calculi  from  the  outside,  as  they  lie  within  the  gall-bladder — by  means 
of  the  fingers  or  special  forceps  with  protected  blades — and  manipulating  the 
fragments  on  into  the  cystic  duct.  The  operation  is  sometimes  applicable  in 
cases  of  soft  and  friable  stones.  Fragments  of  hard  stones  are  apt  to  wound  the 
gall-bladder.  Small  stones  may  sometimes  be  pushed  or  worked  on  out  of  the 
gall-bladder  into  the  cystic  and  common  duct  without  being  broken. 


CHOLECYSTECTOMY. 


IO29 


The  steps  of  the  operation  are  the  same  as  those  for  Cholecystotomy,  up 
to  the  point  of  exposing  the  gall-bladder — after  which  it  is  a  process  of  palpation 
and  manipulation  with  the  fingers,  or  special  protected  forceps. 


CHOLECYSTECTOMY. 

Description.— The  total  excision  of  the  gall-bladder.  Indicated  when 
the  gall-bladder  or  the  cystic  duct  is  considerably  changed  by  disease,  or  where 
contracted  and  deep-lying,  making  difficult  the  approximation  of  the  gall- 
bladder to  the  abdominal  wall  (cholecystotomy) ;  and  where  the  hepatic  and 
common  bile-ducts  are  patulous. 

Preparation — Position — Landmarks — Incision. — As  for  Cholecysto- 
tomy by  vertical  subcostal  incision. 


Fig. 755.— Cholecystectomy  by  Vertical  Subcostal  Incision: — A,  Liver  displaced  upward, 
exposing  fossa  of  gall-bladder;  B,  Gauze  pad  protecting  neighboring  structures;  C,  Longitudinally 
incised  peritoneum  over  gall-bladder  being  separated  from  the  bladder  by  blunt  dissection  ;  D,  Liga- 
ture placed  around  pedicle  of  gall-bladder. 

Operation. — (1)  Having  exposed  the  subhepatic  region  by  thorough  re- 
traction, aided  by  the  reversed  Trendelenburg  position,  and  packed  off  the 
neighboring  vicinity  with  gauze,  the  gall-bladder  is  isolated  (Fig.  755).  (2) 
The  peritoneum  binding  the  gall-bladder  to  its  fossa  is  incised  over  the  pro- 
minent inferior  surface  of  the  gall-bladder — either  in  one  straight  line  in  the 
long  axis  of  the  bladder,  from  fundus  to  cystic  duct — or  in  the  form  of  an 
ellipse  (especially  where  the  bladder  is  large),  the  two  limbs  meeting  at  the 
fundus  and  cystic  duct.     (3)  This  incision  having  passed  simply  through  the 


1030  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

serous  covering  into  the  underlying  connective  tissue,  the  peritoneum  is  sepa- 
rated from  the  gall-bladder  by  blunt  dissection,  from  fundus  to  neck,  and 
throughout  its  width,  and  retracted  to  either  side.  Having  dissected  and 
peeled  back  the  peritoneal  covering,  the  gall-bladder  itself  is  then  dissected,  or 
shelled  out,  by  blunt  dissection  from  its  fossa  and  freed  to  its  pedicle — working 
with  curved  blunt  scissors  and  a  blunt  dissector,  and  keeping  strictly  in  the 
connective-tissue  plane.  The  pedicle,  formed  by  the  cystic  duct  and  vessels, 
is  well  isolated,  doubly  ligated  with  chromic  gut,  and  divided  between  the 
ligatures,  the  adjacent  structures  having  been  protected  with  gauze  packing. 
The  end  of  the  divided  duct  may  be  immediately  cauterized.  (4)  The  divided 
peritoneum,  which  has  been  separated  and  retracted  in  the  form  of  two  flaps, 
is  now  sutured  with  gut  over  the  fossa  of  the  gall-bladder.  (5)  The  abdomen 
is  closed — generally  without  drainage. 

Comment. — (1)  It  may  be  necessary  to  separate  adhesions  by  blunt  dis- 
section, or  by  division  between  ligature.  (2)  If  much  distended,  the  gall- 
bladder should  be  first  partially  emptied  by  aspiration  through  a  fine  needle — 
the  needle  wound  being  subsequently  puckered  together  with  a  purse-string 
ligature  before  manipulating  the  bladder.  (3)  Avoid  the  inclusion  of  the 
hepatic  and  common  ducts.  (4)  The  abdominal  wound  may  be  closed  in 
part  only,  leaving  a  temporary  drain.  (5)  The  cystic  duct  and  artery  may 
be  tied  or  clamped  at  the  neck  of  the  gall-bladder  first  and  the  organ  removed 
from  behind  forward — thus  giving,  possibly,  a  clearer,  because  less  bloody, 
field  for  the  most  difficult  stage  of  the  operation.  The  peritoneum  is  then 
raised  from  the  gall-bladder  from  below  and  the  viscus  enucleated  in  the  act 
of  working  forward.  The  incised  peritoneum  is  sutured  over  the  gall-bladder 
bed. 

IX.  THE  GALL-DUCTS. 

SURGICAL  ANATOMY. 

Hepatic  Duct. — Formed  by  right  and  left  bile-ducts  uniting  generally  at 
their  emergence  from  the  liver.  Length  from  3  to  5  cm.  {i\  to  2  inches). 
Diameter,  about  4  mm.  (nearly  f\  inch).  Passes  downward  in  right  border 
of  gastro-hepatic  omentum,  having  vena  cava  behind  and  hepatic  artery  to 
left.     Unites  with  cystic  duct  to  form  common  bile-duct. 

Cystic  Duct. — Begins  at  neck  of  gall-bladder — is  directed  slightly  to  left — 
and  ends  at  its  junction  with  hepatic  duct  at  an  acute  angle,  to  form  common 
bile-duct.  Length,  2.5  to  4  cm.  (1  to  1^  inches).  Passes  downward,  back- 
ward, and  to  left  in  gastro-hepatic  omentum — having  hepatic  artery  to  left 
and  portal  vein  behind. 

Common  Bile-duct. — Formed  by  union  of  hepatic  an4  cystic  ducts. 
Length,  about  7.5  cm.  (3  inches),  dependent  upon  site  of  union  of  cystic  and 
hepatic  ducts.  Diameter,  about  6  mm.  (nearly  \  inch).  Its  course  and  re- 
lations are  the  following; — continuing  the  direction  of  hepatic  duct,  it  passes 
downward  and  backward  in  hepato-duodenal  portion  of  gastro-hepatic  liga- 
ment, having  hepatic  artery  and  its  gastro-duodenal  branch  to  left,  and  portal 
vein  behind  and  between — enters  right  pancreatico-gastric  fold  behind  first 
portion  of  duodenum  (superior  curve),  then  passes  between  second  portion  of 
duodenum  (descending  part)  and  head  of  pancreas — and  ends  by  entering 
posterior  and  inner  wall  of  descending  portion  of  duodenum  (being  crossed  on 
the  way  by  the  pancreatico-duodenal  artery),  running  obliquely  for  about  2  cm. 
(f  inch)  through  its  walls  and  opening  upon  a  papilla  of  mucous  membrane 
about  10  cm.  (4  inches)  from  the  pylorus.  The  pancreatic  duct  joins  the  com- 
mon bile-duct  just  before  its  termination. 


SUPRADUODENAL  CHOLEDOCHOTOMY. 


1031 


SURFACE  FORM  AND  LANDMARKS.    INSTRUMENTS. 
See  these  headings  under  the  Liver  and  Gall-bladder. 

GENERAL  SURGICAL  CONSIDERATIONS. 

The  common  bile-duct  lies  in  the  hepato-duodenal  ligament,  near  its  right 
free  margin — in  the  free  border  which  constitutes  the  fold  at  the  entrance  of 
the  foramen  of  Winslow — the  hepatic  artery  lying  nearby  to  its  left — and  the 
vena  porta  behind  and  between  the  common  duct  and  hepatic  artery — owing 
to  which  important  relations,  the  ducts  should  be  fully  exposed  before  being 
opened.     (See  Fig.  756.) 

Where  more  than  usual  room  is  required,  resection  of  the  right  costal  arch 
may  be  performed. 

No  suture  should  be  used  which  will  come  within  the  lumen  of  any  of  the 
ducts — for  fear  of  forming  the  nucleus  of  calculi. 

The  exact  nature  of  the  operation  to  be  done  is  frequently  not  known  until 
the  gall-bladder  and  ducts  are  exposed  and  examined 


Fig.  756.— Hepato-duodenal  Ligament  and  Contained  Structures:  — A,  Ligamentum 
hepato-duodenale  ;  B,  Common  bile-duct;  C,  Vena  porta?  ;  D,  Hepatic  artery;  E,  Gall-bladder;  F, 
Arrow  within  foramen  of  Winslow. 


SUPRADUODENAL  CHOLEDOCHOTOMY. 

Description. — Incision  of  common  bile-duct  above  the  duodenum.  Gen- 
erally performed  for  the  removal  of  calculi. 

Preparation — Position — Landmarks. — As  for  exposure  of  gall-bladder 
by  vertical  subcostal  incision,  page  1024. 

Incision. — The  site  of  operation  is  often  reached  in  the  course  of  some 
other  operation  about  the  liver  or  gall-passages.  Where  especially  planned 
for  the  removal  of  a  stone  in  the  common  duct,  a  vertical  incision  may  be 
made  along  the  outer  border  of  the  right  rectus,  its  upper  end  being  extended 
along  the  upper  part  of  the  subcostal  border  (the  Robson  incision,  Fig.  751). 
A  curved  incision  may  also  be  used — from  just  below  the  outer  aspect  of  the 
ensiform  cartilage,  thence  parallel  with  and  about  1.2  cm.  (^  inch)  from  the 
costal  arch  to  a  point  about  1.2  cm.  {\  inch)  above  the  end  of  the  eleventh  rib. 
In  either  of  these  incisions  only  the  ninth  nerve  need  be  divided.  Fenger 
gives  a  vertical  incision,  combined,  if  necessary,  with  a  transverse  addition. 


I032  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

Operation. — (1)  The  abdomen  having  been  opened — the  liver  retracted 
well  upward — the  intestines  depressed  (or  having  fallen  away  in  the  reversed 
Trendelenburg  position) — the  gall-bladder  is  exposed.  (2)  The  bladder  is 
then  first  palpated  for  calculi — and  the  cystic  and  hepatic  ducts  are  followed 
down  until  the  common  duct  is  reached — manipulating  in  the  manner  de- 
scribed below.  (3)  All  adhesions  present  should  be  broken  down  by  blunt 
dissection,  or  divided  between  chromic  gut  ligatures.  These  adhesions  are  apt 
to  be  found  between  gall-bladder,  stomach,  transverse  colon,  great  omentum, 
and  duodenum.  The  entire  area  should  be  packed  off  with  gauze.  By  means 
of  a  piece  of  gauze  the  liver  and  gall-bladder  are  grasped,  drawn  down  from 
under  the  costal  arch,  and  rotated  in  such  a  way  as  to  stretch  and  make  promi- 
nent the  common  duct  and  bring  it  nearer  the  surface.     (4)  After  tracing 


Fig. 757 — Choledochotomy  and  Choledochorrhaphy,  by  Vertical  Subcostal  Incision 
in  Right  Linea  Semilunaris: — A,  Foramen  of  Winslow,  leading  behind  hepato-duodenal  liga- 
ment ;  B,  Distended  common  bile-duct  incised  over  a  calculus.  Lembert  interrupted  sutures  are 
shown  placed  ready  to  be  tied  after  extraction  of  stone;  C,  Position  of  vena  portae  ;  D,  Position  of 
hepatic  artery. 


down  the  cystic  duct,  expose  the  anterior  surface  of  the  hepato-duodenal 
ligament  down  to  the  duodenum — demonstrate  the  free  border  of  the  liga- 
mentum  hepato-duodenale  to  the  right — insert  the  left  index-finger  into  the 
foramen  of  Winslow  (with  pulp  of  finger  forward)  and  left  thumb  upon  the 
anterior  surface  of  this  ligament — follow  its  structure  downward  to  the  duo- 
denum, having,  between  the  fingers,  the  common  duct  to  the  right,  the  hepatic 
artery  to  the  left,  and  the  vena  portae  on  a  plane  posterior  to  and  between  the 
other  two.  (5)  Having  located  the  stone  by  the  above  method  of  palpation, 
especially  guard  against  its  slipping  into  the  hepatic  duct  from  between  the 
thumb  and  index — by  pressing  it  forward  against  the  anterior  wall  of  the  duct 
and  steadying  it  in  that  position.     (6)   Incise  the  duct  in  its  long  axis,  directly 


SUPRADUODENAL  CHOLEDOCHOTOM  V. 


1Q33 


over  the  stone,  for  a  distance  of  from  i  to  3  cm.  (J  to  i\  inches) ,  as  indicated 
(Fig.  757) .  The  escaping  bile  is  caught  in  gauze — and  the  presenting  calculus 
removed  with  special  forceps  or  scoop.  Having  removed  the  stone,  the  com- 
mon duct  should  be  examined  for  other  stones — by  means  of  the  hnger  or  probe 
— and  from  the  duodenum  to  and  into  the  cystic  and  hepatic  ducts.  (7)  Hav- 
ing extracted  the  stone,  the  wound  in  the  duct  is  generally  closed — either  by 
simple  suturing — or  by  suturing  aided  by  some  such  mechanical  device  as  one 
of  Halsted's  hammers  ( which  are  of  various  sizes),  (a)  Closure  Aided  by 
Halsted's  Hammer; — Preliminary  to  the  incision,  two  traction-sutures  are 
inserted  on  either  side  of  the  line  of  the  future  incision,  through  the  outer  coats 
of  the  duct — for  the  purpose  of  aiding  the  manipulation.  Having  evacuated 
the  duct  and  examined  its  cavity  for  other  calculi,  Halsted's  hammer  is  in- 
troduced by  insinuating  its  longer  arm  into  the  incised  wound — the  hammer 
portion  distending  the  duct  and  rendering  it  easier  to  suture  its  walls  over  the 
round,  firm  form — which  also  obstructs  the  flow  of  bile  during  the  operation. 
(Fig.  758.)  The  opening  is  finally  closed  either  by  Halsted's  mattress  sutures 
passed  through  the  outer  coats  of  the  duct, — or  two  rows  of  ordinary  sutures 
may  be  used — an  inner  row  of  interrupted  gut  sutures  through  the  muscular 
and  external  coats,  without  penetrating  the  mucous  membrane — and  an  outer 
row  of  interrupted  silk  sutures  through  the  serous  surfaces.  The  peritoneum 
covering  the  anterior  aspect  of  the  hepato-duodenal  ligament  is  included  in  the 
suturing,  (b)  Closure  by  Simple  Suturing; — Having  incised  the  duct  over  the 
stone,  before  the  stone  is  removed  the  first  row  of  sutures,  inserted  upon  a 
small,  fully  curved  needle  through  the  muscular  and  external  coats,  is  passed 
while  the  stone  is  still  in  situ  (using  the  stone  as  a  distender  of  the  gut) — these 
stitches  are  then  held  apart  and  the  stone  is  withdrawn  between  them — after 
which  the  first  row  is  tied  and  an  outer  row  of  interrupted  silk  sutures  is  passed 
through  the  serous  surfaces,  as  above  described  (Fig.  757).  (8)  In  completing 
the  operation,  a  rubber  drainage- 
tube  may  be  carried  down  to  the 
wound  in  the  duct,  and  this  sur- 
rounded by  gauze — the  abdominal 
wound  being  closed  except  where 
the  drainage  comes  out — consti- 
tuting indirect  drainage.  Or  a 
drainage-tube  may  be  carried  into 
the  wound  of  the  common  duct,  or 
into  the  gall-bladder,  or  into  the 
cystic  duct  if  the  gall-bladder  have 
been  removed  (direct  drainage). 

Comment. — (1)  If  distended, 
the  gall-bladder  or  duct  should 
first  be  partly  aspirated.  (2)  Where 
choledochotomy  with  suture  of  the 
duct  is  done,  cholecystostomy  is  fre- 
quently done  at  the  same  time,  to 
relieve  the  tension  upon  the  stitches 
and  as  a  drain.  (3)  It  is  easier  to 
suture  a  thickened  duct,  and  harder 

to  suture  a  thin  one.  If  it  be  impossible  to  suture  the  duct,  insert  a  small 
rubber  drainage-tube  into  the  opened  duct  and  pack  around  it  with  gauze. 
(4)  If  the  stone  can  be  shifted,  it  is  better  to  shift  it  nearer  the  duodenum  before 
incising  the  duct — as  there  is  less  danger  of  wounding  the  vena  portae.     (5) 


Fig.  758.— Choledochorrhaphy,  Aided  by 
Halsted's  Hammer  :  — The  hammer  is  shown  in 
situ  during  placing  of  sutures— and  is  withdrawn 
prior  to  tightening  last  of  the  sutures. 


1034  OPERATIONS    UPON    THE    AHDOMINO-PELVIC    REGION. 

After  incising  the  duct,  it  may  be  necessary  to  crush  the  stone  in  situ  by  inserting 
special  crushing  forceps  through  the  wound  in  the  duct  and  then  removing 
the  debris  with  scoop  or  forceps.  (6)  If  possible,  ascertain  with  the  probe 
whether  duct  into  the  duodenum  is  patulous. 


RETRODUODENAL  CHOLEDOCHOTOMY. 

iiaasler's  operation. 

Description. — Calculi  have  sometimes  proved  inaccessible  by  the  ordinary 
route  of  approach — and  have  been  removed  by  exposing  and  incising  the 
common  duct  behind  the  duodenum.  An  attempt,  however,  should  first  be 
made  to  dislodge  such  calculi  upward  into  the  more  readily  accessible  part 
of  the  duct. 

Preparation — Position — Landmarks — Incision. — As  in  supraduodenal 
choledochotomy. 

Operation. — Having  opened  the  abdomen  and  brought  the  field  of  opera- 
tion into  access,  the  common  duct  is  exposed.  The  parietal  peritoneum  of 
the  posterior  abdominal  wall  is  then  incised  vertically,  about  4  cm.  (1^  inches) 
to  the  right  of  the  duodenum.  The  peritoneum  is  raised  by  blunt  dissection 
until  the  second  portion  of  the  duodenum  is  reached — which  is  then  displaced 
to  the  left,  thus  exposing  its  posterior  surface.  The  second  portion  of  the 
common  duct  is  located,  covered  by,  or  in  a  groove  of,  the  pancreas — and  is 
exposed  by  blunt  dissection — and  incised  over  the  calculus.  The  duct  is 
then  explored  and  sutured  as  in  the  preceding  operation — and  drainage  of  its 
bed  established. 


TRANSDUODENAL  CHOLEDOCHOSTOMY. 

kocher's  operatiox. 

Description.- — The  second  or  third  part  of  the  common  duct  is  opened  to 
remove  an  impacted  calculus — by  incising  the  anterior  and  posterior  walls  of 
the  second  portion  of  the  duodenum  and  the  portion  of  the  pancreas  sur- 
rounding the  duct. 

Preparation — Position — Landmarks — Incision. — As  for  supraduodenal 
choledochotomy. 

Operation. — The  abdomen  is  opened — the  liver  elevated  and  retracted — 
and  the  site  of  the  common  duct  and  duodenum  exposed  and  packed  off. 
The  duodenum  is  mobilized  by  a  vertical  incision  about  4  cm.  (ij  inches) 
to  the  outer  aspect  of  the  duodenum— and  from  this  incision  the  peritoneum 
is  detached  by  blunt  dissection  up  to  the  duodenum.  The  duodenum, 
together  with  the  head  of  the  pancreas,  is  further  freed  toward  the  middle 
line.  A  couple  of  fingers  are  then  inserted  behind  the  duodenum,  or  through 
the  foramen  of  Winslow,  and  the  bowel  elevated  into  the  abdominal  wound, 
the  hold  upon  the  intestines  being  maintained  throughout  the  operation. 
After  the  stone  has  been  steadied  an  incision  is  made  through  the  walls  of  the 
duodenum,  in  the  long  axis  of  the  intestine,  and  the  two  edges  of  the  intestinal 
wound  held  apart  by  special  clamps — the  intestinal  outflow  being  caught 
upon  gauze  (Fig.  759).  The  interior  of  the  intestine  is  examined — the  stone 
is  felt  through  its  posterior  wall — and  the  opening  of  the  ampulla  is  located 
somewhat  lower  down.  In  the  rare  cases  in  which  the  stone  can  be  protruded 
through  the  ampulla,  further  incision  is  unnecessary.     Otherwise,  the  incision 


CYSTICOTOMY, 


I°3S 


is  made  directly  over  the  stone,  in  the  long  axis  of  the  intestine,  through  its 
posterior  wall.  When  the  knife  reaches  the  calculus,  two  catgut  stitches  are 
carried  through  the  lips  of  the  intestinal  wound,  one  on  either  side — to  be 
first  used  as  tractors  and  subsequently  as  sutures.  The  intestinal  incision  is 
now  lengthened  and  the  stone  removed  with  scoop  or  forceps.  A  third  stitch 
may  be  carried  through  the  upper  angle  of  the  wound,  including  duct,  pan- 
creas, and  intestinal  wall.  The  outflow  of  bile  is  caught,  and  the  duct  is 
explored  toward  the  gall-bladder,  by  both  finger  and  probe.  Having  com- 
pleted the  operation,  the  traction-sutures  are  tied  as  plain  sutures  and  additional 
ones  inserted,  if  necessary,  using  catgut  and  carrying  them  through  all  the 
coats.  If  the  duct  has  been  incised  in  its  interstitial  part,  no  suturing  is 
needed — but  sutures  should  be  placed  if  the  incision  has  been  higher.  The 
incision  through  the  anterior  wall  of  the  duodenum  is  first  sutured  with  through- 
and-through  sutures  of  all  the  coats,  followed  by  a  seromuscular  suture.  The 
site  of  suture  may  be  reinforced  with  an  omental  graft.  The  duodenum  is 
now  allowed  to  fall  back  into  place — and  the  abdomen  closed — generally 
without  drainage,  unless  cholecystotomy  or  cholecystectomy  have  been  done. 


Fig.  750. — Transduodenal  Choledochostomy: — The  anterior  wall  of  the  duodenum 
is  incised — showing  the  papilla  of  the  common  duct  and  the  incision  into  the  duct  through  the 
posterior  wall  of  the  duodenum. 

Comment. — If  the  calculus  be  impacted  in  the  interstitial  portion  of  the 
common  duct,  the  incision  is  made  into  but  not  through  the  posterior  wall  of 
the  duodenum.  If  the  calculus  be  impacted  at  the  orifice  of  the  ampulla, 
and  cannot  be  extracted  from  the  orifice  with  forceps,  the  margin  of  the 
ampulla  is  incised  and  the  calculus  then  withdrawn  (Ampullary  Choledoch- 
otomy  of  McBurney). 


CYSTICOTOMY. 

Description. — The  incision  of  the  cystic  duct — an  operation  performed 
for  the  removal  of  a  calculus  from  the  cystic  duct — when  not  removable 
through  the  gall-bladder  or  the  common  duct. 

Preparation — Position — Landmarks — Incision. — As  for  Supraduodenal 
Choledochotomy,  page  1031. 

Operation. — The  technic   here  is  practically  the  same  as  employed  in 


1036  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

choledochotomy.  By  rotation  and  traction  upon  the  liver  the  neck  of  the 
gall-bladder  and  the  cystic  duct  are  exposed.  The  duct  and  its  calculus  are 
steadied  in  the  wound — and  an  incision  made  over  the  stone  through  the  duct 
wall.  If  further  exploration  of  the  gall-bladder  tract  prove  it  to  be  clear, 
the  wound  in  the  cystic  duct  is  closed — by  a  continuous  fine  catgut  suture  of 
the  outer  coats  (avoiding  the  mucosa) — followed  by  the  suturing  of  the  serosa 
with  fine  silk  or  celluloid  thread.  The  gall-bladder  is  drained — and  the 
abdomen  otherwise  drained. 

HEPATICOTOMY. 

Description. — The  incision  of  the  hepatic  duct — an  operation  sometimes 
performed  for  the  removal  of  a  calculus  from  the  hepatic  duct — when  not 
removable  by  downward  displacement  and  incision  of  the  common  duct. 

Preparation — Position — Landmarks — Incision. — As  for  Supraduodenal 
Choledochotomy,  page  103 1. 

Operation. — The  technic  here  employed  is  similar  to  that  just  given  for 
incising  the  cystic  duct.  The  wound  in  the  duct  is  sutured  in  the  same 
manner — and  drainage  of  the  gall-bladder  established. 


X.    THE  SPLEEN. 

SURGICAL  ANATOMY. 

Description  and  Situation. — Situated  chiefly  in  left  hypochondriac 
region — lying  above  left  kidney  and  splenic  flexure  of  colon — between  con- 
cavity of  diaphragm  to  left  and  behind,  and  fundus  of  stomach  to  right  and  in 
front — corresponding,  in  axillary  line,  with  ninth,  tenth,  and  eleventh  left  ribs. 
It  lies  obliquely  from  above  downward  and  from  within  outward.  Its  length 
is  about  12  cm.  (4!  inches) — breadth,  8  cm.  (3 \  inches) — thickness,  3  cm. 
{\\  inches).  The  peritoneum  entirely  surrounds  the  spleen  except  at  its 
hilum — which  is  at  the  center  of  the  internal  surface  (between  the  renal  and 
gastric  portions  of  internal  surface)  through  which  the  arteries  and  nerves  enter 
and  the  veins  and  lymphatics  emerge.  Its  pedicle  is  formed  by  the  reflection 
of  peritoneum  over  the  vessels  at  the  hilum.  The  diaphragm  separates  all 
parts  of  the  normal  spleen  from  the  parietes.  The  spleen  may  be  absent,  or 
there  may  be  from  one  to  twenty  more  or  less  rudimentary  spleens  present. 

Surfaces  and  Borders. — Phrenic  surface;  lies  beneath  left  ninth,  tenth, 
and  eleventh  ribs — peritoneum,  diaphragm,  portions  of  left  pleura  and  lung, 
the  costo-phrenic  sinus  (and  sometimes  left  lobe  of  liver)  intervening.  Renal 
part  of  internal  surface;  touches  superior  and  external  part  of  left  kidney, 
and  generally  the  suprarenal  capsule.  Gastric  part  of  internal  surface;  in 
contact  with  posterior  wall  of  a  filled  stomach.  Basal  surface  (lower  outer 
end) ;  in  contact  with  splenic  flexure  of  colon  and  phreno-colic  ligament  (and 
often  with  tail  of  pancreas).  Anterior  margin;  situated  between  diaphragm 
and  stomach.  Posterior  border;  between  diaphragm  and  left  kidney. 
Superior  end ;  on  level  with  tenth  dorsal  vertebra,  approaching  within  2  to  3 
cm.  (f  to  1  \  inches)  of  spinal  column.  Reaches  to  level  of  ninth  dorsal 
spine.  Inferior  end;  limited  anteriorly  by  costo-clavicular  line  (connecting 
left  sterno-clavicular  articulation  with  anterior  end  of  eleventh  rib).  Reaches 
to  level  of  first  lumbar  spine. 


GENERAL    SURGICAL    CONSIDERATIONS.  1037 

Relations. — Externally  and  Superiorly;  peritoneum;  diaphragm;  left 
ninth,  tenth,  and  eleventh  ribs;  costo-phrenic  sinus;  left  lung  and  pleura;  pos- 
terior thoracic  muscles.  Inferiorly;  splenic  flexure  of  colon;  phreno-colic 
ligament;  tail  of  pancreas  (sometimes).  Internally;  stomach  (posterior  sur- 
face of  fundus) ;  left  kidney  and  capsule;  tail  of  pancreas;  spinal  column  (some- 
times). 

Relations  of  Spleen  to  Thoracic  Cavity. — Upper  third  of  spleen  is 
covered  by  left  lung, — middle  third  is  in  contact  with  left  costo-phrenic  sinus, — 
lower  third  passes  below  lower  pleural  limit  and  costal  origin  of  diaphragm. 

Ligaments  and  Fixations  of  Spleen.— Gastro-splenic  omentum — from 
hilum  to  fundus  of  stomach.  Phreno-splenic  ligament— from  upper  end  of 
spleen  to  diaphragm.  Spleno-renal  ligament — formed  partly  by  greater  and 
lesser  peritoneal  sacs — contains  the  splenic  vessels.  Phreno-colic  ligament — 
affords  support,  though  not  connected  with  spleen.  Pancreatico-splenic  liga- 
ment— present  when  tail  of  pancreas  does  not  reach  spleen.  Spleno-colic  liga- 
ment— from  basal  aspect  of  spleen  to  colon  (sometimes  present). 

Arteries. — Splenic. 

Veins.— Splenic. 

Lymphatics. — Empty  into  glands  at  hilum. 

Nerves. — From  cceliac  plexus  and  right  pneumogastnc. 


SURFACE  FORM  AND  LANDMARKS. 

Upper  end  of  spleen  lies  opposite  level  of  ninth  dorsal  spine — lower  end 
opposite  level  of  first  lumbar  spine.  The  inner  border  comes  within  3.8  to 
5  cm.  (ih  to  2  inches)  of  the  median  plane  of  the  body.  The  outer  border  lies 
just  posterior  to  the  mid-axillary  line — not  coming  further  forward  than  a  line 
joining  the  left  sterno-clavicular  articulation  and  the  anterior  end  of  the 
eleventh  rib.  The  spleen  corresponds  with  the  ninth,  tenth,  and  eleventh  left 
ribs — separated  from  them  by  the  diaphragm  and,  in  its  upper  part,  also  by  the 
lung.  Its  long  axis  about  corresponds  with  the  line  of  the  left  tenth  rib.  It 
slightly  overlaps  the  outer  border  of  the  left  kidney  below. 


GENERAL  SURGICAL  CONSIDERATIONS. 

The  spleen  may  be  exposed  in  several  ways — by  oblique  subcostal  incision 
parallel  with  costal  arch;  by  vertical  incision  in  left  linea  semilunaris;  by  ver- 
tical incision  to  left  of  left  linea  semilunaris;  by  median  abdominal  incision;  by 
intercostal  incision;  by  partial  excision  of  one  or  more  ribs,  followed  by  sub- 
pleural  or  transpleural  exposure  of  spleen.  If  more  room  be  needed,  any  of  the 
vertical  incisions  may  be  increased  by  a  transverse  or  curved  incision  extending 
toward  flank  or  median  line,  from  the  lower  part  of  the  vertical  incision. 
Where  an  abdominal  incision  is  first  made  for  pure  exploratory  purposes,  the 
median  abdominal  incision  is  probably  best.  There  is  general  similarity  in 
the  technic  of  hepatic  and  splenic  operations.  The  freest  exposure  of  the 
splenic  region,  as  of  the  hepatic  region,  is  secured  by  the  temporary  resection 
of  the  costal  cartilage  (page  1017). 


1038  OPERATIONS   UPON    THE    ABDOMINO-PELVIC    REGION. 

INSTRUMENTS. 
See  those  used  in  operating  upon  the  Liver. 


EXPLORATORY  PUNCTURE  OF  SPLEEN. 

Exploratory  puncture  of  the  spleen  is  macte  in  the  same  general  manner, 
and  with  the  same  general  precautions,  as  is  exploratory  puncture  of  the  liver 
(see  page  1008) .  As  in  the  case  of  the  liver,  exploratory  puncture  of  the  spleen 
is  rarely  warrantable,  owing  to  the  risks  of  sepsis  and  hemorrhage — and  should 
not  be  used  except  in  the  case  of  tumors,  which  are  almost  certainly  adherent 
to  the  abdominal  wall,  thus  shutting  off  the  general  peritoneal  cavity— and 
especially  in  those  projecting  below  the  ribs.  The  site  of  the  tumor  and  the 
general  relations  given  under  Surgical  Anatomy  will  serve  as  the  guide  for  the 
site  of  puncture — the  puncture  itself  being  made  exactly  as  it  is  in  the  case 
of  the  liver. 


SPLENOTOMY 

BY  OBLIQUE  SUBCOSTAL  INCISION. 

Description. — Incision  of  the  spleen — by  an  incision  just  below  and  paral- 
lel with  the  left  costal  arch.  The  spleen  may  be  exposed  by  any  of  the  incisions 
mentioned  under  General  Surgical  Considerations — one  of  the  first  three  being 
preferable.  The  operation  may  be  done  in  one  stage- — or  in  two  stages  (after 
adhesions  have  formed) — and  is  generally  resorted  to  for  the  liberation  of  pus. 

Preparation — Position. — As  for  Median  Abdominal  Section. 

Landmarks. — Lower  border  of  left  costal  arch;  left  linea  semilunaris; 
position  of  tumor,  if  any. 

Incision. — Oblique  incision  parallel  with  and  about  1.3  cm.  (\  inch)  below 
left  costal  arch,  with  its  center  over  the  site  of  spleen  (the  inner  border  of  which 
comes  to  within  4  to  5  cm.  [1^  to  2  inches]  of  the  median  plane — and  whose 
outer  border  extends  just  posteriorly  to  the  mid-axillary  line). 

Operation. — (1)  Having  opened  the  abdomen  in  the  same  manner  as  in 
Hepatotomy  by  the  same  incision,  the  spleen  is  isolated  and  brought  into  the 
wound  as  far  as  possible  and  the  neighboring  field  packed  off  with  gauze.  In 
dealing  with  fluid  collections  within  the  spleen  substance,  the  tension  should  be 
lessened  by  partial  aspiration  of  the  contents  preliminarily  to  incision  of  the 
viscus,  after  the  organ  is  brought  into  the  wound.  (2)  The  operation  may  be 
completed  in  one  or  in  two  stages; — (a)  In  One  Stage: — Having  been  brought 
as  near  the  surface  of  the  wound  as  possible,  and  after  packing  off  the  vicinity 
as  securely  as  possible,  the  spleen  is  incised  in  the  same  general  manner  and 
with  the  same  precautions  as  in  the  case  of  the  liver  (seepage  10 12).  In  the 
case  of  a  fluid  collection,  the  edges  of  the  pus  or  cyst  cavity  are  then  seized  and 
brought  forward  and  sutured  into  the  lower  plane  of  the  abdominal  wound 
(which  is  closed  in  from  either  end  for  a  part  of  the  distance) — the  sutures 
passing  through  spleen  substance  and  capsule  at  some  distance  from  the 
wound  in  the  viscus,  on  the  one  hand,  and  through  parietal  peritoneum  and 
part  of  the  thickness  of  the  lower  plane  of  the  lips  of  the  abdominal  wound,  on 
the  other — thus  approximating  the  peritoneum  of  the  spleen  and  the  perito- 


SPLENOPEXY.  IO39 

neum  of  the  abdominal  wall  all  around,  (b)  In  Two  Stages;— The  spleen  is 
brought  into  the  wound  and  the  parietal  peritoneum  and  edges  of  the  abdo- 
minal wound  are  stitched  in  an  elliptical  manner  to  the  serous  surface  and  to 
the  substance  of  the  spleen — the  wound  of  the  abdomen,  which  is  partly  closed 
from  one  or  both  ends,  is  then  packed  with  gauze  and  two  or  three  days  given 
for  union — after  which  the  spleen  is  incised.  x\ll  incisions  into  spleen  sub- 
stance are  planned  so  as  to  avoid,  as  far  as  possible,  the  large  vessels  of  the 
viscus.  (3)  Where  the  spleen  has  been  incised  for  exploration  simply,  and 
nothing  has  been  found,  splenorrhaphy  is  done  and  the  abdomen  closed. 

Comment. —  When  indicated,   the  costal  cartilages  may  be  temporarily 
resected  (page  10 17). 


EXPOSURE  OF  SPLEEN  BY  SUBPLEURAL  ROUTE 

BY  PARTIAL  EXCISION  OF  ONE  OR  TWO  RIBS. 

Description. — For  the  general  description,  see  the  corresponding  opera- 
tion upon  the  liver.  The  ribs  chosen  are  usually  the  tenth  and  eleventh 
(and  the  former  when  only  one  rib  is  excised) — the  site  of  excision  lying  mid- 
way between  a  point  about  4  to  5  cm.  (1^  to  2  inches)  from  the  median  plane, 
and  a  point  just  posterior  to  the  mid-axillary  line.  The  steps  of  the  operation 
are  the  same  as  those  for  the  subpleural  exposure  of  the  liver  by  the  partial  ex- 
cision of  one  or  more  ribs  (see  page  1014). 


SPLENORRHAPHY. 

Description. — Suturing  of  the  spleen.  Generally  resorted  to  for  incised 
and  lacerated  wounds,  and  for  approximating  surfaces  after  partial  splenec- 
tomy. The  route  of  approach  is  often  determined  by  a  pre-existing  wound  or 
operation — if  not,  the  oblique  subcostal  incision  parallel  with  the  left  costal 
arch  gives  the  best  exposure.  For  the  method  of  approaching  the  spleen, 
therefore,  see  Partial  Splenectomy  by  Oblique  Subcostal  Incision  parallel  with 
the  Ribs,  page  1040.  For  the  details  of  the  operation,  after  exposing  the 
organ,  see  Hepatorrhaphy,  page  10 19,  the  technic  being  practically  the  same. 


SPLENOPEXY. 

Description. — Bv  Splenopexy  is  meant  the  fixation,  generally  by  means 
of  suturing,  of  a  displaced  spleen  back  to  its  original  site,  or  to  another  site. 
Indicated  in     wandering"  spleen  (Splenoptosis). 

Preparation — Position — Landmarks. — As  for  Partial  or  Total  Splen- 
ectomy, according  to  the  incision  adopted. 

Incision. — The  organ  may  be  approached  by  a  vertical  incision  in  the  left 
linea  semilunaris;  by  an  oblique  subcostal  incision;  or  by  a  median  vertical 
incision.  The  first  incision  given  provides  the  most  convenient  approach  to 
the  parts  involved.  The  median  incision  has  been  used  by  Rydygier,  who  in- 
troduced the  operation. 


1040  OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

Operation. — Having  opened  the  abdomen,  isolated  and  exposed  the  dis- 
placed spleen,  its  position,  its  environments,  and  the  laxity  of  its  ligaments  are 
studied,  and  a  site  for  its  fixation  decided  upon,  (a)  Rydygier,  having  opened 
the  abdomen  in  the  median  line,  elevated  the  spleen  to  a  proper  height— then 
detached  from  the  parietes  sufficient  peritoneum  to  form  a  pocket — dividing  the 
parietal  peritoneum  with  a  transverse  upward  convexity,  detaching  it  down- 
ward from  the  abdominal  wail.  The  lower  half  of  the  spleen  was  then  placed 
in  this  pocket — the  parietal  peritoneum  was  sutured  to  the  underlying  tissues 
along  the  lowest  line  of  separation  (to  prevent  further  separation) — and  the 
free  border  of  the  parietal  peritoneum  was  attached  to  the  gastro-splenic 
omentum  above,  (b)  Bardenhauer  entered  the  abdominal  cavity  by  a  some- 
what rectangular  incision,  made  by  a  vertical  incision  extending  from  the  ribs 
to  the  superior  iliac  crest,  the  upper  line  of  which  was  extended  transversely 
forward  along  the  inferior  border  of  the  tenth  rib.  The  flap  thus  included  was 
detached  downward  to  but  not  through  the  peritoneum  and  turned  inward — 
the  peritoneum  was  then  incised  sufficiently  to  enable  the  spleen  to  be  drawn 
through  edgewise.  A  strong  purse-string  suture  of  silk,  previously  placed 
around  the  margin  of  the  peritoneal  opening,  was  then  drawn  so  as  to  pucker  it 
around  the  pedicle  but  not  constrict  it.  A  suspensory  silk  suture  was  passed 
under  the  end  of  the  spleen  and  over  the  tenth  rib  as  a  sling.  Other  sutures 
were  passed  where  indicated.  The  spleen  was  thus  practically  extraperito- 
neally  placed.     The  abdomen  is  closed  without  drainage. 


PARTIAL  SPLENECTOMY 

BY  SUBCOSTAL  INCISION  PARALLEL  WITH  RIBS. 

Description. — Excision  of  part  of  spleen.  Generally  done  for  removal  of 
tumor  involving  a  portion  of  the  organ. 

Preparation — Position. — As  for  median  abdominal  section. 

Landmarks. — Lower  border  of  left  costal  arch — or  modified  by  the  position 
of  a  tumor,  if  one  be  present. 

Incision. — Obliquely  curved  incision  parallel  with  and  about  1.2  cm. 
(^  inch)  below  the  left  costal  arch,  with  its  center  over  the  site  of  the  spleen 
(whose  inner  border  extends  to  within  4  or  5  cm.  [1^  or  2  inches]  of  the  median 
plane,  and  whose  outer  border  extends  just  posteriorly  to  the  mid-axillary  line), 
— or,  if  a  tumor  be  present,  directly  over  the  tumor. 

Operation. — (1)  Having  incised  the  skin  and  fascia;  the  external  oblique 
transversely;  separated  the  internal  oblique  in  the  cleavage  line;  retracted 
what  nerves  could  be  spared;  divided  the  transversalis  obliquely;  and  the  trans- 
versalis  fascia,  subserous  areolar  tissue,  and  peritoneum  in  the  line  of  the 
original  wound,  the  abdominal  cavity  is  opened.  (2)  Having  retracted  the 
wound  and  brought  the  spleen  as  far  into  the  opening  as  possible,  the  area  of 
the  spleen  to  be  removed,  including  the  tumor,  if  any,  is  now  to  be  surrounded 
in  sections  by  interlocking  silk  or  chromic  gut  ligatures  and  tightened — or  other 
form  of  ligature  which  will  compress  the  entire  area  to  be  circumscribed  and 
removed.  When  the  entire  portion  to  be  removed  has  been  thus  circum- 
scribed by  a  compressing  ligature,  the  tied- off  area  is  excised  with  curved 
scissors,  or  by  the  actual  cautery — further  ligating  any  portions  requiring  lig- 
ature. Where  the  area  to  be  removed  has  any  ligamentous  attachments  corre- 
sponding to  it,  or  adhesions  connected  with  it,  these  are  first  tied  off  and  divided 
between  ligatures.     (3)  Where  possible,  the  surfaces  left  by  the  partial  ex- 


TOTAL    SPLENECTOMY. 


IO41 


cision  should  be  approximated  by  deeply  placed  sutures.  See  Splenorrhaphy, 
page  1039.  The  spleen  is  then  dropped  back  into  place — and  the  abdomen 
generally  closed  without  drainage. 

Comment. — Where  the  tumor  or  tumors  are  small,  small  wedge-shaped 
masses  may  be  removed  and  the  edges  approximated  by  deeply  placed  sutures, 
which  both  coapt  the  surfaces  and  control  the  hemorrhage — thus  obviating 
any  previous  ligation  of  the  spleen  substance. 


TOTAL  SPLENECTOMY 

BY  VERTICAL  INCISION  IN  LEFT  LINEA  SEMILUNARIS. 

Description. — Excisions  of  entire  spleen.  Resorted  to  in  some  cases  of 
movable  spleen,  injury  of  the  organ,  simple  hypertrophy  and  in  some  tumors. 

Preparation. — As  for  Median  Abdominal  Section. 

Position. — As  for  Median  Abdominal  Section — the  position  of  the  surgeon 
to  the  right  of  the  patient  giving  better  access  to  and  control  of  the  pedicle. 

Landmarks.— Left  linea  semilunaris. 

Incision. — Vertical  incision  in  left  linea  semilunaris,  beginning  near  the 
left  costal  arch  and  extending  downward  as  far  as  necessary.     (Such  an  incision 


Fig.  760. — Total  Splenectomy: — The  spleen  is  exposed  by  chondroplastic  resection 
of  the  chest-wall  and  drawn  forward.  The  pedicle  is  clamped  preparatorily  to  ligation  in 
sections.     (Modified  from  Guibe.) 

will  divide  the  ninth  nerve  transversely  on  a  line  with  the  lower  border  of  the 
ninth  rib.)  The  spleen  may  also  be  exposed  by  one  of  the  incisions  given 
under  General  Surgical  Considerations. 

Operation. — (1)  Having  incised  abdominal  wall  and  opened  the  peritoneal 
cavity  and  retracted  the  lips  of  the  wound,  the  spleen  is  located  and  brought  as 
prominently  forward  as  possible.  If  any  adhesions  be  found  between  the 
spleen  and  neighboring  viscera,  or  the  abdominal  wall,  these  are  separated  by 
blunt  dissection,  or  divided  between  double  ligatures— carefully  avoiding  in- 
jurv  to  the  spleen.  (2)  Freeing  Splenic  attachments  (ligaments)  and  Enu- 
cleation of  the  Spleen; — The  phreno-splenic  ligament  is  best  reached  and 

66 


1042  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

treed,  as  suggested  by  Jonnesco,  by  covering  the  spleen  with  a  square  of  gauze, 
to  avoid  slipping  of  fingers,  and  then  depressing  the  spleen  downward  and  to 
the  right,  while  an  assistant  draws  the  left  lower  edge  of  the  abdominal  wound 
to  the  left — thus  exposing  the  bed  of  the  spleen  and  vault  of  the  diaphragm  and 
the  phreno-splenic  ligament,  which  latter  is  divided  between  double  ligatures. 
(3)  Following  this,  the  remaining  ligaments  and  attachments  of  the  spleen  to 
its  bed  are  freed,  commencing  at  its  lower  aspect.  The  spleen  is  then  enu- 
cleated and  delivered  through  the  abdominal  wound.  The  gastro-splenic 
ligament  is  the  omentum  surrounding  the  pedicle,  and  therefore  a  part  of  the 
pedicle — and  is  treated  in  ligating  the  pedicle.  (4)  Ligation  and  Division  of 
the  Pedicle  (Fig.  760) ; — The  spleen  having  been  delivered,  is  then  turned 
toward  its  left  and  made  to  rest  upon  its  convexity,  thus  exposing  its  pedicle. 
The  constituent  vessels  of  the  pedicle,  beginning  with  the  most  important, 
should  all  be  separated  and  each  doubly  ligated  and  divided  between  the  two 
ligatures,  which  should  be  of  strong  silk.  This  is  the  most  important  step  of  the 
operation.  Separate  ligation  is  better  than  ligation  en  masse,  or  in  two  or  three 
divisions  or  groups  of  vessels — though  the  latter  may  be  done  in  cases  of  haste 
or  other  need.  Traction  upon  the  constituents  of  the  pedicle,  which  are  easily 
ruptured,  is  to  be  avoided.  Adherence  of  the  splenic  artery  and  vein  to  the 
tail  of  the  pancreas  often  adds  to  the  difficulty  of  isolation  and  separate  liga- 
ture of  these  vessels.  (5)  Hemostasis  of  the  Splenic  Bed; — Having  removed 
the  spleen,  its  bed  is  carefully  examined — and  every  bleeding  point  ligated  with 
chromic  gut.  Especially  examine  the  pillar  of  the  diaphragm,  where  the 
phreno-splenic  ligament  has  been  divided — after  drawing  the  stomach  and 
intestines  to  the  right.  Limited  bleeding  surfaces  may  be  controlled  by  su- 
turing peritoneum  over  them,  where  possible.  (6)  The  abdominal  wound  is 
closed — unless  drainage  be  specially  indicated,  or  there  should  be  uncertainty 
as  to  the  hemostasis.  Full  elastic  dressings  are  applied  so  as  to  compress  the 
region  formerly  occupied  by  the  spleen. 

Comment. — (1)  It  is  better  to  ligate  the  pedicle  at  once — than  to  clamp 
first  and  then  ligate.  (2)  Some  surgeons,  especially  in  very  large  spleens,  pre- 
fer to  ligate  the  pedicle  first,  with  the  spleen  in  situ — then  draw  the  spleen 
down  and  tie  off  the  gastro-splenic  omentum — then  deliver  the  spleen.  (3) 
The  vessels  are  often  enormously  enlarged — and  the  veins  are  often  especially 
thin.  (4)  Tie  the  arteries  first — then  the  veins — as  less  blood  is  thus  lost.  (5) 
See  that  ligatures,  in  tying  off  the  pedicle,  pass  between  rather  than  through 
the  vessels — passing  through  connective  tissue  between  the  vessels.  (6)  Some 
surgeons  advise  first  clamping  and  separating  the  gastro-splenic  ligament — in 
order  to  enable  the  spleen  to  be  lifted  up  and  the  pedicle  better  exposed  (J. 
Wesley  Bovee — but  adds  that  this  is  often  impossible  in  marked  hypertrophy — 
in  which  cases  the  vessels  are  ligated  in  the  order  encountered).  (7)  Some 
surgeons,  in  dealing  with  less  accessible  pedicles,  transfix  the  entire  splenic 
omentum  with  double  ligature,  tying  each  half  separately — then  subsequently 
surround  the  entire  pedicle  with  another  single  ligature.  The  pedicle  may  be 
crushed  with  an  angiotribe  and  then  ligated  in  segments.  (8)  After  exposing 
the  spleen,  the  hand  should  be  passed  between  it  and  the  diaphragm  and  its 
surface  examined — as  well  as  its  other  aspects,  as  far  as  possible.  Very  ex- 
tensive and  firm  adhesions  would  contraindicate  the  continuance  of  the  opera- 
tion. There  may  be  visceral,  parietal,  and  omental  adhesions.  If  much 
damage  be  done  in  separating  adhesions,  temporary  drainage  is  indicated. 
(9)  Practise  no  traction  upon  the  pedicle,  both  because  of  the  friable  vessels 
and  because  of  the  general  bad  symptoms  which  are  apt  to  supervene  from 


SURGICAL    ANATOMY    OF    THE    PANCREAS.  1043 

pressure  upon  the  splenic  plexus  (from  the  solar  plexus).  Relax  the  pedicle 
before  tightening  each  ligature.  (10)  Treatment  of  the  pedicle  comes  first  in 
importance  and  treatment  of  adhesion  second.  Hemorrhage  is  the  chief  dan- 
ger. (11)  If  secondary  hemorrhage  be  feared,  suture  the  pedicle  to  the  abdo- 
minal wall. 


XI.   THE   PANCREAS. 

SURGICAL  ANATOMY. 

Description. — The  pancreas  lies  transversely  across  the  posterior  abdo- 
minal wall,  the  large  vessels  intervening  between  it  and  the  wall — being  on  a 
level  with  the  second  lumbar  vertebra  (and  sometimes  with  the  first  or  third) — 
lying  in  the  epigastric  and  left  hypochondriac  regions — having  the  stomach  in 
front,  duodenum  to  the  right,  and  spleen  to  the  left — and  the  aorta,  vena  cava, 
cceliac  plexus,  thoracic  duct,  and  diaphragmatic  crura  behind.  It  lies  behind 
the  posterior  wall  of  the  lesser  omental  cavity  and  is  between  the  laminae  of  the 
mesocolon  of  the  transverse  colon.  The  head  of  the  pancreas  is  surrounded  by 
the  loop  of  the  duodenum.  The  tail  of  the  pancreas  is  in  contact  with  the 
interno-inferior  aspect  of  the  spleen.  Peritoneum  covers  the  pancreas  except 
upon  its  posterior  surface.  The  viscus  is  15  to  16  cm.  (about  6  inches)  in 
length — 3  to  4  cm.  (1  \  to  ij  inches)  in  width — and  15  to  18  mm.  (about  h,  inch) 
in  thickness. 

Relations. — Anteriorly;  Upper  layer  of  transverse  mesocolon;  lesser 
peritoneal  sac;  transverse  colon;  gastro-duodenal  and  pancreatico-duodenal 
arteries;  stomach  (posterior  surface).  Posteriorly;  second  (sometimes  third 
or  first)  lumbar  vertebra;  crura  of  diaphragm;  aorta  and  right  and  left  renal 
arteries  and  superior  mesenteric  artery;  inferior  vena  cava,  superior  and  inferior 
mesenteric,  splenic,  and  right  and  left  renal  veins;  vena  porta? ;  cceliac  plexus; 
thoracic  duct  (origin);  ductus  communis  choledochus  and  pancreatic  duct; 
left  kidney  (and  sometimes  its  capsule).  Superiorly;  Duodenum  (first  part); 
liver;  hepatic  and  splenic  arteries  and  cceliac  axis;  solar  plexus.  Inferiorly; 
Duodenum,  third  (preaortic)  and  fourth  (ascending)  parts;  duodeno-jejunal 
angle;  jejunum;  transverse  colon;  transverse  mesocolon  (inferior  layer); 
superior  mesenteric  artery  and  vein;  inferior  mesenteric  vein;  mesentery. 
Right  end;  Loop  of  duodenum.     Left  end;  Interno-inferior  aspect  of  spleen. 

Fixations. — Held  in  place  by  its  peritoneal  investment  and  by  adjacent 
viscera  and  structures  to  which  attached. 

Pancreatic  Duct  (Canal  of  Wirsung). — Begins  at  left  end,  or  tail,  of 
pancreas — runs  thence  toward  the  head  of  the  organ,  passing  nearer  its  pos- 
terior than  anterior  aspects — after  passing  the  neck,  it  turns  downward,  back- 
ward, and  to  right,  in  the  head  of  the  viscus,  and  runs  to  the  left  side  of  the 
common  bile-duct — entering  the  duodenal  wall  together  and  parallel  with  the 
ductus  communis  choledochus — uniting  with  the  latter  while  running  ob- 
liquely in  thewallsof  the  duodenum — and  emptying  by  a  common  opening  with 
it  upon  a  papilla  of  mucous  membrane  about  10  cm.  (4  inches)  from  the  pylo- 
rus— the  opening  being  covered  by  a  fold  of  mucous  membrane  from  above. 
The  pancreatic  duct  is  recognized  by  its  white  color  and  its  relation  to  the 
pancreatica  magna  artery.  Its  diameter,  near  its  termination,  is  between  2 
and  3  mm.  (about  \  inch).     The  Duct  of  the  Lesser  Pancreas  (Duct  of  San- 


1044  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

torini)  may  join  the  Canal  of  Wirsung  near  its  termination — or  may  empty  into 
the  duodenum  by  a  separate  mouth. 

Arteries. — Pancreaticae  parvae  and  pancreatica  magna  from  splenic  artery; 
pancreatico-duodenalis  superior  from  gastro-duodenalis  of  hepatic;  pancre- 
atico-duodenalis  inferior  from  superior  mesenteric. 

Veins. — Accompany  the  above  arteries,  emptying  into  splenic  and  superior 
mesenteric  veins. 

Lymphatics. — End  in  two  glands  upon  superior  mesenteric  artery. 

Nerves. — From  solar  plexus. 


SURFACE  FORM  AND  LANDMARKS. 

The  pancreas  lies  obliquely  behind  the  stomach — crossing  the  spine  op- 
posite the  second  (or  sometimes  the  first  or  third)  lumbar  vertebra.  Anteriorly, 
it  lies  transversely  about  7.5  cm.  (3  inches)  above  the  umbilicus. 


GENERAL  SURGICAL  CONSIDERATIONS. 

General  Considerations.— (1)  Surgery  of  the  Pancreas  is  limited  to  op- 
erations for  cysts  (which  is  the  most  frequent  operation  done  upon  theviscus), 
removal  of  small  tumors,  abscess,  hemorrhage,  localized  necrosis,  calculi, 
"annular  pancreas,"  and  for  the  removal  of  parts  of  the  organ.  (2)  Anato- 
mically, complete  pancreatectomy  is  very  difficult.  (3)  Surgically,  complete 
removal  with  subsequent  life  has  been  proved  with  animals — but  not  with  man. 
Rapidly  fatal  diabetes  follows  complete  removal  of  the  organ.  (4)  Cysts  may 
be  incised  or  excised.  In  incision,  the  cyst-wall  should  be  sutured  to  the  abdo- 
minal wall  (marsupialization) — for  drainage,  and  to  prevent  pancreatic  juice 
from  getting  into  the  abdominal  cavity.  (5)  Pancreatic  juice  in  the  abdominal 
cavity  is  apt  to  excite  peritonitis.  (6)  If  the  pancreatic  opening  into  the  duo- 
denum be  cut  off,  a  new  route  must  be  made,  or  a  pancreatic  fistula  must  be 
established.  (7)  Suturing  material  should  not  be  left  in  the  pancreatic  ducts, 
as  such  material  may  form  the  nuclei  of  calculi.  (8)  Wounds  of  the  pancreatic 
canals  should  be  closed  by  suture.  (9)  Always  ligate  before  excising  a  portion 
of  the  pancreas — in  order  to  prevent  the  escape  of  pancreatic  juice  into  the 
peritoneal  cavity.  (10)  Extirpation  of  the  tail  and  part  of  the  body,  or  of 
limited  portions  of  the  head,  may  be  done.  The  tail  of  the  organ  is  the  part 
most  safely  operated  upon.  In  operating  upon  the  head,  it  is  necessary  to 
spare  the  canal  of  Wirsung,  or  the  duct  of  Santorini.  In  removing  the  whole 
head  of  the  pancreas,  there  is  no  way  to  restore  the  flow  of  pancreatic  juice  into 
the  intestines. 

Routes  of  Approaching  the  Pancreas. — (1)  Transgastrocolic ; — by 
incising  the  anterior  layers  of  the  gastrocolic  omentum  between  the  greater 
curvature  of  the  stomach  and  the  transverse  colon,  and  thus  entering  the  lesser 
omental  cavity.  This  is  the  route  to  be  preferred — and  is  made  by  a  trans- 
peritoneal median  incision  above  the  umbilicus  (Fig.  761).  (2)  Trans- 
gastrohepatic ; — by  cutting  through  the  gastrohepatic  omentum.  This 
approach  may  be  used  when  the  tumor  presents  above  the  lower  curvature  of 
the  stomach,  as  less  frequently  happens — and  is  made  by  transperitoneal 


GENERAL    SURGICAL    CONSIDERATIONS. 


I°45 


Fig.  761. — Transgastrocolic  Exposure  of  the  Pancreas: — Between  the  stomach 
above  and  the  colon  below;  the  pancreas  is  seen  through  an  incision  in  the  gastrocolic  omen- 
tum. 

median  incision  above   the   umbilicus.     (3)  Transmesocolic ; — by   incising 
the  inferior  layer  of  the  mesocolon.     This  route  may  be  used  when  the  tumor 


Fig.  762. — Transmesocolic  Exposure  of  the  Pancreas: — Having  displaced  the  omentum 
and  colon   upward,  the  pancreas  is  exposed  through  an  incision   in  the  mesocolon. 

lies  between  the  lamina?  of  the  mesocolon — and  is  made  by  a  transperitoneal 
median  incision  above  the  umbilicus  (Fig.  762).     (4)   Access  to  the  posterior 


1046 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


part  of  the  head  of  the  pancreas  may  be  secured  by  Kocher's  method,  of 
"mobilizing  the  duodenum"  described  at  page  987,  Gastroduodenostomy. 
(5)  The  pancreas  has  been  exposed  by  incising  anterior  and  posterior  walls 
of  the  stomach.  Lumbar ; — by  incising  as  for  exposure  of  the  kidney.  Some- 
times done  for  tumors  of  the  tail  of  the  pancreas — and  is  made  by  an  extra- 
peritoneal incision  as  for  exposure  of  the  left  kidney — or  below  and  along  the 
twelfth  rib.     (See  Fig.  763.) 

Methods  of  Drainage  of  Pancreatic  Cavities. — (1)  If  pus  have  col- 
lected in  the  bursa  omentalis,  incise  in  the  median  line,  from  the  ensiform  car- 
tilage downward,  and  cut 
through  the  gastrohepatic 
omentum — -after,  if  possi- 
ble, first  suturing  that 
omentum  to  the  abdom- 
inal wall.  (2)  If  pus  be  in 
the  bursa  omentalis  and 
extend  along  the  pancreas, 
resort  to  Leith's  lumbar 
drainage  mentioned  below. 
(3)  Lumbar  drainage  is 
sometimes  necessary  where 
anterior  drainage  cannot 
be  secured — in  such  cases 
Leith  suggests  a  lumbar  in- 
cision made  under  the  left 
twelfth  rib.  Through  this 
the  finger  is  inserted  by 
the  upper  border  of  the 
quadratus  lumborum,  lo- 
cating the  left  kidney  and 
its  vessels.  The  tail  of  the 
pancreas  and  the  posterior 
and  external  wall  of  the 
bursa  omentalis  are  placed 
above  and  just  internal  to  the  renal  vessels.  The  lesser  peritoneal  cavity 
can  be  here  entered  either  through  the  mesocolon  or  through  the  posterior 
laver  of  the  peritoneum.  (4)  If  pus  be  retroperitoneal — make  a  lumbar  in- 
cision as  for  exposure  of  the  left  kidney  and  reach  the  site  extraperitoneally. 


Fig.  763. — Illustrating  Routes  of  Approach  to  Pan- 
creas:—A,  Gastro-colic  ;  B,  Trans-mesocolic  ;  C,  Trans-gas- 
trohepatico-omental  (epigastric);  D,  Lumbar;  E,  Pancreas. 
(Modified  from  Gray.) 


INSTRUMENTS. 
See  those  given  under  the  Liver  (page  1008). 


Description 

or  abscess  of  that  organ 


PANCREATOTOMY 

BY  GASTROCOLIC  ROUTE. 

Incision  of  the  pancreas.     Generally  resorted  to  for  cyst 


The  method  of  approach  is  generally  one  of  the 


PARTIAL    PANCREATECTOMY.  1047 

first  three  given  under  General  Surgical  Considerations — and  is  usually  the 
one  above  mentioned.  In  the  case  of  a  cyst  of  the  pancreas,  its  walls  may 
be  excised,  or,  as  is  more  generally  done,  sutured  to  the  abdominal  wall  and 
drained. 

Preparation — Position— Landmarks. — As  for  Median  Abdominal  Sec- 
tion. 

Incision. — In  median  line,  with  its  center  opposite  the  lower  border  of 
the  stomach — which  is  about  4  cm.  (ij  inches)  above  the  umbilicus.  Where 
a  tumor  is  evident,  the  incision  is  usually  placed  directly  over  it. 

Operation. — (1)  Having  opened  the  abdomen  as  in  median  section, 
the  gastrocolic  omentum  is  exposed.  (2)  Having  displaced  the  stomach 
upward  and  the  transverse  colon  downward,  the  gastrocolic  omentum  is  in- 
cised vertically,  between  the  lower  border  of  the  stomach  and  the  upper 
border  of  the  colon — thus  reaching  the  lesser  peritoneal  cavity.  (3)  Having 
controlled  all  hemorrhage,  the  pancreas  is  reached  through  the  opening  in  < 
the  omentum  and  drawn  forward  into  the  wound — packing  off  the  vicinity 
with  gauze.  (4)  If  haste  be  necessary,  the  operation  is  completed  in  one 
stage,  the  cyst  being  incised  and  its  edges  sutured  into  the  lower  plane  of  the 
abdominal  wound,  having  been  brought  through  the  rent  in  the  gastrocolic 
omentum,  which  is  sutured  around  the  opening  in  the  pancreas  as  well  as 
possible.  (5)  If  haste  be  unnecessary,  the  operation  is  concluded  in  two 
stages — the  first  step  being  similar  to  the  one  just  described — the  second  step, 
the  incision  of  the  viscus,  being  performed  two  or  tHree  days  later,  after 
adhesions  have  formed  and  the  general  peritoneal  cavity  has  been  shut  off. 
(6)  In  any  event,  therefore,  drainage  is  temporarily  provided  for  through  the 
abdominal  incision,  which  is  usually  accomplished  by  drainage-tube  and 
gauze  packing. 

Comment. —  (1)  Adhesions  are  apt  to  be  found  in  such  cases,  and  should 
be  separated  by  blunt  dissection,  or  divided  between  chromic  ligatures, 
before  attempting  to  expose  the  pancreas  in  the  wound.  (2)  In  distended 
cysts  or  abscesses,  partial  aspiration  should  first  be  done  to  lessen  tension. 
(3)  In  some  cases  adhesions  are  found  walling  off  the  general  peritoneal 
cavity — so  that  it  is  possible  to  incise  directly  through  the  abdominal  wall 
and  gastrocolic  omentum  into  the  pus  or  fluid  cavity.  (4)  In  exceptional 
cases  cysts  may  be  excised  in  the  same  manner  as  small  tumors. 


PARTIAL  PANCREATECTOMY 

BY  GASTROCOLIC  ROUTE. 

Description. — Excision  of  part  of  the  pancreas.  Generally  performed 
in  connection  with  removal  of  a  tumor  involving  a  portion  of  the  organ. 

Preparation — Position  —  Landmarks — Incision. — As  for  Pancreatot- 
omv. 

Operation. — The  pancreas  is  exposed  in  precisely  the  same  manner  as 
for  Pancreatotomy.  The  tumor  in  the  organ  is  sought  and  brought  as  well 
forward  as  possible.  Chromic  gut  ligatures  are  then  placed  deeply  around 
the  mass  to  be  removed,  so  as  to  completely  circumscribe  it — thus  preventing 
both  hemorrhage  and  the  escape  of  pancreatic  fluid.  This  having  been 
done,  the  tumor  is  excised  with  curved,  blunt-pointed  scissors,  aided  by  blunt 
dissection.     If  a  marked  cavitv  is  left,  and  it  is  possible  to  do  so,  the  walls  of 


1048  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION". 

the  cavity  are  approximated  by  dee])  chromic  gut  sutures.  Drainage  is  then 
established  between  the  site  of  the  operation  and  the  abdominal  wound — 
and  the  remainder  of  the  abdominal  incision  closed. 


XII.   THE  KIDNEYS. 

SURGICAL  ANATOMY. 

Description. — Each  kidney  lies  partly  in  the  hypochondriac,  lumbar, 
epigastric,  and  umbilical  regions — abutting  upon  the  confines  of  each — 
resting  upon  the  lower  part  of  the  diaphragm  and  areolar  fatty  tissue  covering 
the  quadratus  lumborum  and  psoas  magnus — and  placed  behind  the  peri- 
toneum. They  lie  embedded  in  abundant  fatty  areolar  tissue,  more  abundant 
posteriorly  than  anteriorly — constituting  the  fatty  areolar  capsule.  The 
right  kidney  generally  (though  not  always)  lies  about  7  mm.  to  1.3  cm.  (3  to 
\  inch)  lower  than  the  left  (owing  to  the  presence  of  the  liver  upon  the  right). 
Vertically,  the  kidneys  correspond  to  the  space  between  the  upper  border 
of  the  twelfth  dorsal  and  the  first  and  second  (and  sometimes  the  upper  half 
of  the  third)  lumbar  vertebras — and  to  the  eleventh  and  twelfth  ribs  and 
transverse  processes  of  the  first  and  second  lumbar  vertebrae — the  left  kidney 
generally  reaching  to  the  upper  border  of  the  eleventh  rib — and  the  right 
kidney  generally  reaching  to  the  lower  border  of  the  eleventh  rib.  Outer 
borders  of  the  kidneys  lie  from  9  to  10  cm.  (3^  to  4  inches)  external  to  the 
lumbar  spines.  The  superior  poles  of  the  kidneys  lie  about  5  cm.  (2  inches), 
and  the  inferior  poles  from  6.3  to  7.6  cm.  (2%  to  3  inches),  from  the  median 
line.  Inner  border  of  right  kidney  lies  close  to  the  vena  cava — the  inner 
border  of  the  left  kidney  lies  within  2.5  cm.  or  more  (1  inch  or  more)  of  the 
aorta.  The  kidneys  average  10  to  12  cm.  (4  to  4!  inches)  in  length — 2.8  cm. 
(i£  inches)  in  thickness — 6.3  cm.  (2^  inches)  in  breadth — and  weigh  about 
4^  ounces.  There  may  be  an  irregularity  from  the  normal  in  the  form,  size, 
number,  position,  and  mobility  of  the  kidneys. 

Peritoneal  Relations  of  the  Kidneys. — 

Posterior  surfaces  of  both  kidneys  are  uncovered  by  peritoneum.  Upon 
the  anterior  surface  of  the  right  kidney — the  hepatic  and  mesocolic  areas  are 
peritoneal — and  the  areas  of  the  duodenum  and  transverse  colon  are  non- 
peritoneal.  Upon  the  anterior  surface  of  the  left  kidney — the  gastric  area 
is  peritoneal— the  pancreatic  area  is  non-peritoneal — the  outer  part  of  the 
colic  area  is  non-peritoneal,  and  the  inner  part  of  the  colic  area  is  peritoneal. 

Fixations. — (1)  Fatty  areolar  tissue,  or  capsule — in  which  the  kidneys 
are  embedded — derived  from  parietal  subperitoneal  fascia — and  separates 
them  from  the  diaphragm  and  from  the  anterior  lamella  of  the  lumbar  fascia 
covering  the  quadratus  lumborum  and  psoas  muscles.  (2)  Vessels,  nerves, 
and  connective  tissue  form  the  pedicle.  (3)  Partial  covering  of  peritoneum 
upon  their  anterior  surfaces  and  borders. 

Relations. — Anterior  Surface — (a)  Right  Kidney; — Liver  (right  lobe) 
— iperitoneum  intervening;  ascending  colon  and  hepatic  flexure;  duodenum 
(descending  part);  suprarenal  capsule  (to  slight  extent),  (b)  Left  Kidney; — ■ 
Stomach  (fundus) — peritoneum  of  lesser  sac  intervening;  pancreas  (tail); 
splenic  artery  and  vein;  splenic  flexure  of  colon  and  upper  part  of  descending 
colon;  duodenum  (ascending  part);  suprarenal  capsule  (to  slight  extent). 
Posterior  Surface — (Both   Kidneys) — Areolar  fatty  tissue,   separating  the 


SURGICAL    ANATOMY    OF    THE    KIDNEYS. 


1049 


kidneys  from  diaphragm  and  quadratus  lumborum  and  psoas  muscles;  pos- 
terior abdominal  wall,  corresponding  to  eleventh  and  twelfth  ribs  and  trans- 
verse processes  of  first  and  second  lumbar  vertebrae;  diaphragm  (areolar 
tissue  intervening);  anterior  layer  of  posterior  aponeurosis  of  transversalis 
(/.  e.,  anterior  layer  of  lumbar  fascia),  separating  kidney  from  quadratus 
lumborum;  psoas;  diaphragmatic,  transversalis  and  iliac  fascia  lining  dia- 
phragm, transversalis  and  iliacus;  twelfth  dorsal,  ilio-hypogastric  and  ilio- 
inguinal nerves;  anterior  divisions  of  first  and  second  lumbar  arteries  and 
veins.  The  nerves  and  vessels  just  mentioned  all  pass  downward  and  out- 
ward anteriorly  to  the  quadratus  lumborum  and  pierce  the  transversalis 
beyond  the  external  border  of  the  quadratus.  Note. — The  left  kidney  is  in 
contact  with  a  larger  area  of  diaphragm  than  the  right — and  the  amount  of 
diaphragm  in  contact  may  be  increased  on  both  sides  when  the  arcuate  liga- 
ments are  attached  to  the  tips  of  the  transverse  processes  of  the  second  lumbar 
vertebra.  External  border — (a)  Right  Kidney;  liver  (upper  two-thirds); 
ascending  colon  (lower  third),  (b)  Left  Kidney;  spleen  (above);  descending 
colon  (below).  Internal  border — (a)  Right  Kidney;  near  vena  cava;  struc- 
tures of  hilum  (q.  v.).  (b)  Left  Kidney;  2.5  cm.  or  more  (1  inch  or  more) 
from  aorta;  structures  of  hilum  (q.  v.).  Superior  extremity— (Both  Kid- 
neys)— Suprarenal  capsule — which  encroaches  also  upon  the  anterior  and  in- 
ternal border  and  is  bound  to  the  kidney  by  the  connective  tissue  of  the  sub- 
peritoneal fascia.  Inferiorly — (Both  Kidneys) — come  within  about  5  cm. 
(2  inches)  of  the  crest  of  the  ilium. 

Relations  of  the  Pleurae. — The  pleurae  are  in  proximity  to,  but  not  in 
relation  with,   the  kidneys.     The  lower  limit  of  the  pleura  extends  nearly 


Fig.  764.— Horizontal  Section  through  Upper  Lumbar  Region  :— A,  Pancreas;  B,  De- 
scending colon;  C,  Spleen;  D,  Ascending  colon;  E,  Small  intestine;  F,  F,  Kidneys;  G,  External 
oblique;  H,  Internal  oblique;  I,  Transversalis;  J,  Psoas  magnus ;  K,  CJuadratus  lumborum;  L, 
Erector  spina; ;  M,  Latissimus  dorsi.     (Modified  from  Esmarch.) 


horizontally  outward  from  the  lower  margin  of  the  twelfth  dorsal  vertebra — 
crossing  the  twelfth  rib  close  to  its  neck — and  crossing  the  eleventh  rib  about 
5  cm.  (2  inches)  beyond  (external  to)  its  neck. 

Relation  of  Structures  within  the  Sinus  of  the  Kidney.— (A)  Struc- 
tures;— Branches  forming  renal  artery;  branches  forming  renal  vein;  lymph- 
atic vessels  and  glands;  plexus  of  nerves;  ureter;  areolar  fatty  tissue.  (B) 
Order  of  Structures  from  Before  Backward; — (a)  Right  Kidney — vein,  artery, 
ureter: — (b)  Left  Kidney— vein,  artery,  ureter.  (C)  Order  of  Structures 
from  Above  Downward; — (a)  Right  Kidney — vein,  artery,  ureter:— (b) 
Left  Kidney — artery,  vein,  ureter. 


1050  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

Arteries. — Renal,  suprarenal,  spermatic,  and  lumbar — all  from  aorta. 

Veins. — Renal.  Right  vein  empties  directly  into  vena  cava.  Left  vein 
receives  left  spermatic  (or  left  ovarian),  left  inferior  phrenic,  and  sometimes 
left  suprarenal  before  emptying  into  vena  cava. 

Nerves. — From  solar  and  aortic  plexuses,  semilunar  ganglia,  splanchnics, 
and  pneumogastrics. 

Lymphatics. — Superior  and  deep  sets — emptying  into  lumbar  glands. 


Fig.    765. — Showing  the  General  Relations  of  the  Kidneys  to  the  Vertebr.k  and 
Ribs.     (Modilied  from  Deaver.) 

Description  of  Lumbar  Fascia. — Consists  of  three  layers,  which  en- 
sheathe  erector  spinae  and  quadratus  lumborum  muscles.  (1)  Posterior  or 
superficial  layer : — Layer  through  which  latissimus  dorsi,  and  serratus  pos- 
ticus inferior  beneath  it,  are  connected  to  the  vertebral  spines  (same  thing  as 
aponeurosis  of  those  muscles).  Latissimus  dorsi  is  connected  with  it  most 
posteriorly — serratus  posticus  inferior,  lying  beneath  latissimus  dorsi,  is  con- 
nected with  its  upper  part  anteriorly  to  latissimus  dorsi — and  beyond  the  line 
along  which  these  two  muscles  are  connected  with  it  (/.  e.,  after  these  two 
muscles  are  free  of  it)  it  gives  origin  to  the  posterior  part  of  the  internal  ob- 
lique— and  then  passes  on  (after  internal  oblique  is  free  of  it)  to  merge  with 
middle  layer — thus  binding  down  posterior  aspect  of  erector  spinae.     It  is  con- 


SURFACE    FORM    AND    LANDMARKS.  1051 

tinuous  with  the  vertebral  aponeurosis.  (2)  Middle  layer: — Arises  from 
tips  of  lumbar  transverse  processes — runs  outward  between  quadratus  lum- 
borum  in  front  and  erector  spina?  behind,  to  fleshy  part  of  transversalis  muscle 
— forming  posterior  aponeurosis  of  transversalis.  It  is  joined  at  outer  border 
of  erector  spina?  by  posterior  layer — and  at  outer  border  of  quadratus  lum- 
borum  by  anterior  layer.  It  is  attached,  above,  to  lower  margin  of  last  rib — 
and,  below,  to  ilio-lumbar  ligament  and  adjacent  iliac  crest.  (3)  Anterior 
layer  : — attached  to  front  of  lumbar  transverse  processes  at  inner  border  of 
quadratus  lumborum — covering  anterior  surface  of  quadratus  lumborum  to  its 
outer  border,  where  it  becomes  united  with  middle  layer  and  becomes  the  trans- 
versalis fascia.  Attached  above  (forming  ligamentum  arcuatum  externum) 
to  front  of  transverse  processes  of  first  (or  second)  lumbar  vertebra  and  apex 
of  last  rib,  and,  below,  to  ilio-lumbar  ligament  and  iliac  crest  (Figs.  764  and 
765J- 


SURFACE  FORM  AND  LANDMARKS. 

(1)  A  horizontal  line  through  the  umbilicus  will  be  below  the  lower  border 
of  each  kidney — about  2.5  cm.  (1  inch)  below  the  right  kidney,  and  4  cm. 
(1^  inches)  below  the  left  (Quain).  According  to  Treves,  such  a  line  will  in- 
tersect the  lower  portion  of  the  right  kidney,  and  pass  below  the  left.  (2)  A 
vertical  line  from  the  middle  of  Poupart's  ligament  upward  to  the  costal  arch 
will  have  one-third  of  the  kidney  to  its  outer,  and  two-thirds  of  the  kidney  to 
its  inner  side.  (3)  Posteriorly,  the  kidney  lies  within  a  parallelogram  in- 
cluded within  the  four  following  lines:  (a)  Line  parallel  with  and  2.5  cm. 
(1  inch)  external  to  the  spine,  from  the  lower  border  of  the  tip  of  the  eleventh 
dorsal  spine  to  the  center  of  the  tip  of  the  third  lumbar  spine, — (b)  Line  drawn 
outward  for  7  cm.  (2%  inches)  at  a  right  angle  to,  and  from  the  upper  end  of  line 
"a," — (c)  Line  drawn  outward  for  7  cm.  (2%  inches)  at  a  right  angle  to,  and 
from  the  lower  end  of  line  "a," — (d)  Line  parallel  with  line  "a,"  between  the 
outer  ends  of  lines  "b"  and  "c."  (4)  The  right  kidney  is  generally  from  1.3 
to  2  cm.  (h  to  f  inch)  lower  than  the  left, — and  will  lie  that  far  below  the 
measurements  given  in  (3)  above.  (5)  The  upper  border  of  the  kidney  lies 
upon  a  level  with  the  eleventh  intercostal  space  and  with  the  eleventh  or  twelfth 
dorsal  spine — the  right  kidney  lying  somewhat  lower.  (6)  The  twelfth  ribs 
divide  the  kidneys,  approximately,  into  a  superior  and  an  inferior  half. 
(7)  The  lower  border  of  the  kidney  about  corresponds  with  the  center  of  the 
spinous  process  of  the  third  lumbar  vertebra.  (8)  The  kidneys  are  accessible 
to  pressure  in  the  triangle  formed  by  the  lower  border  of  the  twelfth  rib  above, 
and  the  outer  border  of  the  erector  spina?  internally.  (9)  The  axes  of  the  kid- 
neys are  oblique — from  above  and  within,  downward  and  outward.  (10) 
The  superior  pole  of  the  kidney  is  about  5  cm.  (2  inches)  from  the  median 
plane,  (n)  The  hilum  of  the  kidney  lies  about  5  cm.  (2  inches)  from  the 
median  plane,  on  a  level  with  the  first  or  second  lumbar  spine,  or  opposite  the 
interval  between  them.  (12)  The  inferior  pole  of  the  kidney  lies  about  6.3  to 
7.5  cm.  (2%  10  3  inches)  from  the  middle  line.  (13)  The  inner  border  of  the 
upper  part  of  the  kidney  lies  about  2.5  cm.  (1  inch)  external  to  the  middle  line 
of  the  body.  The  inner  border  lies  upon  the  external  border  of  the  psoas — the 
rest  of  the  kidney  lying  upon  the  lumbar  fascia  covering  the  quadratus  lum- 
borum. (14)  The  outer  border  of  the  lower  part  of  the  kidneys  is  about  9.5 
cm.  (3^  inches)  from  the  middle  line.  The  external  border  lies  from  2  to  3  cm. 
(f  to  1  j  inches)  to  the  outer  side  of  the  external  border  of  the  quadratus  lum- 


1052 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


borum  muscle.  (15)  The  ureter  expands  into  the  pelvis  of  the  kidney  op- 
posite the  lower  half  of  the  kidney.  (16)  Both  kidneys  rest  upon  the  lower 
portion  of  the  arch  of  the  diaphragm  (as  it  comes  downward  between  the  kid- 
neys and  the  twelfth  ribs),  quadratus  lumborum,  anterior  layer  of  lumbar 
fascia,  and  psoas  muscle.  (17)  The  external  border  of  the  erector  spinae  is  the 
superficial  guide  to  the  kidney — and  the  quadratus  lumborum  the  deep  guide, 
—the  former  muscle  marking  the  twelfth  rib  about  6.3  cm.  (2^  inches)  from 
the  median  line — and  the  latter  being  attached  to  the  inner  half  of  the  twelfth 
rib  (Fig.  766). 


Fig.766. — Relations  of  Kidneys  to  Vertebra,  Ribs,  Pleur/E,  and  Overlying  Muscles: 
— A,  A,  Latissimus  dorsi ;  B,  B,  Erector  spince  ;  C,  C,  Quadratus  lumborum  ;  D,  External  oblique  ;  E, 
Internal  oblique;  F,  Transversalis ;  G,  Lower  limit  of  pleura.  Ascending  colon  is  seen  on  the  right, 
the  descending  on  the  left.     (Modified  from  Gray,  and  from  Esmarch  and  Kowalzig.) 


GENERAL  SURGICAL  CONSIDERATIONS. 

Preparation. — -Bowels  and  bladder  emptied — part  shaved. 

Position. — In  operating  extraperitoneally,  the  patient  lies  upon  the  sound 
side,  near  the  edge  of  the  table,  with  a  firm  cushion  or  support  under  the  op- 
posite loin,  to  round  out  and  make  prominent  the  side  of  the  operation  and  in- 
crease the  interval  between  the  twelfth  rib  and  the  iliac  crest.     The  surgeon 


RETROPERITONEAL  EXPOSURE  OF  THE  KIDNEY.       1053 

stands  at  the  patient's  back,  cutting  from  above  downward  on  the  right  side, 
and  in  the  reverse,  or  in  the  same  direction,  on  the  left.  The  assistant  stands 
opposite.  In  operating  transperitoneally,  the  position  is  the  same  as  for 
median  abdominal  section. 

Approach  to  the  kidney  may  be  by  the  extraperitoneal  or  transperitoneal 
route — preferably  the  former. 

Always  ascertain  that  the  opposite  kidney  is  present  before  removing  a 
kidney. 

An  incision  to  expose  the  kidney  may  go,  with  safety,  to  the  lower  border  of 
the  twelfth  rib.  If  the  eleventh  be  the  last  rib,  the  pleura  would  be  endangered 
if  that  rib  were  taken  for  the  twelfth.  If  the  thirteenth  rib  be  present,  the 
operation  area  would  be  contracted. 

Do  not  take  for  granted  that  the  last  rib  is  the  twelfth  rib — else  the  pleura 
may  be  wounded.     Always  count  the  ribs  from  above. 

The  pleurae  may  reach  lower  where  the  arcuate  ligaments  are  attached  to 
the  second  lumbar  vertebra. 

If  necessary  to  better  expose  the  kidney,  the  twelfth  rib  may  be  excised 
subperiosteal! v,  in  whole  or  in  part. 

Hemorrhage  in  kidney  operations  is  often  great.  It  may  be  controlled: — 
by  compression  of  the  pedicle  by  the  fingers,  or  a  special  forceps  temporarily 
applied, — by  gauze-pressure  of  the  bleeding  surface, — by  hot  douching.  Su- 
turing of  bleeding  surfaces  in  contact  also  controls  hemorrhage.  In  bisection 
of  the  healthy  kidney,  pressure  of  the  pedicle  is  necessary.  Diseased  kidney 
bleeds  less  than  healthy  kidney  substance. 

The  right  renal  vein  is  generally  much  shorter  than  the  left — a  fact  to  be 
remembered  in  handling  the  pedicle  of  the  right  kidney. 

Gut  is  preferable  to  silk  throughout  in  kidney  surgery — as  being  absorb- 
able— and  less  apt  to  form  the  nuclei  of  calculi. 


INSTRUMENTS. 

Scalpels;  bistouries;  scissors,  various;  forceps,  dissecting,  toothed,  and 
dressing;  blunt  dissector;  probe;  sound;  grooved  director;  tenacula ;  exploratory 
syringe  and  needle;  needle  in  handle,  for  exploration;  periosteotomes;  costo- 
tome;  pedicle  forceps;  special  stone  scoops  and  forceps;  stone-searcher;  an- 
eurism-needles; artery-clamp  forceps;  dilators;  ureteral  buttons;  needle-holder; 
needles,  straight  and  curved;  sutures  and  ligatures,  of  chromic  and  plain  gut, 
kangaroo  tendon,  and  silk;  ligature-carriers;  long  tenotome;  drainage-tubes; 
gauze;  blunt  hooks;  clamps,  various;  retractors. 


RETROPERITONEAL  EXPOSURE  OF  THE  KIDNEY 

P.V  OBLIQUE  LUMBAR  INCISION. 

Description. — The  most  generally  applicable  method  of  exposing  the 
kidnev,  for  whatever  purpose  indicated.  The  incision  admits  of  being  ex- 
tended upward  over  the  twelfth  or  eleventh  rib,  exposing  them  for  partial 
excision,  if  necessary — as  well  as  downward  toward  the  anterior  superior  iliac 
spine,  and  onward  and  downward  just  aoove  and  parallel  with  Poupart's  liga- 


io54 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


ment,  exposing,  if  need  be,  the  entire  length  of  the  ureter — the  parts  being  ex-, 
ttosed  throughout,  extraperitoneaily. 

Preparation — Position. — See  General  Surgical  Considerations. 

Landmarks. — Twelfth  rib;  outer  border  of  erector  spina*;  iliac  crest; 
Poupart's  ligament. 

Incision. — Begins  in  the  triangle  made  by  the  lower  border  of  the  twelfth 
rib  and  the  outer  border  of  the  erector  spina* — at  a  point  about  1.3  cm.  (\  inch) 
below  the  twelfth  rib,  and  just  to  the  outer  border  of  the  erector  spinae  (which 
crosses  the  twelfth  rib  about  6.3  cm.  \p.\  inches]  from  the  median  line) — passes 
thence  obliquely  downward  and  forward  in  the  direction  of  the  anterior  superior 


Fig.767.— Incision  for  Exposure  of  Kidneys  by  the  Lumbar  Route:— A,  Retroperitoneal 
exposure  by  oblique  lumbar  incision  ;  B,  Continuation  of  this  incision  where  additional  room  is 
required  ;  C,  Retroperitoneal  exposure  by  Koenig's  angular  lumbo-abdominal  incision  ;  D,  Incision 
in  Edebohls's  operation  of  nephropexy. 


iliac  spine,  generally  at  first  for  7.5  to  10  cm.  (3  to  4  inches) — and  may  be  subse- 
quently extended  both  upward  and  downward  as  mentioned.  When  so  con- 
tinued downward,  it  passes  to  within  2  to  2.5  cm.  (f  to  1  inch)  of  the  anterior 
superior  iliac  spine,  and  thence  turns  downward  and  inward  parallel  with  and 
about  the  same  distance  above  Poupart's  ligament  (Fig.  767,  A  and  B,  and 
Fig.  768). 

Operation. — (1)  Incise  skin  and  superficial  fascia,  exposing  the  posterior 
layer  of  the  lumbar  fascia,  the  anterior  part  of  the  latissimus  dorsi  and  the 
posterior  part  of  the  external  oblique.  Continuing  the  incision  in  the  original 
line,  the  anterior  portion  of  the  latissimus  dorsi  will  be  incised  transversely  to 
its  fibers.  The  upper  part  of  the  serratus  posticus  inferior  will  be  incised 
transversely  beneath  it.  The  posterior  border  of  the  external  oblique  will  be 
divided,  and,  if  the  incision  be  continued  far  toward  the  iliac  crest,  the  knife 
will  pass  into  the  intermuscular  cleavage  line  of  this  muscle  (Fig.  769).     (2) 


RETROPERITONEAL    EXPOSURE    OF    THE    KIDNEY. 


I055 


The  outer  border  of  the  erector  spinas  is  exposed,  but  its  sheath  is  not  opened. 
The  internal  oblique  is  incised  nearly  at  a  right  angle  to  its  course.  The  pos- 
terior aponeurosis  of  the  transversalis  muscle  (fascia  lumborum)  is  divided 
also  to  the  full  length  of  the  wound.  Between  the  internal  oblique  and  trans- 
versalis, branches  of  the  last  dorsal  nerve  and  last  intercostal  artery  may  be 
encountered  passing  downward  and  forward  near  the  twelfth  rib — and 
branches  of  the  first  lumbar  nerve  and  last  lumbar  artery  near  the  iliac  crest. 
The  nerves  are  retracted  wherever  possible.  The  arteries  are  ligated  with  gut. 
All  the  parts  are  retracted  as  divided.  (3)  The  outer  border  of  the  quadratus 
lumborum  muscle  and  the  anterior  layer  of  the  fascia  lumborum  are  now  en- 
countered. The  latter  is  incised  to  the  limit  of  the  wound.  The  outer  border 
of  the  former  is  retracted — or  may  be  incised  if  necessary.  This  divided  layer 
is  also  retracted.  (4)  The  fas- 
cia transversalis  is  thus  ex- 
posed, and  is  similarly  divided 
— when  the  entire  depth  of  the 
wound  is  well  retracted  on  each 
side.  (5)  The  fatty  areolar 
capsule  of  the  kidney  is  now 
exposed,  retroperitoneal!}' — and 
is  opened  up,  partly  by  careful 
incision,  and  partly  by  blunt 
dissection  of  the  perirenal  tis- 
sue— while  an  assistant,  by 
pressure  upon  the  abdominal 
wall,  thrusts  the  kidney  into  the 
lumbar  wound — thus  exposing 
the  surface  of  the  organ.  (6) 
The  special  object  of  the  opera- 
tion is  now  accomplished — and 
the  wound  treated  as  indicated. 
Comment.  —  (1)  There  is 
more  chance  to  separate,  rather 
than  divide,  some  of  the  mus- 
cle-fibers in  this  incision,  if  it 
become  necessary  to  extend  it, 

than  in  most  of  the  other  incisions.  (2)  In  exploratory  incisions,  and  in 
limited  operations  upon  the  kidney,  it  is  generally  only  necessary  to  divide  the 
skin,  superficial  fascia,  lumbar  fascia,  latissimus  dorsi,  and  serratus  posticus 
inferior  over  a  distance  between  the  anterior  border  of  the  erector  spinas  and  the 
posterior  edges  of  the  external  and  internal  oblique  muscles.  (3)  In  thick  loins, 
longer  incisions  are  necessary.  (4)  Where  the  kidney  does  not  extend  down 
as  far  as  usual,  the  incision  may  be  extended  well  over  the  twelfth  rib  (but  see 
Surgical  Anatomy).  (5)  Guard  against  opening  the  pleura,  which  is  only 
separated  by  a  comparatively  thin  layer  of  fibrous  tissue  from  the  renal  fatty 
tissue  at  the  costo-lumbar  hiatus  of  the  diaphragm.  (6)  Proximity  of  the 
kidney  is  sometimes  noticed,  in  approaching  from  behind,  by  the  finer  texture 
of  the  fatty  areolar  tissue  near  it.  (7)  Avoid  the  colon,  which  sometimes 
pushes  its  way  into  the  wound.  (8)  If,  in  the  course  of  operation,  more  room 
be  needed,  the  incision  may  be  extended  in  one  of  three  directions; — (a)  back- 
ward, dividing,  if  necessary,  the  anterior  border  of  the  erector  spinas: — (b)  up- 
ward and  backward  over  the  twelfth  rib,  which  maybe  partially  excised: — (c) 


Fig.  768. — Oblique  Lumbo-abdominal  Incision  : 
exposure  of  kidney  and  ureter. 


ioq6 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


downward  and  forward  toward  the  anterior  superior  iliac  spine,  and  thence 
parallel  with  and  about  2.5  cm.  (1  inch)  above  Poupart's  ligament.  (9)  If  it 
be  desired  to  examine  the  opposite  kidney  during  operation  (which  should  al- 
wavs  be  done  before  removing  a  kidney,  except  where  that  ground  has  been 
preliminarily  covered  by  vesical  catheterization  of  the  opposite  ureter),  Kocher 
resorts  to  the  following  technic; — he  divides  the  transversalis  muscle  sufficiently 


Fig.  76Q.— Retroperitoneal  Exposure  of  Kidney  by  Oblique  Lumbar  Incision: — A, 
Latissimus  dorsi ;  B,  Serratus  posticus  inferior;  C,  Erector  spinse  ;  D,  Quadratus  lumborum  ;  E, 
External  oblique;  F,  Internal  oblique;  G,  Transversalis  aponeurosis;  H,  Fatty  areolar  tissue; 
I,  Intercostal  nerve  and  artery;  J,  Last  dorsal  nerve  and  lumbar  artery;  K,  Kidney;  L,  Pelvis  of 
kidney. 

far  forward  to  expose  the  reflection  of  the  peritoneum  on  to  the  colon,  near  the 
posterior  axillary  line — then  he  opens  the  peritoneum  and  passes  his  hand 
through  the  opening  and  around  to  the  opposite  kidney — the  inferior  surface  of 
the  liver  and  gall-bladder  being  thus  palpable  also.  After  accomplishing  the 
examination,  the  opening  in  the  peritoneum  is  sutured  and  the  operation  con- 
tinued. (10)  By  keeping  close  to  the  outer  edge  of  the  quadratus  lumborum 
muscle,  there  is  minimum  danger  of  wounding  the  peritoneum. 


RETROPERITONEAL  EXPOSURE  OF  THE  KIDNEY 

BY  KOEXIG'S  ANGULAR  LUMBO-ABDOMINAL  IN'CISION. 

Description. — A  retroperitoneal  exposure  of  the  kidney  where  an  espe- 
cially large  amount  of  room  is  required. 

Preparation— Position. — See  Surgical  Considerations. 

Landmarks. — Twelfth  rib;  outer  border  of  erector  spina?;  iliac  crest; 
umbilicus. 

Incision. — Begins  about  2  cm.  (f  inch)  below  the  twelfth  rib,  at  the  outer 
border  of  the  erector  spina? — passes  almost  vertically  downward  (having  slight 
outward  tendency)  along  the  outor  border  of  the  erector  spina?,  to  just  above 
the  iliac  crest — thence  curves  forward  and  upward  and  passes  in  a  straight  line 
toward  the  umbilicus,  stopping  at  the  outer  border  of  the  rectus  (Fig.  767,  C). 

Operation. — (1)  Incise,  in  the  vertical  portion  of  the  incision,  the  skin, 
superficial  fascia,  posterior  layer  of  the  lumbar  fascia,  latissimus  dorsi,  serratus 


TRANSPERITONEAL  EXPOSURE  OF  THE  KIDNEY.  1057 

posticus  inferior,  middle  layer  of  lumbar  fascia,  quadratus  lumborum,  an- 
terior layer  of  lumbar  fascia,  and  subperitoneal  fatty  areolar  tissue.  The 
vessels  and  nerves  encountered  in  this  portion  of  the  incision  are  the  same  as 
those  in  the  oblique  lumbar  incision.  (2)  The  lips  of  this  wound  are  retracted 
— the  fingers  are  inserted  and  the  peritoneum  detached  and  pushed  ahead  in 
advance  of  the  oblique  part  of  the  wound,  as  it  is  being  made.  (3)  The  ob- 
lique portion  of  the  incision  is  now  carried  out,  dividing  the  skin,  superficial 
fascia,  latissimus  dorsi,  external  oblique,  internal  oblique,  transversalis,  trans- 
versalis  fascia,  and  subperitoneal  areolar  tissue.  All  nerves  encountered  are 
preserved,  by  retraction,  as  far  as  it  is  possible.  The  peritoneum  is  carefully 
detached  and  held  out  of  the  way  ahead  of  the  incision  until  its  end  is  reached. 
(4)  The  perirenal  fatty  areolar  tissue  is  now  opened  up  and  the  kidney  ex- 
posed. (5)  The  special  operation  is  accomplished — and  the  wound  treated 
accordingly. 

Comment. — This  operation  gives  abundant  room,  and  is  retroperitoneal — 
but  is  very  extensive,  and  a  weakened  abdominal  wall  is  apt  to  follow. 


RETROPERITONEAL  EXPOSURE  OF  THE  KIDNEY 

PA'  THE  LUMBAR  INTRAMUSCULAR  METHOD. 

Description. — A  retroperitoneal  exposure  of  the  kidney  in  the  intramus- 
cular cleavage  line  and  without  severing  important  nerves  and  vessels.  Chiefly 
for  diagnostic  purposes — and  such  steps  as  can  be  carried  out  through  a 
limited  space.  The  principle  involved  is  the  same  as  that  in  McBurney's 
intramuscular  operation. 

Preparation — Position. — See  General  Surgical  Considerations. 

Landmarks. — Tip  of  twelfth  rib;  anterior  superior  iliac  spine. 

Incision. — Begins  just  internal  to  the  anterior  superior  iliac  spine — and 
passes  upward  and  backward,  in  the  cleavage  line  of  the  external  oblique,  to 
the  tip  of  the  twelfth  rib. 

Operation. — Incise  skin  and  superficial  fascia — expose  external  oblique 
and  separate  its  fibers  in  their  cleavage  line,  throughout  the  entire  length  of 
the  wound,  from  the  anterior  superior  iliac  spine  to  the  tip  of  the  twelfth  rib — 
retract  the  separated  fibers  forward  and  upward,  and  backward  and  down- 
ward— expose  the  internal  oblique,  running  almost  directly  across  the  external 
oblique,  and  separate  its  fibers  similarly,  along  as  much  of  the  line  as  possible, 
from  the  ninth  costal  cartilage  toward  the  posterior  superior  iliac  spine,  and 
retract  the  separated  fibers  forward  and  downward,  and  backward  and  up- 
ward— expose  the  transversalis  and  separate  its  fibers  similarly,  and  retract  the 
separated  fibers  upward  and  downward — divide  the  transversalis  fascia — then 
the  subperitoneal  connective  tissue — open  up  the  perirenal  fatty  areolar  tissue 
— retract  the  walls  of  the  wound  well — and  expose  the  kidney. 


TRANSPERITONEAL  EXPOSURE  OF  THE  KIDNEY 

BY  VERTICAL  INCISION*  IN  THE  LINEA  SEMILUNARIS  —  LANGENBUCH'S 

OPERATION. 

Description. — An  anterior  transperitoneal  exposure,  with  division  of  the 
mesocolon  over  the  kidney.     Chiefly  indicated  in  large  tumors — in  narrow, 
deformed  lumbar  regions — in  thick  lumbar  regions — where  much  room  is  re- 
quired— and  as  furnishing  an  easv  approach  and  examination  of  both  kidnevs 
67 


1058  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

and  ureters.  Incision  over  the  linea  semilunaris  gives  a  more  direct  route 
than  incision  in  the  median  line. 

Preparation — Position. — As  for  median  abdominal  section. 

Landmarks. — Linea  semilunaris;  costal  arch. 

Incision. — Begins  just  below  the  border  of  the  ribs,  in  the  linea  semilunaris 
of  the  affected  side,  and  extends  vertically  downward  in  that  line  for  10  or  12.5 
cm.  (4  or  5  inches) — the  incision  having  its  center  about  opposite  the  umbilicus. 

Operation. — (1)  The  abdominal  cavity  is  opened  in  the  usual  way  and 
the  wound  well  retracted.  The  small  intestines  are  held  out  of  the  way  by 
gauze  pads  and  special  retractors.  The  hand  is  introduced  and  the  condition 
of  both  kidneys  examined.     (2)  The  colon  is  displaced  toward  the  median  line 


Fig.  770. — Transperitoneal  Exposure  of  Kidney,  by  Vertical  Incision  in  Linea  Semi- 
lunaris (Langenbuch's  Operation): — A,  Ascending  colon  displaced  toward  median  line  ;  B, 
Outer  layer  of  mesocolon  incised  over  kidney;  C,  Ligature  around  renal  vein  ;  D,  Ligature  of  renal 
artery;  E,  Ligature  of  ureter. 

and  the  outer  layer  of  the  mesocolon  is  incised  in  a  vertical  direction  over  the 
site  of  the  kidney — thus  avoiding  the  vessels  to  the  colon  (Fig.  770).  (3)  The 
fingers  of  the  surgeon  are  passed  through  this  incision  in  the  mesocolon  down 
upon  the  kidney — the  posterior  surface  of  which  is  then  freed  and  exposed,  as 
it  lies  in  its  fatty  areolar  bed.  (4)  The  special  steps  of  the  operation  are  then 
concluded — and  the  abdomen  closed.  For  the  details  of  total  nephrectomy 
by  the  abdominal  route,  see  page  1072. 

Comment. — (1)  Where  drainage  is  necessary  in  connection  with  the 
anterior  transperitoneal  operation,  a  counter-opening  is  made  in  the  loin — the 
incision  being  made  from  without  upon  a  sound  pressing  against  the  lumbar 
wall  from  within.     (2)  Where  it  is  necessary,  in  the  anterior  operation,  to  fix 


EXPOSURE  OF  KIDNEY  BY  ABDOMINO-LUMBAR  ROUTES.       1059 

a  diseased  ureter  into  the  lumbar  skin,  an  incision  is  made  by  cutting  from 
without  upon  a  pair  of  forceps  introduced  from  within,  near  the  outer  edge  of 
the  quadratus  lumborum.  (3)  Before  closing  the  abdomen,  the  incised  wound 
in  the  mesocolon  is  sutured  with  gut. 


TRANSPERITONEAL  EXPOSURE  OF  THE  KIDNEY 

BY  MEDIAN  ABDOMINAL  SECTION. 

Description. — Exposure  of  the  kidney  by  an  incision  in  the  median  line. 
Practically  the  same  as  exposure  by  vertical  incision  in  the  linea  semilunaris, 
except  for  the  position  of  the  incision — the  operation  last  described  giving  the 
most  direct  access  to  the  kidney. 

Preparation  —  Position  —  Landmarks  —  Incision. — As  in  median  ab- 
dominal section. 

Operation. — Essentially  the  same  as  in  exposure  by  the  vertical  incision 
in  the  linea  semilunaris.  Having  displaced  the  intestines  to  the  opposite  side, 
the  mesocolon  is  divided  over  the  kidney.  The  lateral  layer  of  the  mesocolon 
is  preferably  divided.  If  circumstances  make  this  inconvenient,  the  median 
layer  of  the  mesocolon  is  divided.  Having  passed  through  the  opening  in  the 
mesocolon,  the  kidney  is  isolated  and  exposed — its  anterior  surface,  lateral 
borders,  upper  and  lower  poles,  posterior  surface,  and  pelvis  being  made  ac- 
cessible. Having  accomplished  the  object  of  the  operation,  the  incision  in  the 
mesocolon  is  sutured — and  the  abdomen  closed. 

Comment. — Wherever  the  fatty  areolar  capsule  has  been  opened  up  very 
extensively  in  exposing  the  proper  capsule  of  the  kidney,  at  the  close  of  the 
operation  the  fatty  areolar  connective  tissue  is  sutured  about  the  kidney  again 
— and,  if  necessary,  anchored,  by  a  chromic  gut  stitch  or  two,  to  the  neighbor- 
ing structures. 


EXPOSURE  OF  THE  KIDNEY  BY  THE  COMBINED  ABDOMINO-LUMBAR 

OPERATION 

BY  ANTERIOR  TRANSPERITONEAL  AND  POSTERIOR  RETROPERITONEAL 

INCISIONS. 

Description.— Consists  of  one  of  the  anterior  transperitoneal  operations 
combined  with  one  of  the  posterior  retroperitoneal  operations.  Generallv 
resorted  to  where  it  is  wished  to  make  a  previous  examination  of  the  abdominal 
cavity,  chiefly  for  diagnostic  purposes  connected  with  both  kidneys  and  ureters 
— or  where  a  large  tumor  is  to  be  removed.  The  intra-abdominal  operation  is 
first  performed.  Guided  by  one  hand  within  the  peritoneal  cavity,  the  kidnev 
can  be  exposed  through  a  smaller  lumbar  wound,  and  with  greater  ease,  and 
with  less  danger  of  wounding  the  colon  and  peritoneum.  The  great  objection, 
however,  is  the  double  operation — and  the  involvement  of  the  peritoneal  cavity. 

Preparation. — As  for  both  the  abdominal  and  lumbar  operations. 

Position. — Patient  is  supine  during  the  anterior  operation,  and  partlv 
upon  the  side  during  the  lumbar  incision.  The  surgeon's  position  changes 
with  the  steps  of  the  operation. 

Landmarks. — Those  of  both  the  abdominal  and  lumbar  operations. 

Incision. — The  incisions  usually  adopted  are,  for  the  anterior  operation, 
Langenbuch's  vertical  incision  in  the  linea  semilunaris — and,  for  the  posterior 
operation,  the  oblique  lumbar  incision.  See  the  descriptions  of  these  incisions, 
pages  1053  and  1058. 


io6o 


OPERATIONS  UPON  THE  AP.DOMINO-l'ELVIC  REGION. 


Operation. — The  abdominal  operation  is  first  done — the  examination 
made — and  then,  guided  by  the  left  hand  within  the  abdomen,  the  lumbar  in- 
cision is  made  and  the  operation  completed  extraperitoneally,  accomplishing 
the  special  object  sought  through  the  posterior  wound,  as  a  rule — after  which, 
the  abdomen  is  closed.  The  posterior  wound  is  either  entirely  closed — or 
partially  closed  and  drained,  as  indicated. 


EXPLORATORY  PUNCTURE  OF  THE  KIDNEY. 

Description. — Exploration  of  the  kidney  by  solid  needle  for  calculus — or 
by  hollow  needle  and  syringe  for  pus  or  other  fluid.  Two  forms  of  puncture 
may  be  made — (a)  Puncture  from  Without ;  the  puncture  is  here  made  through 
unbroken  skin,  or,  in  the  case  of  a  large  needle,  after  incising  the  skin  alone; — 
the  needle-puncture  is  made  on  anatomical  grounds,  and  is  made  below  the 
level  of  the  pleura  (see  pages  759  and  1049).    (See  Comment.)     (b)  Puncture 

after  exposure  of  the 
Kidney — which  will 
be  here  described. 
In  the  latter  case  the 
exposure  is  usually 
made  through  the 
oblique  lumbar  in- 
cision. 

Preparation — 
P  o  s  i  t  i  o  n — L  and- 
marks — Incision. — 
As  for  exposure  of 
the  kidney  by  an 
oblique  lumbar  in- 
cision. 

Operation.— 
Having  exposed  and 
incised  the  perirenal 
fatty  tissue,  the  kid- 
ney surface  (the 
proper  capsule)  is 
exposed  over  as  large 
an  area  as  consid- 
ered necessary,  by  a 
blunt  dissector  and 
the  finger.  The  kid- 
ney is  then  steadied 
by  the  fingers  of  the 
operator's  left  hand 
— while  a  needle, 
held  between  the  right  index  and  thumb  (remembering  the  dimensions  of  the 
kidney),  is  thrust  into  the  viscus — always  being  introduced  in  a  straight  line, 
and  thrust  from  its  point  of  entrance  toward  the  hilum — being  introduced, 
preferably,  from  the  convex  border — next,  in  the  sides — and,  last,  at  the  hilum. 
A  needle  may  be  thus  introduced  a  dozen  or  more  times — always  being  with- 
drawn and  re-entered  before  being  made  to  travel  in  a  new  direction.  The 
operation  will  be  concluded  according  to  the  result  of  the  puncture.    (Fig.  771.) 


Fig.  771.— Exploratory  Incision  and  Puncture  of  Kidney 
and  Pelvis  :— A,  Nephrotomy  ;  B,  Bisection  of  kidney  ;  C,  Explora- 
tory puncture  of  kidney  substance  with  solid  needle  ;  D,  Exploratory 
puncture  with  aspiratory  needle  ;  E,  Sound  passed  through  pelvis  of 
kidney  to  explore  ureter;  F,  Forceps  holding  apart  lips  of  pyelotomy 
wound. 


NEPHROTOMY.  1061 

Comment. — Transperitoneal  puncture  should  never  be  made — it  is  both 
unsafe  and  uncertain.  Extraperitoneal  lumbar  puncture  is  not  so  dangerous — 
and,  when  made  through  the  unbroken  skin,  while  not  so  unsafe  as  transperi- 
toneal puncture,  it  is  quite  uncertain.  The  most  advisable  form  of  puncture  is 
first  to  expose  the  kidney  deliberately,  and  then  to  puncture. 


NEPHROTOMY. 

Description. — Incision  of  the  kidney  substance  for  the  removal  of  calculi 
or  tumors,  or  for  the  evacuation  of  pus  or  other  fluid  from  the  kidney  proper, 
calices  or  pelvis — or  for  nephralgia.  The  kidney  may  be  exposed  by  any  of  the 
incisions  given — the  oblique  lumbar  incision  being  probably  the  best. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
the  kidney  by  the  oblique  lumbar  incision. 

Operation. — (I)  Having  exposed  the  kidney  and  brought  it  into  the  field, 
by  counter-pressure  from  in  front,  and  by  drawing  it  down  from  under  the  rib 
the  site  of  the  calculus  or  fluid  is  discovered  by  the  introduction  of  the  solid  or 
hollow  needle,  after  the  manner  described  under  Puncture  of  the  Kidney.  (2) 
Having  located  the  object,  an  incision  is  made  down  upon  it  exactly  as  de- 
scribed under  Nephrolithotomy  (page  1062),  stone  being  the  most  usual  in- 
dication for  Nephrotomy.  (3)  Following  the  operation  for  stone,  the  kidney 
wound  is  treated  as  under  Nephrolithotomy.  (4)  Following  the  operation  for 
pus  or  fluid,  drainage  is  carried  down  into  the  cavity  of  pus  or  fluid — after, 
where  it  is  possible,  the  lips  of  the  cavity  have  been  brought  up  and  sutured  to 
the  deeper  structures  of  the  abdominal  wound — or  the  cavity  may  be  partly 
closed  around  a  drainage-tube  going  to  its  bottom.  (5)  Where  the  kidney  has 
been  cut  into  and  no  cause  for  drainage  is  found,  the  kidney  substance  is 
brought  together  by  alternate  deep  and  superficial  catgut  sutures.  (6)  The 
fatty  areolar  capsule  is  also  closed  by  deep  buried  gut  sutures  in  all  such  cases. 
(7)  The  lumbar  wound  is  sutured  in  part,  leaving  room  for  drainage — or 
entirely,  as  indicated.     (Fig.  771.) 

Comment. — (1)  Where  hemorrhage  is  severe  on  cutting  into  the  kidney, 
it  may  be  controlled  by  compressing  the  pedicle  (which  should  have  been 
demonstrated  in  advance)  between  the  fingers  or  special  clamps — or  by  gauze 
packing.  Hemorrhage  from  a  healthy  kidney  is  often  enormous — while  it  is 
generally  much  less  from  a  diseased  one.  (2)  Incision  along  the  convex  border 
of  the  kidney  is  always  preferable.  It  is  better  to  remove  a  calculus  in  the 
pelvis  of  the  kidney  through  an  incision  from  the  convex  border  than  by  an  in- 
cision directly  into  the  pelvis — fistula  being  more  apt  to  follow  incision  of  the 
pelvis.  (3)  Where  all  is  favorable,  complete  suturing  of  the  kidney  substance 
should  be  done  after  the  removal  of  a  stone.  (4)  Splitting  of  the  capsule  alone 
may  be  done  in  Nephralgia.  (5)  It  is  often  hard  to  find  the  pelvis  in  the 
normal  kidney,  even  after  incising  from  the  convex  border.  (6)  After  neph- 
rotomy for  pus,  always  unite  the  margins  of  the  cavity  to  the  structures  in 
the  lower  part  of  the  wound,  if  possible — to  avoid,  if  possible,  infection  of  the 
perirenal  tissue.  (7)  In  unhealthy  or  suspicious  cases,  drainage  is  estab- 
lished down  to  the  kidney — or,  if  indicated,  into  not  only  the  kidney  itself, 
but  even  into  the  pelvis — with  gauze  or  tube,  preferably  gauze  packed  into 
the  pelvis  and  calices. 

Bisection  of  Kidney. — In  cases  where  limited  incisions  into  the  kidney 
substance  will  not  suffice,  it  is  sometimes  necessary  to  lay  the  kidney  widely 
open — splitting  it  into  two  halves  flat-wise,  or  "  bisecting  "  it.     An  incision  is 


1062  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

made  in  the  middle  line  of  the  convex  border,  from  the  upper  to  the  lower  pole 
— passing  straight  into  the  pelvis — thus  dividing  the  fewest  vessels  and  urin- 
iferous  tubules.  The  narrow  calices  are  dilated  with  the  tip  of  the  finger  or  a 
pair  of  forceps — a  probe  is  passed  thence  into  the  pelvis — and  a  bougie  may  be 
passed  down  the  ureter  even  into  the  bladder.  Having  accomplished  the 
object  of  the  exploration,  and,  in  suitable  cases,  having  corrected  the  condi- 
tion, the  bisected  kidney  is  sutured  with  alternate  deep  and  superficial  cat- 
gut sutures — the  deep  ones  passing  through  the  entire  thickness  of  the  kidney. 
(Fig.  772.) 

PYELOTOMY. 

Description. — Pyelotomy,  or  Pelviotomy,  consists  in  the  incision  of  the 
pelvis  of  the  kidney.  Generally  resorted  to  for  calculus,  or  for  exploration. 
Usually  done  by  the  oblique  lumbar  incision.  Pelvio-lithotomy,  or  Pyelo- 
lithotomy,  is  the  same  operation  done  especially  for  the  removal  of  stone  from 
the  pelvis  of  the  kidney. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
the  kidney  by  an  oblique  lumbar  incision. 

Operation. — Having  incised  and  freed  the  fatty  capsule  and  exposed  the 
kidney  by  blunt  dissection,  the  organ  is  brought  forward  and  steadied — as  far 
out  into  the  wound  as  possible.  A  longitudinal  incision  (in  the  course  of  the 
pelvis)  is  made  through  the  posterior  wall  of  the  pelvis.  Scarcely  any  hem- 
orrhage follows  incision  of  the  pelvis,  as  a  rule — in  contradistinction  to  the 
rather  free  hemorrhage  which  nearly  always  at  first  follows  incision  of  the  kid- 
ney parenchyma.  Insert  two  temporary  silk  traction-sutures  into  the  wound- 
lips  of  the  pelvis.  Into  the  opening  thus  made  and  held  apart  by  the  traction- 
sutures,  a  special  sound,  or  the  finger,  is  introduced  and  an  examination  made 
for  the  object  suspected — both  in  the  calices  above,  and  in  the  ureter  below. 
Having  accomplished  the  object  of  the  operation  (which  is  often  the  removal  of 
a  calculus)  the  wound  in  the  pelvis,  in  clean  cases,  is  closed  by  interrupted  or 
continuous  sutures,  applied  like  the  Lembert  suturing,  through  all  the  coats  of 
the  pelvis  except  the  mucous.  For  fear  of  leakage,  drainage  is  generally  es- 
tablished down  to  the  pelvis.  In  infected  cases,  free  drainage  is  established 
to  and  even  into  the  pelvis — in  the  latter  case,  omitting  the  suturing  of  the  en- 
tire pelvis-wound.  The  lumbar  wound  is  closed  up  to  the  exit  of  the  drain. 
(Fig.  771,  E.) 

Comment. — (1)  While  incision  into  the  pelvis  is  followed  by  little  or  no 
hemorrhage,  and  admits  of  probing  the  ureter,  it  gives  no  access  to  the  kidney 
parenchyma — and  but  imperfect  access  to  the  calices — and  is  more  apt  to  be 
followed  by  urinary  fistula.  (2)  After  Pyelotomy,  in  order  to  avoid  urinary 
fistula,  especial  care  should  be  taken  to  see  that  the  ureter  is  patulous — if  it  be 
not  patulous,  the  obstacle  should  be  removed — or  an  ureterostomy,  or  other 
operation,  be  done.  (3)  The  calix,  or  the  site  of  the  lodged  stone,  may  have 
to  be  dilated  with  special  forceps  before  it  can  be  loosened  and  removed. 


NEPHRO-LITHOTOMY. 

Description. — Incision  of  the  kidney  for  the  removal  of  stone.  The 
operation  consists,  practically,  of  a  Nephrotomy — and  is  generally  done 
through  the  oblique  lumbar  incision. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
kidney  by  oblique  lumbar  incision. 


NEPHRORRHAPIIY.  1063 

Operation. — (1)  Having  located  the  kidney  and  pressed  (by  counter- 
pressure)  and  drawn  it  into  the  wound,  divide  the  fatty  areolar  tissue  and  ex- 
pose the  surface  of  the  organ.  (2)  Insinuate  the  index-finger  (of  that  hand 
corresponding  with  the  kidney  involved)  beneath  the  fatty  capsule,  through  the 
freeing  incision,  and  feel  the  organ  by  palpating  it  between  thumb  and  index, 
counter-pressure  being  maintained  the  while.  If  the  stone  be  palpated,  steps 
for  its  removal  may  be  at  once  undertaken.  (3)  If  the  stone  be  not  detected 
by  palpation,  several  means  of  investigation  are  available;  (a)  While  the  kidney 
is  steadied,  a  small,  long,  solid  needle  may  be  thrust  in  various  directions, 
entered  at  the  external  border  and  thrust  toward  the  hilum — being  withdrawn 
between  each  thrust.  This  is  the  simplest  and  best  instrumental  exploration. 
(b)  A  special  sound  may  be  passed  through  an  incision  made  in  one  of  the 
lowest  calices  and  the  pelvis  of  the  kidney  thus  examined,  or  a  finger  may  be 
introduced.  Chiefly  indicated  when  a  stone  is  impacted  there  and  is  not  re- 
movable from  the  external  border  of  the  kidney,  (c)  An  incision  along  the 
convex  border  of  the  kidney,  lengthwise  of  the  kidney,  may  be  made — pass- 
ing as  far  into  the  substance  of  the  organ  as  indicated,  even  into  the  calices. 
Note — Methods  ''a"  and  "c"  are  to  be  preferred  to  opening  the  pelvis  of  the 
kidney,  which  is  apt  to  be  followed  by  fistula.  (4)  When  located,  the  stone  is 
cut  down  upon  by  the  most  direct  route,  by  a  straight  incision  from  the  cortex 
toward  the  hilum — and,  when  reached,  the  calculus  is  removed  by  the  finger 
alone,  or  aided  by  special  scoop  or  forceps — or  may  be  broken  and  removed  in 
pieces.  (5)  Having  removed  the  calculus,  and  cleansed  by  douching  or  gauze- 
sponging,  as  indicated,  the  site  occupied  by  the  stone,  the  wound  in  the  kidney, 
in  clean  cases,  should  be  repaired  by  fine  catgut  (see  Nephrorrhaphv),  and 
temporary  drainage  down  to  the  kidney  established.  If  purulent  conditions 
be  present,  the  kidney  wound  should  not  be  entirely  sutured — and  drainage  to, 
or  into,  the  pus  cavity  be  instituted. 

Comment. — (1)  Following  free  incision  of  the  kidney  substance,  con- 
siderable hemorrhage  is  apt  to  occur  at  first,  but  is  generally  capable  of  speedy 
arrest  by  gauze  pressure,  or  hot  douching — or,  these  failing,  by  compression 
of  the  pedicle.  (2)  Incisions  into  the  kidney  substance  should  be  made  in  a 
straight  line  toward  the  hilum  (centering  toward  the  hilum  like  the  spokes  of  a 
wheel).  (3)  To  aid  in  examining  the  pelvis  of  the  kidney,  turn  the  external 
border  of  the  kidney  upward  and  forward.  (4)  In  manipulating  near  the 
anterior  wall  of  the  kidney,  take  care  lest  the  peritoneal  cavity  be  entered.  (5) 
Where  the  kidney  has  been  exposed  by  an  anterior  incision  (transperitoneal) 
and  drainage  is  necessary,  a  posterior  counter-opening  should  be  made  by 
cutting  from  without  down  upon  some  instrument  pressed  against  the  lumbar 
wall  from  within.  The  peritoneum  is  then  closed  over  the  anterior  aspect  of 
the  kidney,  and  the  posterior  wound,  with  drainage,  is  left  open.  These  re- 
marks just  made  apply  to  the  sometimes  indicated  removal  by  a  posterior  in- 
cision of  a  stone  which  has  been  discovered  by  an  anterior  operation. 


NEPHRORRHAPHY. 

Description. — Suturing  of  the  kidney  substance — here  used  in  connection 
with  suturing  kidney  wounds,  either  accidental  or  those  made  in  the  course  of 
an  operation.  The  kidney  is  exposed  either  by  enlarging  the  original  wound — 
or,  if  deliberately  exposed,  generally  by  the  oblique  lumbar  incision.  Every 
Nephropexy  involves  nephrorrhaphv — but  not  vice  versa.  See  Nephropexy 
page  1064. 


1064 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


Operation. — Having  exposed  the  kidney  and  brought  it  into  convenient 
position  for  manipulation,  the  edges  of  the  wound  are  brought  together  and 

sutured  with  catgut,  car- 
A  ried  upon  a  fully  curved 
needle  held  in  a  needle- 
holder.  Interrupted  su- 
tures are  generally  more 
satisfactory  than  continu- 
ous sutures.  Where  the 
wound  is  superficial,  a 
single  row  of  sutures,  all 
of  the  same  depth,  suffices. 
Where  the  wound  is  more 
extensive,  it  is  well  to  put 
in  a  double  row — a  deeper 
row  outlying  the  more 
superficial  row, — or  a  sin- 
gle row  may  be  used, 
putting  in  each  alternate 
suture  a  deep  one.  Ordi- 
nary suture  may  be  used — 
either  interrupted  or  con- 
tinuous— or  the  Halsted 
quilt  suture  may  be  used,  especially  where  much  loss  of  kidney  substance  has 
occurred.     (Fig.  772.) 


Fig.  772.— Nephrorrhaphv  and  Pyelorrhaphy  :  —  A, 
Small  nephrotomy  wound  closed  with  superficial  sutures;  B, 
Long  and  deep  nephrotomy  wound  closed  with  alternate  super- 
ficial and  deep  sutures;  C,  Pyelotomy  wound  closed  with 
Lembert  sutures. 


NEPHROPEXY 

BY  SUTURING  SPLIT  AND  EVERTED  PROPER  CAPSULE  OF  KIDNEY  TO  LUMBAR 
WALL—  EDEBOHLS'S  OPERATION. 

Description. — The  fibrous  capsule  of  the  kidney  is  split  along  the  con- 
vexity of  the  organ  and  peeled  back  toward  the  pelvis,  on  both  aspects,  for 
about  half-way — after  which,  chromic  gut  sutures  are  passed  through  both  the 
detached  and  undetached  portions  of  this  capsule,  and  through  the  lips  of  the 
lumbar  wound.  When  these  sutures  are  tightened  and  tied,  they  approximate 
the  partly  decapsulated  kidney  to  the  raw  portions  of  the  lumbar  wound. 

Position. — Patient  lies  prone  upon  Edebohls's  kidney  air-cushion — which, 
pressing  against  the  abdomen,  aids  in  bringing  the  kidney  prominently  into 
the  wound.  Surgeon  stands  on  left  side  in  operating  upon  left  kidney,  cutting 
from  above  downward — and  on  right  side  in  operating  upon  right  kidney, 
cutting  from  below  upward  (or  stands  on  opposite  side  of  body,  cutting  from 
above  downward).     Assistant  stands  upon  the  opposite  side  of  the  body. 

Landmarks. — Twelfth  rib;  iliac  crest;  outer  border  of  erector  spina? 
muscle;  anatomical  relations  of  kidnev. 

Incision. — Straight  incision  along  the  external  border  of  the  erector  spina? 
muscle,  passing  from  the  inferior  border  of  the  twelfth  rib  to  the  iliac  crest. 
Where  the  space  between  rib  and  ilium  is  very  narrow,  this  incision  may  begin 
at  the  same  point  but  run  more  obliquely  and  reach  the  ilium  further  to  the 
Duter  side  of  the  erector  spinas.     (Fig.  767,  D.) 

Operation. — (1)  Incise  skin  and  fascia.  Recognize  the  latissimus  dorsi 
and  separate  its  fibers  in  their  cleavage  line — beginning  the  separation  over  the 
outer  aspect  of  the  erector  spina?  and  continuing  it  upward  and  outward.  The 
sheath  of  the  erector  spina?  is  not  opened.     (2)  Divide  the  transversalis  fascia, 


NEPHROPEXY 


106s 


exposing  the  perirenal  fatty  areolar  tissue.  If  the  ilio-hypogastric  nerve  can- 
not be  retracted  to  one  side,  it  is  cut  and  subsequently  sutured  with  gut,  after 
the  kidney  has  been  sutured  into  place.  (3)  The  sheath  of  the  quadratus 
lumborum  is  incised  from  the  twelfth  rib  to  the  iliac  crest,  along  the  anterior 
surface  of  its  lateral  border — exposing,  by  the  retraction  of  its  incised  edges, 
considerable  raw  muscle.  (4)  The  kidney  is  now  freed  by  blunt  dissection, 
aided  by  clips  of  curved,  blunt  scissors,  if  necessary — and  is  delivered  upon  the 
back,  surrounded  by  its  fatty  capsule — which  delivery  is  aided  by  rolling  the 
patient  up  and  clown  upon  the  air-pillow.  The  size  of  the  opening  in  the 
abdominal  parietes  may  be  increased,  if  need  be.  (5)  Dissect  away  the  entire 
fatty  capsule  from  the  proper  fibrous  capsule  of  the  kidney.  (6)  Any  explora- 
tion of  the  kidney  by  palpation,  x-raying,  or  instrumental  means  may  now  be 
done — and  any  measure  carried  out  that  may  be  indicated.     (7)  At  this  stage, 


tiP 


Fig. 773. — Nephropexy — Kdebohls's  Operation: — I,  Placing  fixation  or  suspension  sutures — the 
kidney  is  shown  delivered  through  lumbar  wound — the  proper  capsule  split  and  stripped  back  half- 
way— and  the  four  fixation  sutures  passed  through  reflected  and  attached  portions  of  proper  capsule, 
and  not  penetrating  kidney  substance.     (Modified  from  Edebohls.j 


if  the  removal  of  the  appendix  vermiformis  be  indicated — which  the  author  of 
the  operation  considers  to  be  so  in  a  certain  percentage  of  cases — the  perito- 
neum is  opened  external  to  the  kidney,  and  to  the  outer  side  of  the  ascending 
colon — part  of  the  ascending  colon  is  drawn  out  and  one  of  its  longitudinal 
bands  is  followed  down  to  the  caecum  and  the  appendix  thus  located  at  the 
termination  of  the  muscular  band — after  which  the  appendix  is  delivered  into 
the  wound  (the  kidney  having  been  temporarily  replaced) — and  is  either  in- 
verted entire  into  the  caecum,  after  ligating  the  meso-appendix,  or  excised  and 
the  stump  treated  according  to  the  operator's  individual  ideas.  (8)  Following 
the  replacing  of  the  intestines,  the  author  of  the  operation — who  considers  that 
there  is  an  association,  in  a  certain  percentage  of  cases,  between  nephroptosis 
and  disease  of  the  bile-passages — explores,  by  palpation,  the  gall-bladder, 


1066  OPERATIONS  UPON  THE  ABOOMINO-PELVIC  REGION. 

cystic  and  common  ducts,  inferior  aspect  of  liver,  and  the  pyloric  end  of  the 
stomach,  through  the  lumbar  wound.  (9)  The  peritoneal  wound  is  then 
closed  and  the  kidney  again  delivered  through  the  lumbar  wound,  in  prepara- 
tion for  anchorage.  Where  the  peritoneum  has  not  been  opened,  the  kidney 
remains  delivered,  as  described  under  (4),  from  the  time  of  its  first  exposure. 
(10)  Incise  the  proper  capsule  of  the  kidney  at  the  center  of  its  convex  border, 
carefully  avoiding  entering  the  kidney  substance.  Pass  a  grooved  director  be- 
tween the  fibrous  capsule  and  kidney  proper,  first  toward  the  upper  pole,  and 
then  toward  the  lower  pole,  to  and  half-way  around  both  poles.  The  fibrous 
capsule  is  then  separated  from  the  kidney  by  blunt  dissection,  from  the  line 
of  incision,  peeling  it  off  (as  the  skin  from  an  orange)  on  both  sides  toward  the 
pelvis — until  practically  one-half  of  the  kidney  is  denuded — the  detached  por- 


Fig  774.— Nkphropexy — Edehohls's  Operation  : — II,  Anchoring  kidney  and  closing  lumbarwound 
—the  skin  wound  is  shown  retracted,  and  the  kidney  has  been  returned  within  abdominal  wound. 
A,  A,  Two  upper  buried  fixation  sutures,  untied.  The  two  lower  fixation  sutures  are  tied.  B,  Untied 
buried  suture  uniting  lips  of  lumbarwound  in  cleavage  line  of  latissimus  dorsi.  Similar  sutures  below 
are  tied.     (Modified  from  Edebohls.) 

tion  remaining  continuous  with  the  undetached  portion,  and  turned  back  upon 
the  latter  as  the  lapel  of  a  coat.  If  the  proper  capsule  appear  excessive,  a  por- 
tion may  be  excised  (Fig.  773).  (")  Four  forty-day  chromic  gut  fixation  or 
suspension  sutures  are  now  introduced  through  both  that  portion  of  the  proper 
capsule  which  has  been  detached  and  reflected,  and  through  the  still  adherent 
portion — the  passage  of  the  sutures  occurring  near  the  line  of  reflection  and 
being  accomplished  as  shown  in  Fig.  773, — two  being  placed  upon  the  anterior 
and  two  upon  the  posterior  aspect  of  the  kidney,  at  the  center  of  the  upper  and 
lower  halves  on  each  side.  A  straight  Hagedorn  needle  is  used— the  suture  is 
carried  from  within  outward  entirely  through  the  reflected  proper  capsule,  near 
the  line  of  reflection— travels  transversely  to  the  axis  of  the  kidney  and  enters 
the  attached  portion  of  the  proper  capsule  (directly  opposite  its  point  of  emer- 


NEPHROPEXY 


1067 


gence  from  the  detached  portion)  and  pierces  it  from  without  inward,  just  be- 
yond the  line  of  reflection — thence  the  Hagedorn  needle  travels,  flatwise,  en- 
tirely between  the  proper  capsule  and  the  kidney  substance,  parallel  with  and 
just  below  the  line  of  reflection,  for  2  or  3  cm.  (f  to  i^  inches) — thence 
emerges  through  the  attached  capsule  from  within  outward — and,  traveling 
transversely  to  the  axis  of  the  kidney,  passes  through  the  reflected  proper 
capsule  from  without  inward,  parallel  with  the  companion  limb  of  the  suture. 
(12)  Having  placed  all  four  sutures,  the  kidney, with  the  eight  suture  ends  hang- 
ing free,  is  returned  within  the  bod}-.  Each  suture  is  now  passed  through 
the  entire  lumbar  wall,  from  within  outward — either  by  threading  a  needle 
upon  each  and  penetrating  the  wall  from  within  outward,  or  by  passing  a 
Reverdin  needle  through  the  abdominal  parietes  from  without  and  drawing  the 
sutures  through  from  with- 
in. The  four  inner  sutures 
will  thus  pierce  the  lumbar 
wall  on  the  inner  side  of 
the  incision,  and  at  a  dis- 
tance from  each  other 
equivalent  to  the  distances 
apart  at  which  they  pene- 
trate the  proper  capsule — 
and  will  pass  through  the 
retracted  sheath  of  the 
quadratus  lumborum  near 
its  edge,  through  the  quad- 
ratus muscle,  and  through 
the  erector  spinae.  The 
four  outer  sutures  will 
pierce  the  lumbar  wall  on 
the  outer  side  of  the  inci- 
sion, at  the  same  distance 
from  each  other  as  those 
of  the  opposite  side,  and 
each  at  a  distance  from  its 
companion  suture  of  the 
opposite  side  equivalent  to 
the  antero-posterior  thick- 
ness of  the  kidney — and 
will  pass  through  the 
transversalis  fascia  and  the 
latissimus     dorsi     muscle. 

The  highest  sutures  pass  through  immediately  below  the  last 'rib.  These 
eight  sutures  are,  at  first,  left  untied.  (13)  The  incision  in  the  lumbar  wall 
is  now  closed,  in  the  cleavage  line  of  the  latissimus  dorsi,  by  from  four  to  six 
deeply  buried  interrupted  sutures  of  forty-day  chromic  gut,  in  such  a  manner 
as  to  turn  the  raw  surface  of  the  quadratus  lumborum  muscle  toward  the 
kidney.  This  is  accomplished  by  suturing  the  latissimus  dorsi  and  lumbar 
fascia,  composing  the  external  margin  of  the  wound — to  the  latissimus  dorsi, 
the  sheath  of  the  erector  spinae,  and  the  external  margin  of  the  incised  sheath 
of  the  quadratus  lumborum,  composing  the  inner  margin  of  the  wound  (Fig. 
774).  (14)  The  eight  free  suspension  or  fixation  sutures  are  now  drawn  taut, 
thus  snugly  approximating  the  decapsulated  convex  surface  of  the  kidney  into 
contact  with  the  raw  substance  of  the  quadratus  lumborum,  from  rib  to  ilium 


Fig.  775.  —  Nephropexy  —  Edebohls's  Operation:  —  III, 
Cross-section  of  region  of  operation.  A,  Psoas  magnus  ;  B, 
Erector  spinae  ;  C,  Quadratus  lumborum  ;  D,  Latissimus  dorsi ; 
E,  Rectus  abdominis;  F,  External  oblique;  G,  Internal  ob- 
lique; H,  Transversalis;  I,  Lumbar  incision  exposing  kid- 
ney ;  J,  The  decapsulated  convexity  of  kidney  is  shown  ap- 
proximated to  raw  substance  of  quadratus  lumborum  by  the 
fixation-sutures  seen  passing  through  both  the  detached  and 
adherent  portions  of  proper  kidney  capsule.  (Modified  from 
Edebohls.) 


io68 


OPERATIONS  UPON  THE  ADDOMINO-PELVIC  REGION. 


— and  are  then  tied  (Fig.  775).  (15)  The  skin  and  fascia  are  then  closed  in 
the  line  of  the  original  incision,  with  a  subcuticular  suture — and  a  broad  lum- 
bar dressing  applied. 


NEPHROPEXY 

BY  SUTURING  SPLIT  PROPER  CAPSULE  AND  PARENCHYMA  OF  KIDNEY  TO  LUMBAR 
WALL,  BY  OBLIQUE  LUMBAR  INCISION  —  TUFFIER'S  OPERATION. 

Description. — Anchoring  of  an  abnormally  movable  kidney  into  its  own 
or  another  adjacent  site — by  suturing  of  the  parenchyma  and  partially  stripped 
fibrous  capsule  to  the  lumbar  wall  or  lower  ribs.  The  kidney  may  be  exposed 
through  any  of  the  posterior  incisions  recently  described — but  is  generally  ex- 
posed through  the  oblique  lumbar  incision. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
the  kidney  by  an  oblique  lumbar  incision. 

Operation. — (1)  Having  exposed  the  kidney  and  brought  it  well  into  the 
wound,  partly  by  pressure  from  the  abdomen,  and  partly  by  drawing  the  organ 

downward  and  backward  from  under  the  rib 
(or  simply  backward,  where  already  much  dis- 
placed and  loosened  from  its  natural  position), 
the  fatty  areolar  capsule  is  divided  and  partly 
turned  backward,  exposing  the  kidney  and  its 
proper  fibrous  capsule.  (2)  Trim  away  any 
excess  of  fatty  capsule.  Incise  the  proper  fi- 
brous capsule  of  the  kidney  along  its  mid-pos- 
terior aspect,  in  the  long  axis  of  the  kidney  and 
for  its  entire  length — adding  a  cross-cut,  at 
right  angles,  at  either  end  of  the  vertical  inci- 
sion, of  about  2.5  cm.  (1  inch)  in  length,  half  of 
its  length  being  on  either  side  of  the  vertical  cut. 
Peel  back  the  fibrous  capsule  thus  liberated  for 
about  1.3  cm.  (J  inch)  on  either  side  of  the 
median  incision.  Pass  from  four  to  six  chromic 
gut  or  kangaroo  tendon  sutures,  in  a  curved 
needle,  held  in  a  holder,  so  as  to  include,  on  one 
side,  the  deeper  structures  in  one  lip  of  the  lum- 
bar wound  (but  not  the  entire  thickness  of  the 
lumbar  wound),  the  transversalis  fascia,  fatty 
capsule,  reflected  portion  of  fibrous  capsule, 
part  of  unreflected  portion  of  fibrous  capsule, 
and  about  1.3  cm.  (£  inch)  of  kidney  substance, 
— emerging  from  the  kidney  substance  on  the 
opposite  side,  it  takes  up,  in  reverse  order,  part  of  the  unreflected  portion  of 
the  kidney  capsule,  reflected  portion  of  the  proper  capsule,  fatty  capsule, 
transversalis  fascia  and  deeper  structures  in  the  opposite  lip  of  the  lumbar 
wound  (Fig.  776).  These  are  tied  as  buried  sutures,  simultaneously  drawing 
the  kidney  up  to  the  lumbar  fascia,  posterior  abdominal  wall,  and  borders  of 
the  wound,  and,  at  the  same  time,  approximating  the  deeper  parts  of  the  lips 
of  the  wound.  Care  is  taken  to  draw  the  kidney  up  to  and  under  the  lips  of 
the  wound  and  in  contact  with  as  much  raw  surface  as  possible — but  not  into 
and  between  the  wound.  It  is  also  essential  to  see  that  the  reflected  most,  to 
of  the  proper  capsule  remains  spread  out  with  its  raw  surface  upper  portion 
add  to  the  extent  of  raw  surface  for  adhesion.     (3)  The  upper  depth  and 


Fig.  776.— Nephropexy  by  Su- 
ture of  Split  Capsule  and  Kid- 
ney Parenchyma  : — Sutures  are 
seen  penetrating  kidney  substance 
and  split  capsule,  which  latter  has 
been  turned  back  on  either  side. 
The  outer  limbs  of  the  sutures  are 
ready  to  be  carried  through  site  of 
abdominal  wall,  or  other  site,  to 
which  kidney  will  be  approximated 
by  tightening  the  sutures.  Tuf- 
fier's  method. 


NEPHROPEXY.  1069 

skin  margins  of  the  wound  are  then  closed  with  interrupted  sutures  of  silk  or 
chromic  gut. 

Comment. — (1)  This  may  be  regarded  as  one  of  the  best  methods  of 
Nephropexy — granulations  of  the  raw  surface  of  the  kidney  and  capsule  form 
stronger  adhesions  than  when  the  kidney  is  not  partly  stripped.  And  stronger 
union  is  formed  than  when  the  stripped  capsule  alone  is  sutured  into  the 
wound  (instead  of  the  stripped  capsule  and  kidney  substance).  (2)  The  split 
fibrous  capsule  is  sometimes  also  sutured  to  the  periosteum  of  the  twelfth  rib. 
(3)  In  some  cases  gauze  packing  is  used  down  to  the  kidney  in  the  center  of  the 
wound,  to  strengthen  adhesion  by  granulation.  (4)  Avoid  including  nerves 
in  suturing  of  the  kidney  to  the  lumbar  wall.  (5)  Deep  drainage  may  be 
temporarily  used — but  is  generally  not  indicated. 


NEPHROPEXY 

BY  SIMPLE  SUTURING. 

Description. — Here  neither  the  fatty  nor  the  fibrous  capsule  of  the  kidney 
is  split — one  or  both  of  these  structures  being  sutured  to  some  neighboring 
structure.  See,  further,  "Description"  of  the  last  operation.  The  kidney  may 
be  exposed  by  any  of  the  incisions  given — the  oblique  lumbar  incision  being 
preferable 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
kidney  by  oblique  lumbar  incision. 


Fig.  777—  Nephropexy  by  Simple  Suturing  : — A,  Sutures  passing  through  lower  portion  of  lips 
of  wound,  perirenal  fatty  areolar  tissue,  and  kidney  substance,  ready  to  bind  kidney  to  and  into  lower 
plane  of  wound  ;  B,  Sutures  passing  through  skin  and  upper  portion  of  lips  of  wound.  The  structures 
are  the  same  as  those  enumerated  in  Fig.  769. 

Operation. — Having  exposed  the  kidney  as  in  the  last  operation,  the  dis- 
placed organ  may  be  treated  in  one  of  several  ways;  (a)  By  Suturing  of  the 
Unopened  Fatty  Capsule; — Excess  of  fatty  areolar  capsule  is  trimmed  away, 
and  the  remaining  shortened  capsule  is  stitched  into  the  lower  plane  of  the 
lumbar  wound  by  four  to  six  interrupted  chromic  gut  or  kangaroo  tendon 
sutures — the  upper  layers  of  the  lumbar  wound  being  closed  as  in  the  last  oper- 
ation (Fig.  777).     (b)  By  Suturing  of  the  Parenchyma,  together  with  the  un- 


1070 


OPERATIONS  UPON  THE  ABDOMINO-PELV1C  REGION. 


stripped  Fatty  and  Fibrous  Capsules; — Having  shortened  the  excess  of  fatty 
capsule,  if  necessary  (by  excising  a  portion),  three  or  four  kangaroo  tendon  or 
chromic  gut  sutures  are  passed,  with  fully  curved  needle,  dipping  about  1.3  cm. 
(^  inch)  into  the  kidney  substance,  and  taking  up  about  2  cm.  (f  inch)  in  width 
of  the  kidney,  into  the  posterior  aspect  of  the  kidney,  in  a  horizontal  direction — 
the  sutures  passing  through  the  muscles  of  the  wound,  transversalis  fascia, 
fatty  capsule,  fibrous  capsule,  and  the  above  amount  of  kidney.  These  are 
buried  sutures.  The  upper  layers  of  the  wound  are  separately  sutured  by  in- 
terrupted sutures.  The  fatty  capsule  is  thus  sutured  between  the  lips  of  the 
wound. 

Comment. — (1)  The  above  operation  is  inferior  to  splitting  the  fibrous 
capsule.  (2)  Sometimes  the  fatty  and  fibrous  capsules,  without  including  the 
kidney,  are  sutured  to  the  lumbar  wound.  (3)  Sometimes  the  fibrous  capsule 
is  exposed  and  sutured  to  the  periosteum  of  the  twelfth  rib.  (4)  The  upper 
kidney  sutures  may  be  carried  around  the  twelfth  rib  and  tied  (Fig.  778). 


Fig.  778. — Nephropexy: — The  two  uppermost  kidney  sutures  are  carried  around  the 
twelfth  rib,  the  remaining  kidney  sutures  being  carried  through  the  lumbar  aponeuroses  and 
muscles.  The  overlying  muscles  and  aponeuroses  are  then  drawn  together  by  sutures  passing 
through  their  substance.     (Modified  from  Duval.) 


TOTAL  NEPHRECTOMY 

BY  OBLIQUE  LUMBAR  INCISION. 

Description.— Excision  of  one  entire  kidney.  Generally  indicated  in 
tumor,  extensive  suppuration,  tuberculosis,  fistula.  No  kidney  should  be  re- 
moved until  the  presence  of  an  opposite,  and,  if  possible,  healthy  one  is  as- 
certained (by  vesical  catheterization  of  its  ureter — or  by  actual  palpation  by 
hand  in  the  abdominal  or  lumbar  wound).  The  kidney  may  be  removed  by 
several  routes — lumbar  nephrectomy — abdominal  nephrectomy.  The  lumbar 
route  is  to  be  preferred — and  of  the  lumbar  incisions,  the  oblique  lumbar  is  the 
best,  being  especially  capable  of  extension  in  either  direction  to  give  the  neces- 
sary room. 


NEPHROPEXY. 


IO71 


Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
kidney  by  oblique  lumbar  incision. 

Operation. — (1)  The  perirenal  adipose  tissue  having  been  exposed  and 
separated  from  the  kidney  by  blunt  dissection — the  kidney  being  enucleated, 
as  it  were,  by  the  finger — the  kidney  itself  is  brought  well  into  the  wound, 
partly  by  abdominal  pressure  from  in  front,  and  partly  by  traction,  while  the 
lips  of  the  wound  are  drawn  well  apart  (Fig.  779).  (2)  The  pedicle  is  care- 
fully isolated  and  freed  by  blunt  dissection—and  the  kidney  is  then  delivered 
outside  of  the  wound  if  possible — especially  avoiding  traction  and  twisting  of 
the  structures  of  the  pedicle  during  delivery.  (3)  The  pedicle  should  be  tied 
with  strong  silk  carried  upon  a  blunt  aneurism-needle.     Where  possible,  the 


Fig.  779.— Total  Nephrectomy  by  Oblique  Lumbar  Incision: — A,  Kidney  brought  out  of 
wound  in  grasp  of  vulsellum  ;  B,  Ligature  of  renal  artery  ;  C,  Ligature  of  renal  vein  ;  D,  Ligature  of 
ureter;  E,  Quadratus  lumborum  muscle  and  last  dorsal  nerve  and  lumbar  artery;  F,  Erector  spinae 
muscle  ;  C,  Serratus  posticus  inferior;  I,  External  oblique  ;  J,  Internal  oblique  muscle,  and  intercostal 
nerve  and  artery  ;  K,  Transversalis  aponeurosis. 


artery  and  vein  should  be  tied  separately,  and,  preferably,  prior  to  their  division 
into  branches — the  artery  being  tied  first.  If  not  easily  differentiated  and 
isolated,  the  artery  and  vein  may  be  tied  en  masse — or  in  several  bundles,  re- 
gardless of  whether  arteries  or  veins.  If  possible,  all  the  structures  should  be 
doubly  ligated — and  the  structures  forming  the  pedicle  should  be  relaxed  dur- 
ing the  placing  of  ligatures.  The  ureter  should  always  be  tied  separatelv. 
The  pedicle  is  then  severed  between  the  double  ligatures,  or  between  kidnev 
and  single  ligatures.  (4)  If  healthy,  the  proximal  end  of  the  ureter  should  be 
cauterized  and  dropped  back  into  the  wound.  If  unhealthy,  it  should  be  at- 
tached into  the  wound  and  drained.     (5)   In  healthy,  clean  cases  the  entire 


1072  OPERATIONS    UPON   THE    ABDOMINO-PELVIC    REGION. 

pedicle  is  dropped  back  into  the  abdomen  and  the  wound  closed.      In  sus- 
picious cases,  the  pedicle  is  anchored  into  the  wound  and  drained. 

Comment. — (1)  Guard  the  vena  cava,  which  has  been  wounded  in  the 
operation  upon  the  right  side.  (2)  Sometimes  the  fatty  capsule  as  well  as  the 
kidney  must  be  removed — necessitating  the  removal  of  the  entire  mass  from 
the  surrounding  tissues.  (3)  The  peritoneal  cavity  is  often  opened.  If  the 
rent  be  small,  it  is  closed  with  ordinary  continuous  or  purse-string  suture  of  gut. 
If  too  large  to  suture,  it  is  packed  with  gauze.  (4)  The  pleural  cavity  may  be 
opened  in  working  near  the  twelfth  rib — and  should  be  immediately  sutured 
with  continuous  or  purse-string  gut  suture.  (5)  The  colon  may  be  wounded. 
Treat  as  wounds  of  intestine  elsewhere.  (6)  Nephrectomy  by  morcellement 
(piecemeal)  is  sometimes  done.  (7)  If  the  pedicle  have  not  been  doubly 
ligated,  it  should  be  clamped  near  the  kidney  before  division. 


PARTIAL  NEPHRECTOMY 

BY  OBLIQUE  LUMBAR  INCISION. 

Description. — Removal  of  part  of  a  kidney.  May  be  done  in  removal  of 
growths — or  in  badly  lacerated  wounds.  Generally  done  by  the  lumbar  opera- 
tion— unless  occurring  in  the  course  of  some  other  operation. 

Operation. — (a)  In  the  deliberate  removal  of  a  portion  of  the  kidney,  a 
wedge-shaped  piece  should  be  taken  out,  if  possible — so  that  the  sides  of  the 
kidney  wound,  left  after  the  removal  of  the  wedge,  could  be  brought  into  fairly 
accurate  apposition  and  sutured  by  alternate  deep  and  superficial  sutures  of 
gut.  (b)  In  extensive  lacerations,  leaving  irregularities  of  surface,  the  raw 
surfaces  are  to  be  brought  into  contact  and  sutured  in  the  best  manner  pos- 
sible— by  deep  and  superficial  gut  sutures.  The  wound  of  the  abdominal 
wall  is  treated  upon  general  principles. 


SUBCAPSULAR  NEPHRECTOMY. 

Description. — Where  a  dense,  perirenal  capsular  mass  surrounds  the 
kidney  and  is  firmly  adherent  to  the  peritoneum,  colon,  vena  cava,  diaphragm, 
and  other  structures — so  that  damage  to  these  structures  would  likely  result  in 
attempting  to  separate  such  a  capsule,  this  fatty  areolar  capsule  is  incised  and 
the  incision  carried  also  through  the  proper  fibrous  capsule  of  the  kidney — 
which  is  then  peeled  back  to,  and,  if  possible,  into  the  pedicle — which  is  then 
ligated  or  clamped,  and  the  kidney  removed.  The  cavity  of  the  capsule  is 
then  curetted  (where  indicated)  and  packed — the  abdominal-wall  wound  being 
closed  up  to  the  packing.  The  best  approach  in  such  cases  is  by  the  oblique 
lumbar  incision. 


TOTAL  NEPHRECTOMY 

BY  ANTERIOR  TRANSPERITONEAL   OPERATION. 

Description. — Removal  of  an  entire  kidney  through  an  anterior  trans- 
peritoneal route — the  incision  being  made  in  either  the  median  or  linea  semi- 
lunaris region,  the  latter  giving  the  more  direct  approach. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
kidney  by  vertical  incision  in  linea  semilunaris. 


SURGICAL    ANATOMY    OF    THE    URETERS.  1073 

Operation. — (i)  Having  opened  the  abdomen  as  in  the  operation  above 
indicated,  both  kidneys  and  ureters  are  examined  by  the  hand  introduced  into 
the  cavity.  (2)  Displace  the  colon  toward  the  median  line  and  incise  the 
outer  layer  of  the  mesocolon  in  a  vertical  direction.  This  division  of  the  pos- 
terior peritoneum  will  be  upon  either  the  lateral  or  median  aspect  of  the  meso- 
colon, as  determined  by  its  position  on  the  anterior  surface  of  the  kidney.  The 
vessels  of  the  colon  are  less  interfered  with  if  the  peritoneum  be  divided  upon 
the  outer  side  of  the  mesocolon.  (3)  The  fingers  are  now  passed  through  this 
incision  down  upon  the  kidney — the  perirenal  fat  is  incised  and  the  kidney 
enucleated  by  blunt  dissection.  The  pedicle  is  first  to  be  cleared — by  stripping 
off  the  peritoneum  toward  the  aorta.  The  vessels  are  then  ligated  with  silk 
passed  by  means  of  an  aneurism-needle — tying,  preferably,  the  artery  first, 
then  the  veins.  If  room  be  sufficient,  double  ligatures  should  be  used,  pro- 
viding for  division  between  them, — if  not,  the  pedicle  may  be  clamped  near  the 
kidney  (instead  of  the  second  ligature).  (4)  The  pedicle  is  now  divided  be- 
tween the  two  sets  of  ligatures — or  between  the  clamp  and  ligatures.  The 
ureter  should  be  separately  doubly  ligatured  and  similarly  divided.  The  liga- 
tured stump,  with  or  without  cauterization,  as  indicated,  is  returned  to  the 
abdomen.  (5)  The  kidney  is  then  further  enucleated  from  its  perirenal  fatty 
areolar  tissue  and  removed.  All  bleeding  vessels  are  gut-ligatured.  (6)  If 
drainage  be  indicated,  it  is  established  through  the  lumbar  region  by  a  counter- 
opening  made  upon  some  instrument  thrust  backward  from  within  and  cut 
upon  from  without.  (7)  The  incised  mesocolon  is  sutured  with  gut.  (8) 
The  abdominal  wound  is  closed  in  the  general  manner. 

Comment. — (I)  The  kidney  should  be  systematically  exposed,  aftei  in- 
cising the  fatty  capsule — first  the  anterior  surface,  then  the  lateral  borders,  the 
poles,  and  the  posterior  surface.  (2)  Where  anterior  drainage  must  be  es- 
tablished, the  edges  of  the  incision  in  the  posterior  peritoneum  are  sutured  to 
the  edges  of  the  incision  in  the  parietal  peritoneum,  thus  shutting  off  the  gen- 
eral cavity.  Posterior  drainage,  however,  is  always  preferable.  (3)  Sus- 
picious ureters  must  be  brought  out  into  a  posterior  lumbar  wound  made  as  a 
counter-opening.  (4)  Avoid  injury  to  the  nutrient  arteries  of  the  inner  layer 
of  the  mesocolon.  (5)  'The  operation  is  practically  the  same  whether  done 
through  a  vertical  incision  in  the  linea  semilunaris  or  through  a  median  incision. 


XIII.  THE  URETERS. 
SURGICAL  ANATOMY. 

Description. — Fibro-elastic  tubes  of  about  3  to  4  mm.  (|  to  nearlv  j^  inch) 
in  diameter — flattened  from  before  backward — with  walls  of  about  1  mm. 
(o-g-  inch)  in  thickness.  They  consist  of  outer,  fibrous — middle,  muscular — and 
inner,  mucous  coats.  They  have  an  average  length,  in  the  male,  of  about  30.5 
cm.  (12  inches) — extremes  being  from  25.5  to  40.5  cm.  (10  to  16  inches). 
They  are  about  7.5  cm.  (3  inches)  apart  at  their  beginning — about  5  cm.  (2 
inches)  apart  near  the  sacro-iliac  joint — about  3.2  cm.  (1  j  inches)  apart  at  en- 
trance to  bladder — and  about  2  to  2.5  cm.  (f  to  1  inch)  apart  at  their  bladder- 
mouths.  The  ureters  begin  in  the  funnel-shaped  pelvis  of  the  kidney,  opposite 
the  spinous  process  of  the  first  lumbar  vertebra — and  run  downward  through 
a  sort  of  lymph-space  between  the  lahiina;  of  the  subperitoneal  connective  tis- 
sue, downward  and  inward  through  the  lumbar  and  pelvic  regions — ending 

68 


1074  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

in  the  base  of  the  bladder.  The  genitocrural  nerve  is  in  close  relation  with 
the  ureter.  There  are  three  sites  at  which  the  ureter  is  narrower  than  else- 
where,— between  4  and  5  cm.  (i£  and  2  inches)  from  the  pelvis  of  the  kidney — 
crossing  of  iliac  artery — ai  d  at  junction  of  pelvic  and  vesical  portions. 

Course  and  Relations. — (1)  Abdominal  portion :  Male  and  Female : — 
(a)  Right  Ureter,— Runs  downward  and  slightly  inward,  from  pelvis  of  kidney 
to  promontory  of  sacrum,  where  it  crosses  either  common  or  external  iliac 
artery.  Rests  (posteriorly)  upon  psoas  muscle  and  fascia,  genitocrural  nerve, 
common  or  external  iliac  artery.  Covered  (anteriorly)  by  peritoneum,  sper- 
matic and  colic  vessels,  and  ileum.  Internally  lies  inferior  vena  cava,  near  ure- 
ter, (b)  Left  Ureter, — Runs  downward  and  slightly  inward,  from  pelvis  of 
kidney  to  promontory  of  sacrum,  where  it  crosses  either  common  or  external 
iliac  artery  (same  course  as  right  ureter).  Rests  (posteriorly)  upon  psoas 
muscle  and  fascia,  genitocrural  nerve,  common  or  external  iliac  artery  (same 
posterior  relations  as  right).  Covered  (anteriorly)  by  peritoneum,  spermatic 
and  colic  vessels,  and  sigmoid  colon.  Internally  lies  abdominal  aorta,  being 
2.5  cm.  (1  inch)  from  ureter  above,  and  1.3  cm.  (|inch)  below,  near  bifurcation. 
(2)  Pelvic  portion :  Both  sexes :  Both  sides ; — Runs  downward  in  front  of 
sacro-iliac  joint — passes  upon  obturator  internus  and  its  fascia,  lying  irtferiorly 
and  internally  to  psoas — enters  posterior  false  ligament  of  bladder  (rectovesical 
fold,  in  male — uterovesical  fold,  in  female)  below  the  obliterated  hypogastric 
artery — hence  its  course  differs  in  the  two  sexes: — (a)  Male:  Both  sides; — 
It  is  here  crossed  above  and  to  inner  side  by  vas  deferens,  which  intervenes  be- 
tween it  and  bladder — and,  just  before  entering  bladder,  it  passes  beneath  the 
free  extremity  of  the  vesicula?  seminales.  The  two  ureters  are  about  5  cm. 
(2  inches)  apart  at  base  of  bladder,  and  about  4  cm.  (ij  inches)  posterior  to  the 
prostate  gland,  (b)  Female :  Both  sides ; — It  passes  down  parallel  with  the 
cervix  uteri  and  upper  part  of  vagina — lying  about  5  mm.  (i  inch)  external  to 
cervix  opposite  os  internum — running  posteriorly  to  uterine  artery,  through 
the  uterine  venous  plexus,  and  below  the  broad  ligament — crossing  the  vagina 
opposite  its  upper  third,  to  the  vesicovaginal  interspace,  and  entering  the  blad- 
der opposite  the  center  of  the  vagina,  (c)  Intravesical  portion  :  Both 
sexes  :  Both  sides; — Entering  the  bladder  4  to  5  cm.  (1^  to  2  inches)  apart, 
the  ureters  pass  obliquely  downward  and  inward  through  its  wall,  emerging 
upon  the  mucous  membrane  about  2  cm.  (f  inch)  apart,  and  about  the  same 
distance  posterior  to  the  meatus  urinarius  internus. 

Arteries. — From  renal,  spermatic,  internal  iliac,  and  inferior  vesical. 
Veins. — End  in  corresponding  trunks. 

Lymphatics. — Empty  into  pelvic  and  lumbar  glands  and  into  receptacu- 
lum  chyli. 

Nerves. — From  spermatic,  renal,  and  hypogastric  plexuses. 


SURFACE  FORM  AND  LANDMARKS. 

As  the  ureters  are  about  7.5  cm.  (3  inches)  apart  at  their  commencement 
at  the  pelves  of  the  kidneys,  opposite  the  first  lumbar  spinous  process,  the  be- 
ginning of  each  ureter  will  lie  about  4  cm.  (i^  inches)  external  to  the  line  of  the 
spinous  processes,  on  a  level  with  the  spinous  process  of  the  first  lumbar  verte- 
bra. And  they  lie  about  5  cm.  (2  inches)  apart  near  the  sacro-iliac  articulation 
— or  about  2.5  cm.  (1  inch)  from  the  median  line. 

Anteriorly,  the  line  of  the  ureters,  from  the  kidneys  to  the  brim  of  the  pelvis, 


GENERAL    SURGICAL    CONSIDERATIONS.  1075 

may  be  gotten,  approximately,  by  drawing  a  line  vertically  upward  from  the 
junction  of  the  inner  and  middle  thirds  of  Poupart's  ligament.  And  the  posi- 
tion of  the  crossing  of  the  ureters  over  the  brim  of  the  pelvis  may  be  approxi- 
mately represented  by  the  intersection  of  a  vertical  line  extending  upward  from 
the  spine  of  the  pubis,  with  a  horizontal  line  between  the  anterior  superior  iliac 
spines. 


GENERAL  SURGICAL  CONSIDERATIONS. 

(1)  The  ureter  is  so  intimately  adherent  to  the  peritoneum  that  when  the 
peritoneum  is  stript  up,  the  ureter  is  almost  always  reflected  along  with  that 
membrane  and  adherent  to  it.  (2)  In  all  suturing  about  the  ureter,  an 
attempt  should  be  made  not  to  include  the  mucous  membrane — though,  prac- 
tically, this  may  often  be  done  unintentionally.  The  fibrous  and  part  of  the 
muscular  coats  should  be  taken  up  by  the  stitch.  (3)  Fine  silk  is  the  suture 
material  generally  used — it  being  difficult  to  manipulate  gut,  or  to  get  it  fine 
enough.  (4)  There  is  a  tendency  to  narrowing  at  the  site  of  suture,  especially 
after  transverse  division.  (5)  Extra-pelvic  portions  of  the  ureter  should  be 
approached  retroperitoneally — except  where  the  cause  for  the  operation  upon 
the  ureter  arises,  or  is  discovered,  during  an  intra-abdominal  operation.  (6) 
Intra-pelvic  portion  of  the  ureter  is  accessible  by  incision  through  the  abdom- 
inal wall,  bladder,  rectum,  vagina,  perineum,  or  by  sacral  resection.  (7) 
Longitudinal  wounds  of  the  ureter  heal  better  than  transverse  ones.  (8) 
Drainage  is  indicated  in  all  cases  where  infection  is  present  or  suspected,  or 
where  the  technic  is  uncertain.  (9)  In  retroperitoneal  operations,  suture  is  not 
absolutely  necessary,  provided  drainage  be  established  down  to  the  wound. 

(10)  Whenever  the  ureter  is  opened  intraperitoneally,  the  peritoneum  or 
omentum  should  be  sutured  over  the  wound,  so  as  to  make  it  extraperitoneal. 

(11)  Where  the  ureter  has  been  divided  and  must  be  transplanted,  implanta- 
tion into  the  bladder  is  the  most  desirable.  (12)  Where  the  ureter  has  been 
completely  divided  transversely,  it  should  be  repaired  by  uretero-ureterostomy, 
if  possible.  (13)  Where  the  division  is  near  the  kidney,  and  uretero-ureteros- 
tomy cannot  be  performed,  it  should  be  implanted  into  the  pelvis  of  the  kidney. 
If  the  division  be  low  down,  it  should  be  implanted  into  the  bladder.  (14) 
If  such  an  extent  of  ureter  be  lost  that  uretero-ureterostomy  cannot  be  done — 
or  the  end  cannot  be  implanted  into  the  pelvis  of  the  kidney  or  into  the  bladder, 
implantation  into  the  bowel  or  skin  should  be  done.  (15)  Longitudinal 
wounds  of  the  ureter  generally  heal  without  suture,  if  retroperitoneal  drainage 
be  provided.  (16)  Where  it  is  possible,  any  operation  should  be  protected  by 
peritoneum — in  one  of  two  ways: — (a)  Lift  the  ureter  up  out  of  its  bed,  at  the 
site  of  operation,  into  the  peritoneal  cavity — and  draw  the  peritoneum  around 
the  ureter  from  both  sides,  so  stitching  the  serous  membrane  as  to  form  a  tube 
through  which  the  ureter  runs,  practically  excluding  it  from  the  general  peri- 
toneal cavity.  The  suturing  should,  however,  be  lightly  and  carefully  done, 
forming  a  loose  tube,  so  as  to  avoid  subsequent  contraction.  This  is  probably 
the  better  method,  (b)  The  site  of  operation  upon  the  ureter  may  be  sur- 
rounded by  a  detached  piece  of  omentum  lightly  sutured  to  the  ureter.  (17) 
The  ureter  has  been  separated  for  as  much  as  8.3  cm.  (3J  inches)  from  its  at- 
tachments without  gangrene — owing  to  the  long  artery  which  accompanies  it 
and  is  intimately  connected  with  it.  (18)  The  ureter  may  be  lengthened  2.5 
cm.  (1  inch)  or  more,  by  steady,  gentle  traction.  (19)  When  a  gap  in  ureter 
at  the  lower  end  cannot  be  bridged  by  stretching,  a  vesical  diverticulum  can 


1076  OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 

sometimes  be  turned  up  to  meet  the  end  of  the  ureter.  (20)  Ureteroureteros- 
tomy is  generally  practicable  except  in  the  lower  2.5  cm.  (1  inch)  in  the  male, 
and  the  lower  5  cm.  (2  inches)  in  the  female.  (21)  In  severed  ureter,  the  best 
course  is  uretero-ureterostomy  by,  probably,  Van  Hook's  method — and  the 
next  best,  uretero-cystostomy  (v.  i.  ).  (22)  Normal  urine  is  not  injurious  to 
the  peritoneal  cavity,  but  it  is  well  not  to  let  it  come  in  contact  if  it  can  be 
helped. 


INSTRUMENTS. 

See  instruments  used  in  operating  upon  the  Kidneys.  Also  the  following 
special  instruments: — Very  fine  needles,  curved,  straight,  and  plain  cambric 
needles;  fine  silk;  fine  catgut;  fine  forceps;  fine  scissors;  small  needle-holders; 
ureteral  sound;  ureteral  catheters;  cystoscope;  electric  illumination;  urine 
evacuator;  instruments  for  segregation  of  urines. 


EXPOSURE  OF  THE  URETER  IN  GENERAL. 

Description. — The  exposure  of  the  ureter  may  be  made  deliberately — or 
may  be  done  in  the  course  of  some  other  operation.  Most  of  the  operations 
for  exposure  of  the  kidney  generally  also  admit  of  exposure  of  more  or  less  of 
the  ureter.     The  ureter  may  be  exposed  extra-  or  intra-peritoneally. 

Abdominal  portion  of  the  ureter  is  best  exposed  by  the  oblique  lumbar 
incision  used  in  exposing  the  kidney,  extending  from  the  twelfth  rib  above 
Poupart's  ligament  to  about  its  center.  This  incision  will  enable  the  upper 
three-fourths  of  the  ureter  to  be  freely  exposed,  and  will  allow  of  access  to  the 
entire  ureter,  from  kidney  to  bladder — though,  of  course,  not  so  free  access 
to  the  lower  one-fourth  (Fig.  780).  It  is  a  possible  thing  to  thus  expose 
the  entire  ureter  extraperitoneally.  This  exposure  should  be  the  one  of 
preference  for  the  upper  three-fourths  of  the  ureter  (and  may  be  resorted  to 
for  even  the  entire  ureter) — except  when  the  ureter  is  exposed  in  the  course  of 
abdominal  section. 

Pelvic  portion  of  the  ureter  is  readily  accessible  through  the  lower  median 
abdominal  incision — followed  by  retraction  of  the  intestines  (especially  aided 
by  the  Trendelenburg  position) — and  division  of  the  peritoneum  over  the 
course  of  the  ureter.  The  intrapelvic  portion  may  also  be  exposed  by  incision 
through  the  bladder,  vagina,  rectum,  male  perineum,  or  by  sacral  resection. 

Intravesical  portion  of  the  ureter  may  be  exposed  through  a  cystotomy 
wound  (incision  of  the  bladder) — generally  by  the  suprapubic  route. 


EXTRA-PERITONEAL  EXPOSURE  OF  THE  KIDNEY  AND  THE  ENTIRE 

URETER 

BY    OBLIQUE    LUMBO-ILIAC    INCISION. 

Description. — This  incision  will  allow  the  kidney  and  the  upper  three- 
fourths  of  the  ureter  to  be  freely  exposed — and  will  give  access  to  the  entire 
ureter,  though,  of  course,  not  such  free  access  to  the  lower  one-fourth — the 
exposure  being  retro-peritoneal  throughout. 


EXTRA-PERITONEAL  EXPOSURE  OF  THE  KIDNEY  AND  URETER.  1077 

Preparation. — As  for  exposure  of  the  kidney  by  an  oblique  lumbar 
incision. 

Position. — The  patient  lies  upon  the  opposite  side  during  the  work  in  the 
upper  part  of  the  wound — and  upon  the  back  during  the  work  in  its  lower 
portion. 

Landmarks. — Twelfth  rib;  outer  border  of  erector  spinae  muscle;  iliac 
crest;  anterior  superior  iliac  spine;  Poupart's  ligament. 

Incision. — Begins  just  below  the  twelfth  rib,  at  the  angle  of  junction  of 
the  lower  border  of  the  twelfth  rib  and  the  outer  border  of  the  erector  spinas 
muscle — and  passes  thence  obliquely  downward  toward,  and  to  within  2.5  cm. 
(1  inch)  of,  the  anterior  superior  iliac  spine — thence  downward  and  parallel 
with,  and  about  2  cm.  (f  inch)  above,  Poupart's  ligament,  to  just  below  its 
center  (Fig.  780). 


Fig.  780. — Incision  for  Exposing  Kidney  and  Ureter  Extraperitoneally. 

Operation. — The  first  part  of  the  operation  and  the  exposure  of  the  kidney 
are  conducted  as  in  the  more  limited  procedure  of  exposing  the  kidney  alone 
by  an  oblique  lumbar  incision  (page  1053) .  In  the  lower  aspect  of  the  wound 
the  ureter  is  in  relation  with  the  peritoneum  and  ascending  colon  on  the  right 
side,  and  the  peritoneum  and  descending  colon  on  the  left.  The  colon,  in 
either  case,  is  retracted  toward  the  median  line,  together  with  the  peritoneum, 
exposing  the  psoas  muscle  and  the  spermatic  and  colonic  vessels.  The  ureter 
has  a  tendency  to  cling  to  the  peritoneum  as  it  is  displaced.  A  large  retractor 
draws  the  intestines  toward  the  median  line.     The  ureter  is  isolated  at  the 


1078  OFERATIOiNS    UPON    THE    ABDOMINO-PELVIC    REGION. 

lower  pole  of  the  kidney — and  is  carefully  traced  down  to  the  iliac  vessels — 
separating  the  peritoneum  by  blunt  dissection  and  retracting  it  inward  from 
the  course  of  the  ureter — the  superficial  incision  having  been  deepened  through 
skin,  fascia,  external,  internal,  and  transversalis  muscles  and  aponeuroses 
down  to  the  subserous  areolar  tissue — in  which  plane  the  separation  of  the 
ureter  is  accomplished.  In  exposing  the  pelvic  portion  of  the  ureter  the 
patient  is  placed  in  the  Trendelenburg  position.  The  epigastric  vessels  are 
doubly  ligated  and  tied.  The  operator,  with  the  pulp  of  his  thumbs,  continues 
to  free  and  roll  the  peritoneum  off  of  the  pelvic  structures,  still  working  in  the 
plane  of  the  transversalis  fascia  and  progressively  descending  toward  the 
iliac  fossa — pushing  the  peritoneum  toward  the  umbilicus,  in  the  upper  and 
lower  part  of  the  pelvic  wound,  the  parts  being  further  retracted  by  a  large 
retractor.  The  spermatic  cord  and  the  round  ligament  are  encountered 
and  displaced  inward.  The  common  iliac  at  its  bifurcation  into  external  and 
internal  branches  is  exposed.  Thence  the  relations  of  the  ureter  will  depend 
upon  the  sex  being  operated  upon.  In  the  male,  it  is  crossed  above  and  to  the 
inner  side  by  the  vas  deferens,  which  intervenes  between  it  and  the  bladder — 
and,  just  before  entering  the  bladder,  it  passes  beneath  the  free  extremity  of 
the  vesiculae  seminales.  In  the  female  it  passes  down  parallel  with  the  cervix 
uteri  and  upper  part  of  the  vagina — lying  about  5  mm.  (I  inch)  external  to  the 
cervix,  opposite  the  os  internum — running  posteriorly  to  the  uterine  artery, 
through  the  uterine  venous  plexus,  and  below  the  broad  ligament — crossing 
the  vagina  opposite  its  upper  third  to  the  vesico-vaginal  interspace,  and 
entering  the  bladder  opposite  the  center  of  the  vagina.  Entering  the  bladder, 
in  both  sexes,  the  ureter  passes  obliquely  downward  and  inward  through  its 
wall,  emerging  upon  the  mucous  membrane  about  2  cm.  (|  inch)  posterior 
to  the  meatus  urinarius  internus. 


URETEROTOMY. 

Description. — Incision  of  the  ureter.  Generally  done  for  the  removal  of 
calculi — in  which  case  the  operation  may  be  called  uretero-lithotomy.  Calculi 
may  be  lodged  at  either  the  upper  or  lower  end  of  the  ureter,  or  in  the  middle — 
usually  at  one  of  the  two  ends.  Ureterotomy  may  be  extraperitoneal  or  trans- 
peritoneal (intraperitoneal) — when  the  ureter  is  approached,  respectively, 
behind  the  peritoneum,  or  through  the  abdominal  cavity.  Extraperitoneal 
ureterotomy  is  always  preferable.  Where  the  site  of  the  ureterotomy  is  only 
determined  in  the  course  of  an  operation  performed  through  one  of  the  regular 
incisions,  the  ureterotomy  will  be  extraperitoneal  or  intraperitoneal,  according 
to  circumstances.  Even  when  the  ureterotomy  is  done  intraperitoneally,  how- 
ever, the  site  of  the  ureterotomy,  in  concluding  the  operation,  should  be  as 
thoroughly  shut  off  (walled  off)  by  suturing  of  peritoneum  around  the  site,  as 
possible.  Extraperitoneal  ureterotomy  is  usually  done  through  the  oblique 
lumbar  incision,  extended  as  far  forward  and  downward  as  necessary.  Trans- 
peritoneal ureterotomy  is  generally  done  through  a  median  abdominal  incision, 
or  one  in  the  linea  semilunaris. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
the  kidney  by  either  an  oblique  lumbar  or  an  anterior  abdominal  incision. 

Operation. — (a)  In  the  Extraperitoneal  Operation — the  ureter — which 
has  generally  been  found  by  tracing  downward  from  the  pelvis  of  the  kidney — 
is  exposed  and  divided  longitudinally  to  the  necessary  extent — over  the  calculus. 


URETERORRHAPHY.  1079 

if  the  operation  be  done  for  that  purpose — the  ureter  having  been  steadied  and 
carefully  incised  with  a  small,  sharp  knife,  aided  by  fine  forceps — after  which 
the  calculus  is  removed  by  scoop  or  forceps.  The  wound  in  the  ureter,  in 
favorable  cases,  should  be  closed  with  fine  silk  sutures,  passing  through  the 
fibrous  and  muscular  coats.  Temporary  drainage  should  be  employed,  in 
case  of  leakage — the  lumbar  wound  being  closed  elsewhere,  (b)  In  the 
Transperitoneal  Operation — the  ureter  is  exposed — the  peritoneum  divided 
longitudinally  over  it — the  ureter  incised  in  its  long  axis — and  the  object  of  the 
operation  accomplished  (usually  the  removal  of  a  stone).  The  incised  ureter 
is  generally  sutured,  as  in  the  extraperitoneal  operation — and  the  peritoneum 
is  then  sutured  about  the  wound  in  the  ureter  so  as  to  render  it  as  extraperito- 
neal as  possible.  Prior  to  suturing  the  peritoneum  over  the  ureteral  wound,  a 
posterior  counter-opening  is  made,  and  drainage  established  through  this — the 
abdominal  cavity  being  then  closed. 

Comment. — Calculi  lodged  at  the  lower  end  of  the  ureter  may  sometimes  be 
removed  through  the  bladder,  rectum,  or  vagina,  with  or  without  dilating  the 
mouth  of  the  ureter. 


URETERORRHAPHY. 

Description. — Suturing  of  the  ureter.  Generally  done  for  repair  of 
wounds,  or  following  the  incision  after  ureterotomy  for  calculi.  Many  of  the 
wounds  are  accidentally  made  by  the  surgeon  in  the  course  of  other  operations. 

Varieties  of  Wounds. — Longitudinal — Oblique,  incomplete — Oblique, 
complete — Transverse,  incomplete — Transverse,  complete. 

Preparation — Position — Landmarks — Incision. — As  for  Exposure  of 
Ureter. 

Operation. — Suturing  is  generally  done  with  fine  silk,  or  with  very  fine 
catgut— carried  upon  a  fine,  curved  needle,  held  in  a  needle-holder.  The 
edges  of  the  wound  are  brought  together  by  interrupted  sutures,  generally  in- 
troduced in  the  Lembert  fashion — passing  through  the  fibrous  and  part  of  the 
muscular  coats — but  carefully  avoiding  the  penetration  of  the  mucous  coat — 
union  taking  place  by  growth  of  the  connective  tissue  of  the  apposed  surfaces, 
which  is  rendered  raw  in  exposing  the  ureter.  The  following  summary  sug- 
gests the  appropriate  methods  for  dealing  with  the  various  sorts  of  wounds  of 
the  ureter: — (1)  Longitudinal  wounds;  (a)  Close  by  fine  silk  (or  fine  chro- 
mic gut)  Lembert  sutures.  Reinforce,  if  possible,  by  folding  or  stitching  over 
the  suture-line  a  fold  of  peritoneum,  or  an  omental  graft,  (b)  Or  excise  the 
piece  and  do  an  end-to-end  ureteral  anastomosis.  (2)  Oblique  wounds, 
incomplete;  (a)  Same  as  above  (1).  (b)  Or  complete  the  oblique  division 
and  treat  as  a  complete  oblique  division  (v.  i.).  (3)  Transverse  wounds, 
incomplete  ;  (a)  Lembert  sutures,  (b)  Divide  the  upper  lip  of  the  wound  in 
its  center  longitudinally  upward  a  short  distance.  Similarly  divide  the  lower 
lip  of  the  wound  in  its  center  longitudinally  downward  a  short  distance. 
Round  off  the  four  corners  thus  formed  with  scissors — and  suture  the  borders 
as  in  "elbowing"  the  intestines,  (c)  Having  divided  and  incised  as  just  de- 
scribed, suture  as  in  the  operation  of  ureteroplasty  (page  1080)  (see  Figs. 
781-783).  (d)  Or  complete  the  transverse  division  and  do  an  end-to-end 
anastomosis.  (4)  Oblique  wounds,  complete;  (a)  Oblique  end-to-end 
anastomosis.  (5)  Transverse  wounds,  complete ;  (a)  Transverse  end- 
to-end  anastomosis. 


io8o 


OPERATIONS    UPON    THE    ABDOM1NO-PELVIC    REGION. 


URETHROPLASTY. 

Description. — A  congenital  or  acquired  stricture  may  be  encountered 
in  the  course  of  the  ureter.  It  is  often  possible  to  widen  the  caliber  of  such 
a  stricture  by  applying  the  method  adopted  in  pyloroplasty  (page  984).  A 
longitudinal  incision  through  all  the  coats  of  the  ureter  is  made  through  the 
strictured  portion — the  lips  of  which  are  then  sutured  in  a  transverse  direction 
by  means  of  a  fine  silk  suture.  Upon  tying  these  sutures  a  distinct  increase 
of  caliber  is  secured.     (Figs.  781-783.) 


*JrMU& 


A  B  C 

Figs.  781-783. — Urethroplasty: — A,  Axial  incision  through  narrowed  ureter;  B,  Sutures 
placed  in  the  long  axis  of  the  ureter;  C,  The  preceding  sutures  tightened,  thus  enlarging  the 
caliber  of  the  ureter  transversely.     (Redrawn  from  Duval.) 


URETERO-URETERAL  ANASTOMOSIS   (URETEROURETEROSTOMY). 

Description. — Junction,  or  "splicing,"  of  ends  of  ureter — by  suturing 
alone — or  by  suturing  aided  by  supports.  Indicated  in  wounds  accompanied 
by  no  loss,  or  very  little  loss,  of  substance. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
ureter.  Or,  as  is  usually  the  case,  the  ureter  may  be  exposed  in  the  course  of 
some  other  operation. 

Operation. — Having  exposed  the  ureter,  uretero-ureterostomy  may  be 
accomplished  in  one  of  several  ways: — 

(1)  Transverse  End-to-end  Uretero-ureterostomy  by  Suturing, 
without  Support  (Schopf,  Cushing,  and  others) : — (a)  The  ends  are  brought 
together  and  the  walls  are  sutured  with  fine  silk  in  small,  fully  curved  needle, 
held  in  holder — the  sutures  passing  through  the  free  edges  of  the  fibrous  and 
muscular  coats  of  the  divided  ends  (Fig.  784).  (b)  Or  Van  Hook's  method  of 
anastomosing  after  incomplete  transverse  division  may  be  used.  Make  a 
longitudinal  incision  extending  from  the  center  of  each  lip  of  the  transverse 
wound  upward  and  downward,  each  for  a  distance  equal  to  the  transverse 


URETERO-URETERAL    ANASTOMOSIS.  1081 

diameter  of  the  ureter.  The  sharp  angles  are  then  rounded  off — and  the  lips 
of  the  wound  are  then  sutured  longitudinally,  so  as  to  widen  the  site  of  suture 
and  avoid  subsequent  stricture.     This  is,  practically,  an  ureteroplasty. 

(2)  Transverse  End-to-end  Uretero-ureterostomy  by  Suturing, 
with  Support  (Tuffier) : — The  divided  ends  are  brought  together  over  an 
ureteral  catheter  or  bougie — and  are  then  sutured  as  in  the  above  method — ■ 
after  which  the  catheter  is  withdrawn  through  an  incision  made  in  the  ureter 
opposite  the  distal  end  of  the  catheter — and  the  longitudinal  wound  thus  made 
for  its  withdrawal  is  sutured  up  as  a  simple  longitudinal  wound.     (Fig.  785.) 

(3)  Oblique  End-to-end  Uretero-ureterostomy  by  Suturing,  without 
Support  (Bovee) : — To  lessen  tendency  to  contraction,  the  ends  are  divided 
obliquely — then  dilated  with  special  forceps  for  about  2.5  cm.  (1  inch) — then 
approximated — and  sutured  with   fine  silk  in  fully  curved  needle,  through 


Fig.  784. — Ureterorrhaphy  without  Support  (SchofT,  Cushing,  and  others): — The 
obliquely  divided  ureter  is  seen  sutured  with  interrupted  Lembert  sutures  passed  through  the 
outer  coats. 

fibrous  and  muscular  coats  only — the  sutures  used  being  alternating  rectangu- 
lar and  interrupted.  The  peritoneum  is  then  so  adjusted  as  to  exclude  the 
sutured  ureter  from  the  peritoneal  cavity. 

(4)  Uretero-ureterostomy  by  End-into-end  Invagination,  with 
Support,  without  Splitting  (Markoe): — This  method  was  resorted  to  in 
division  of  the  ureter  near  the  bladder.  Two  traction-sutures,  each  threaded 
upon  two  needles,  are  passed  through  the  proximal  ureter  near  its  free  end, 
from  within  outward  and  nearly  2  mm.  (about  y1^  inch)  apart.  The  needles  are 
then  made  to  draw  the  traction-sutures  through  the  wall  of  the  distal  ureter, 
entering  in  the  same  relative  position  and  at  the  same  distance  apart,  passing 
from  within  outward.  An  ureteral  catheter  is  then  passed  through  the  distal 
ureter  into  the  bladder  and  out  of  the  meatus,  being  caught  by  forceps  passed 


Fig.  7S5. — Ureterorrhaphy   with  Sipport  : — Ureteral  catheter   is  seen  within  the  ureter,  over 
which  interrupted  sutures  are  passed  through  the  outer  coats  of  the  ureter. 

through  the  female  meatus  (or  might  be  passed  from  the  urethra,  by  means  of  a 
cystoscope,  in  the  case  of  a  male) — the  opposite  end  of  the  catheter  passing  into 
the  distal  ureter.  Over  this  the  proximal  ureter  is  invaginated  into  the  distal, 
by  the  traction-sutures — which  are  then  tied.  Reinforcing  circular  suturing  is 
used  at  the  line  of  junction,  passing  through  all  the  coats  of  the  distal  and 
through  the  fibrous  and  muscular  coats  of  the  proximal  portions. 

(5)  Uretero-ureterostomy  by  End-into-end  Invagination,  without 
Support,  without  Splitting  (Poggi) : — Dilate  the  distal  end  with  special  for- 
ceps— place  one  (or  two)  pair  of  traction-sutures  through  the  proximal  end — 
two  needles  upon  single  thread,  introduced  nearly  2  mm.  (about  yg  inch)  apart, 


1082 


OPERATIONS    UPON    THE    ABDOMINO-PELVIC    REGION. 


in  the  same  horizontal  plane,  and  about  3  mm.  (£  inch)  from  within  the  lower 
end  of  the  proximal  portion  of  the  ureter — brought  out — and  the  needles  passed 
from  within  outward  in  the  distal  end,  the  same  distance  apart  and  about  7  mm. 
to  1.3  cm.  (^  to  \  inch)  from  the  free  end,  and  opposite  the  points  of  penetra- 
tion above.  The  proximal  end  is  then  invaginated  into  the  distal  by  traction, 
and  the  sutures  tied.  This  invagination  is  then  reinforced  by  a  continuous  or 
interrupted  suture  applied  around  the  line  of  union,  including  all  the  coats  of 
the  distal  and  the  fibrous  and  muscular  coats  of  the  proximal  segments. 


Figs.  786  and  787. — Ureteroureterostomy  (Robson-Winslow  Method): — A,  The 
intussusception  being  invaginated  in  the  split  intussuscipiens;  B,  the  intussustipiens  sutured 
about  the  intussusceptum. 

(6)  Uretero-ureterostomy  by  End-into-end  Invagination,  without 
Support,  with  Splitting  (Robson,  Winslow): — Slit  the  upper  distal  end 
longitudinally — place  one  or  two  pairs  of  traction-sutures  as  above  and  in- 
vaginate  in  the  same  manner — followed  by  suturing  the  slit  in  the  distal  end 
over  the  proximal  end.  If  necessary,  reinforce  with  circular  suturing,  as  ab<  >ve. 
(Figs.  786  and  787.) 


Fig.  7S8. — Uretero-ureterostomy,  by  Van   Hook's  Method 

Van  Hook.) 


-I,   First   step.     (Modified   from 


(7)  Uretero-ureterostomy  by  Lateral  (End-into-side)  Implantation 

(Van  Hook) : — Ligate  the  distal  part  of  the  ureter  circularly,  about  3  to  6  mm. 
(|  to  \  inch)  from  its  free  end,  with  silk  or  gut  (Fig.  788).  Commencing 
about  6  mm.  (\  inch)  below  this  ligature,  make  a  longitudinal  incision  through 
all  the  coats  of  the  distal  ureter  for  a  distance  equal  to  the  diameter  of  the 
ureter — with  fine,  narrow  knife,  or  sharp-pointed  scissors.  Make  a  longitu- 
dinal incision  in  the  proximal  ureter,  from  the  margin  of  the  free  end  upward 
for  about  6  mm.  (\  inch).  A  traction  suture  of  fine  catgut,  upon  two  needles,  is 
passed  just  as  in  the  invagination  method — about  3  mm.  (^  inch)  from  the  free 


URETERO-URETERAL    ANASTOMOSIS.  1083 

end,  and  from  nearly  2  mm.  to  3  mm.  (y1^  to  £  inch)  apart,  and  upon  the  lateral 
aspect  opposite  to  the  vertical  slit  (Fig.  789).  Pass  the  points  of  both  needles 
through  the  slit  into  the  distal  ureter,  and  thence  for  about  1.3  cm.  (h  inch) 
below  its  lower  end — thence  penetrate  the  wall  of  the  distal  ureter  outward, 
upon  the  same  aspect  of  the  ureter  as  the  slit,  and  both  needles  held  at  the 
same  horizontal  level  (side  by  side — not  one  over  the  other).  Unthreading  the 
needles,  draw  (invaginate)  the  proximal  into  the  distal  ureter,  until  the  slit  in 
the  proximal  is  well  within  the  slit  in  the  distal — and  then  tie  the  sutures. 
Complete  the  union  by  suturing  the  edges  of  the  vertical  incision  around  the 


^^SSSiPSiijjj 


Fig.  ;Sq. — Ureteroureterostomy,  by  Van  Hook's  Method: — II,  Second  step.     (Modified  from 

Van  Hook.) 

proximal,  the  sutures  passing  through  the  fibrous  and  muscular  coats  (Fig. 
790).  Further  protect  the  site  by  peritoneum  folded  around  it,  if  the  operation 
be  intraperitoneal.  Note — Where  the  proximal  end  (from  distention  or  other 
cause)  is  too  large  to  go  into  the  distal,  it  may  be  narrowed  by  placing  and  tying 
two  or  more  sutures  in  its  free  end.  Both  ends  of  these  "narrowing  sutures" 
are  then  threaded — and  all  six  needles  passed  into  the  slit,  in  pairs,  as  in  Van 
Hook's  operation,  and  the  threads  tied. 

(8)  Uretero-ureterostomy  by  Ligation  of  Severed  Ends  and  Side- 
to-side  Anastomosis  (D'Urso  and  Fabii's  modification  of  Monari's  method; : 
— Monari  ligated  both  ends  of  the  severed  ureter  and  then  anastomosed  these 
ends  side-to-side,  after  the  corresponding  manner  of  uniting  pieces  of  intestine 
laterally.  D'Urso  and  Fabii  first  introduced  catheters  into  the  two  ends, 
to  distend  the  ureters  during  suturing — then  withdrew  the  catheters  and 
circularly  ligated  the  divided  ends  of  the  ureter.     (Figs.   791-793.) 


Fig. 700.—  Ureteroureterostomy,  by  Van  Hook's  Method: — III,  Third  step.     (Modified  from 

Van  Hook.) 

Comment. — (')  In  the  operations  of  invagination,  instead  of  introducing 
the  traction-sutures  through  all  the  coats  of  the  proximal  end,  it  would  be  better 
to  introduce  a  single  needle  on  a  thread,  from  without  through  the  fibrous  and 
muscular  coats  alone — then,  keeping  the  needle  on  the  original  end,  thread  an- 
other needle  on  the  other  end,  and  proceed  as  is  ordinarily  done.  Thus  no 
capillary  thread  passes  into  the  lumen  of  the  proximal  portion — and  the  ap- 


1084  OPERATIONS    UPON   THE   ABDOMINO-PELVIC    REGION. 

proximated  outer  wall  of  the  proximal  portion  to  the  inner  wall  of  the  distal 
portion  blocks  off  the  wall  of  the  distal  ureter.  (2)  In  some  cases  the  kidney 
has  been  lowered  somewhat  from  its  original  site,  in  order  to  furnish  additional 
length  for  uretero-ureteral  anastomosis. 


.*, 


Figs.  791-793. — Ureteroureterostomy — D'Urso  and  Fabii's  Modification  of 
Monari's  Side-to-side  Anastomosis: — A,  Closure  of  the  ends  and  suturing  of  the  ends  side  to 
side,  with  line  for  incision  into  each  ureter;  B,  Each  ureter  incised  and  the  catheter  passed  into 
the  lumina;  C,  The  openings  into  the  ureter  closed — the  site  of  the  temporary  catheter  being 
shown.     (Redrawn  from  Duval.) 

Comparison  of  Methods  of  Uretero-ureterostomy. — Van  Hook's 
Lateral  Implantation  method  is  probably  the  best  for  all-around  use.  End- 
to-end  anastomosis  is  more  apt  to  be  followed  by  leakage.  End-into-end  anas- 
tomosis is  less  apt  to  be  followed  by  leakage  and  stricture.  In  end-into-end 
anastomosis  about  2.5  cm.  (1  inch)  of  ureter  is  taken  up.  In  end-in-side  im- 
plantation about  4  cm.  (ih  inches)  of  the  ureter  is  consumed. 


IMPLANTATION  OF  URETER,  IN  GENERAL. 

After  division  of  the  ureter,  or  after  excision  of  a  part  of  the  ureter  (by 
accident  or  other  cause),  the  lower  end  of  the  proximal  portion  of  the  ureter 
may  be  implanted,  or  "grafted,"  into  the  bladder,  large  intestine  (ca?cum, 
sigmoid,  or  rectum),  vagina,  opposite  ureter,  pelvis  of  opposite  kidney,  upper 
portion  of  the  distal  end  of  the  same  side  (which  is  really  uretero-ureterostomy), 
or  into  the  skin. 

When  a  simple  division  has  taken  place,  without  loss  of  substance,  a  simple 
implantation,  or  anastomosis  of  the  proximal  into  the  distal  end  (uretero- 
ureterostomy), is  best. 

Where  a  loss  of  some  extent  of  ureter  has  occurred,  a  uretero-ureterostomy 
is  still  the  best  course,  where  it  is  possible  to  approximate  the  ends  without  too 
great  tension.  Where  the  loss  is  too  great  for  this,  an  implantation  into  some 
other  structure  is  necessary. 

The  most  usual  sites  (in  order  of  preference)  into  which  the  proximal  end 
of  the  ureter  is  implanted  are — bladder,  large  intestine  (rectum),  and  skin. 


IMPLANTATION  OF  URETER  INTO  BLADDER. 


10S5 


The  distal  end  is  ligated  and  left  in  situ — some  surgeons  first  cauterizing  the 
stump. 

As  many  of  the  ureteral  implantations  are  done  for  accidents  to  the  ureter 
occurring  during  other  operations,  the  parts  are  usually  already  exposed — re- 
quiring none  or  but  little  more  dissection  to  fully  expose  them. 


IMPLANTATION   OF  URETER   INTO   BLADDER 
CYSTOSTOMY) . 


(URETERO- 


Description. — Implantation  of  ureter  into  male  or  female  bladder.  In 
Uretero-cystostomy  the  implantation  itself  may  be  intraperitoneal  or  extra- 
peritoneal. Where  possible,  the  extraperitoneal  implantation  is  preferable  to 
the  intraperitoneal  implantation — although  when  the  latter  is  done,  the  opera- 
tion-site should  be  so  walled  off  by  peritoneum  as  to  practically  amount  to  an 
extraperitoneal  implantation.  As  to  the  manner  of  exposing  the  ureter,  this 
is  done  generally  by  an  intraperitoneal  operation.  It  is  sometimes  done 
through  an  extraperitoneal  route,  as,  for  example,  in  performing  a  suprapubic 
cystotomy,  followed  by  exposure  of  the  ureter  by  cutting  through  the  base  of  the 
bladder.     It  may  also  be  exposed  extraperitoneal!}'  through  the  vagina.     In 


in 


Figs.  794-796. — Uretero-cystostomy  :— I,  Cut  end  of  ureter  is  shown  grasped  in  forceps  and  pro- 
truded into  bladder  through  incision  in  wall  of  latter.  II,  Sutures  are  passed  through  outer  coats  of 
bladder  and  ureter.  Ill,  Ureter  is  shown  sutured  into  bladder.  The  peritoneum  is  incised  over 
ureter  in  I. 


the  following  description  it  will  be  supposed  that  the  ureter  is  to  be  severed 
near  its  vesical  end. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section  below  the  umbilicus. 

Operation. — (1)  Having  performed  a  lower  median  abdominal  section, 
with  the  patient  in  the  Trendelenburg  position,  displace  the  intestines  toward 
the  diaphragm  and  to  the  opposite  side — isolating  the  ureter  and  tracing  it  to 
the  bladder.  (2)  Incise  the  posterior  peritoneum  over  the  site  of  the  intended 
division  of  the  ureter.  Having  freed  the  peritoneum  and  connective  tissue 
from  the  ureter  by  blunt  dissection,  divide  the  ureter  transversely.  Ligate  the 
distal  end  of  the  ureter  and  return  it  to  its  site  (Figs.  794  and  796).  (3)  Make 
an  incision  through  all  the  walls  of  the  bladder,  as  nearly  the  normal  site  as 


1086  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

possible,  and  in  the  long  axis  of  the  bladder,  and  just  large  enough  to  admit  the 
ureter.  The  ureter  is  then  grasped  with  long,  thin  forceps  and  carried  within 
the  bladder  sufficiently  far  for  its  free  end  to  project  slightly  within  the  bladder- 
cavity.  With  a  fine,  curved  needle,  and  with  silk  or  gut,  the  edges  of  the  blad- 
der-wound are  sutured  around  the  ureter,  passing  through  all  the  coats  of  both 
bladder  and  ureter — except  the  mucous  membrane.  (4)  The  peritoneum  is 
then  sutured  around  the  site  of  junction,  so  as  to  practically  render  it  extra- 
peritoneal. (5)  Where  the  technic  has  been  satisfactory,  the  abdomen  may  be 
entirely  closed  at  once — which  is  always  preferable.  Otherwise  drainage  is 
temporarily  established. 

Comment. — (I)  Where  much  ureter  has  been  lost,  the  bladder  is  some- 
times drawn  up  into  the  pelvis  and  sutured  to  the  broad  ligament,  in  the  female, 
or  other  structure,  before  implanting.  (2)  In  the  female  special  forceps  may 
be  introduced  through  the  vagina,  and  thence  through  the  incision  made  into 
the  bladder  to  receive  the  ureter — seizing  the  ureter  and  drawing  it  through. 
In  such  cases  the  bladder  is  cut  through  from  the  outside  upon  a  sound  intro- 
duced through  the  urethra.  (3)  In  order  to  counteract  the  upward  pull  upon 
the  implanted  end  of  the  ureter,  gut  traction-sutures  are  sometimes  placed  in 
the  end  of  the  proximal  portion,  in  the  case  of  the  female,  and  carried  out  the 
urethra  and  tied  to  the  dressing.  (4)  To  imitate  nature,  the  ureter  has  been 
sutured  into  the  bladder  through  an  oblique  opening.  And  to  give  a  valve 
effect,  the  tip  of  the  free  end  in  the  bladder  has  been  split. 


IMPLANTATION  OF   URETERS  INTO  THE  LARGE  INTESTINE  — (URE- 

TERO-RECTOSTOMY) 

BV  FOWLER'S  METHOD. 

Description. — Implantation  and  suturing  of  the  ureters  into  the  long  axis 
of  some  part  of  the  large  intestine,  generally  either  into  rectum,  sigmoid  flexure, 
or  caecum.  Indicated  especially  where  the  bladder  has  been  removed.  The 
difficulties  of  this  implantation  are  not  so  great — the  chief  source  of  failure 
and  of  death  being  infection  of  the  ureters  and  kidneys  from  the  intestinal 
tract.  In  Fowler's  operation,  which  will  be  here  described,  the  implanta- 
tion into  the  rectum  (uretero-rectostomy)  is  made  in  such  a  manner  as  to 
open  obliquely  upon  an  artificially  formed  valve  of  mucous  membrane,  which 
valve,  together  with  the  circular  action  of  the  muscular  fibers  of  the  intestine, 
will  tend  to  shut  off  the  ureters  and  kidneys  from  ascending  infection  from  the 
bowel,  especially  during  defecation. 

Preparation. — As  for  median  abdominal  section — with  especially  thor- 
ough cleansing  of  the  intestinal  tract,  and  particularly  the  rectum. 

Position. — Patient  in  the  Trendelenburg  position.  Surgeon  to  patient's 
left,  generally.     Assistant,  opposite. 

Landmarks — Incision. — As  for  median  abdominal  section  below  the 
umbilicus. 

Operation. — (1)  The  sphincter  of  the  anus  is  first  dilated.  (2)  The 
abdominal  cavity  is  opened  as  in  ordinary  abdominal  section.  (3)  Displace 
the  intestines  downward  (toward  the  diaphragm)  and  laterally,  exposing  the 
site  of  the  ureters.  (4)  Incise  the  peritoneum  over  the  ureters,  from  the  brim 
of  the  pelvis  to  the  bladder,  and  free,  by  blunt  dissection,  the  ureters  from  their 
bed  to  this  extent.  Ligate  the  ureters  near  the  bladder- wall  and  divide  them 
obliquely  upon  the  side  of  the  ligature  toward  the  kidneys — the  oblique  division 
being  at  the  expense  of  the  under  (posterior)  surface  of  the  proximal  ends  of  the 


FOWLER'S  URETERORECTOSTOMY.  1087 

ureters.  (They  may  be  first  divided  transversely  and  then  the  proximal  end 
beveled  obliquely  as  above.)  (5)  Incise  the  anterior  wall  of  the  rectum  longi- 
tudinally in  its  center,  for  about  7  cm.  (2I  inches) — the  incision  being  so  placed 
that  its  center  will  correspond  with  a  convenient  approximation  of  the  cut  ends 
of  the  ureters.  This  incision  passes  through  the  serous  and  muscular  coats 
only.  Dissect  back,  on  either  side,  the  serous  and  muscular  coats,  exposing 
a  diamond-shaped  area  of  submucous  tissue — an  assistant  holding  aside  the 
margins  with  temporary  traction-sutures  or  tenacula  (Fig.  797).  In  the  lower 
half  of  the  exposed  area  of  submucous  tissue  cut  a  U-shaped  flap  about  2.5  cm. 
(1  inch)  long,  with  free  end  downward,  incising  through  the  mucous  membrane 
into  the  lumen  of  the  rectum.  Turn  the  free  end  of  this  flap  upward  and  out- 
ward upon  itself,  so  that  the  apex  will  point  to  the  base,  and  the  mucous  surface 
will  be  uppermost — forming  a  flap  with  mucous  surface  upon  one  side,  and 
submucous  upon  the  other — and  suture  the  two  surfaces  of  the  reflected  flap 
together  along  their  lateral  aspect  (Fig.  79S).     (6)  Unite  the  two  ureters  upon 


Fig.  797.— Ureterorectostomy,  by  Fowler's  Method: — I,  The  serous  and  muscular  coats 
of  the  rectum  are  incised  and  retracted.  A  U-shaped  flap  is  outlined  upon  the  mucous  membrane. 
(Modified  from  Fowler.) 


their  inner  aspects  by  two  or  three  interrupted  fine  gut  sutures  passed  through 
their  fibrous  and  muscular  coats,  one  placed  near  their  free  end,  the  second 
about  2  to  2.5  cm.  (J  to  1  inch)  above,  and  a  third  may  be  similarly  placed 
above  the  second,  if  there  be  room.  The  ureters  will  be  thus  so  united  as  to 
leave  the  obliquely  beveled  ends  pointing  posteriorly.  (7)  The  two  parallel, 
united  ureters  are  now  so  placed  upon  this  flap  of  mucous  and  submucous  tissue 
that  their  obliquely  beveled  surfaces  will  lie  undermost,  and  in  contact  with 
the  normal  mucous  surface  of  the  reflected  end  of  the  flap — and  with  their  tips 
in  apposition  with  the  upper  part  of  the  reflected  flap  (so  as  to  leave  ample  free 
flap  below  to  serve  as  a  valve).  Suture  the  free  ends  of  both  ureters  to  the 
mucous  flap,  by  fine  gut  sutures  passing  through  only  the  fibrous  and  serous 
coats  of  the  ureters,  and  well  into  both  thicknesses  of  the  mucous  flap.  The 
ureters  are  also  sutured  above  to  the  submucous  tissue  of  the  flap.  (8)  The 
suturing  having  been  completed,  carefully  push  the  mucous  flap  and  attached 
ends  of  the  ureters  back  into  the  rectum.     Then  suture  together,  with  continu- 


io88 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


ous  or  interrupted  catgut,  the  edges  of  the  opening  through  the  submucous  and 
mucous  coats  left  by  the  flap,  continuing  the  suturing  upward  a  little  beyond  the 
base  of  the  flap,  and  beneath  the  ureters,  until  the  furrow  caused  by  approxi- 


Figs.  798-800 — Uretero-rectostomy,  by  Fowler's  Method: — II,  The  U-shaped  flap  is 
incised  and  turned  upward.  The  two  beveled  ureters  are  connected  by  two  sutures,  and  then 
sutured  to  the  mucous  flap.      (Modified  from  Fowler.) 


Fig.801. — Ureterorectostomy,  by  Fowler's  Method: — III,  The  mucous  flap  and  attached 
ureters  are  then  buried  within  the  bowel  by  suturing  the  margins  of  the  opening  through  the  mucous 
membrane.     (Modified  from  Fowler.) 


mating  the  edges  has  been  obliterated  (Fig.  800).      (9)  Suture  together  the 
edges  of  the  serous  and  muscular  coats  of  the  rectum  with  interrupted  silk  or 


URETERECTOMY,   IN  GENERAL. 


1089 


chromic  gut,  thus  further  burying  in  the  tips  of  the  ureters,  and  also  burying  in 
that  portion  of  the  ureters  lying  obliquely  between  the  submucous  and  serous 
coats,  insuring  an  oblique  passage  between  the  rectal  coats  of  about  3  cm.  (i| 
inches).  One  or  two  of  the  sutures,  in  this  line  of  suturing,  should  include 
the  outer  coats  of  the  ureters  (not  entering  their  lumen).  The  outer  coats  of 
the  rectum,  in  this  line  of  suturing,  should  be  well  sutured  around  the  ureters 
at  the  site  where  they  pass  between  these  coats. 
(Fig.  802.)  (10)  Temporary  drainage  may  be  pro- 
vided, if  deemed  necessary — otherwise  the  abdomen 
is  closed  as  usual. 

Comment. — (1)  A  permanent  valve  is  thus 
formed,  with  a  mucous  surface  to  the  ureter,  and  a 
mucous  surface  to  the  lumen  of  the  gut,  thus  clos- 
ing the  ends  of  the  ureters  as  the  bowel  distends 
with  combined  feces  and  urine,  aiding  the  control 
and  safety  from  infection — which  the  oblique  pas- 
sage of  the  ureters  through  the  rectal  wall  further 
aids.  (2)  Various  other  methods  of  intestinal  im- 
plantation have  been  done.  Maydl  transplanted 
both  ureters,  including  an  elliptical  portion  of  the 
trigone  of  the  bladder,  into  the  rectum  or  sigmoid 
flexure — thus  retaining  the  natural  functioning  of 
the  ureteral  openings. 


IMPLANTATION  OF  URETER  UPON  THE  SKIN. 


Fig.  802.— Ureterorec- 
tostomy, by  Fowler's 
Method  : — IV,  The  ureters 
and  mucous  flap  are  still 
further  buried  by  suturing 
the  edges  of  the  incision 
through  the  serous  and  mus- 
cular coats.  (Mollified  from 
Fovs  lei .  1 


Description. — Implantation  of  the  ureter  upon 
the  skin  of  the  loin  or  abdomen.  The  implanta- 
tion upon  the  former  site  is  preferable — as  extension 
of  the  ureter  through  the  abdominal  cavity  furnishes 
a  band  for  possible  intestinal  interference.  Skin- 
implantation,  however,  is  the  least  desirable  form 
of  implantation,  because  of  the  inconvenience  and 
annoyance  of  this  exit  for  the  urine,  and  because  of  the  likelihood  of  infection. 

Operation. — (1)  If  the  ureter  to  be  implanted  be  encountered  during  an 
operation  by  the  oblique  Lumbar  incision, — after  ligating  the  distal  end  of  the 
severed  ureter,  the  proximal  end  is  loosened  up  by  blunt  dissection  sufficiently 
to  free  it  for  the  requisite  length — and  is  then  sutured  into  the  skin  of  the 
lumbar  wound  after  splitting  its  end — the  remainder  of  the  wound  being 
closed  by  suture  in  the  ordinary  fashion.  (2)  If  the  ureter  be  encountered 
in  the  course  of  a  median  abdominal  section,  a  counter  lumbar  opening  is 
made  and  the  ureter  implanted,  as  just  described. 

Comment. — The  proximal  end  of  the  ureter  may  also  be  sutured  to  the 
skin  at  the  nearest  point  possible  to  the  bladder,  in  hope  of  subsequently 
doing  a  plastic  operation  for  the  establishment  of  the  ureter. 


URETERECTOMY.  IN  GENERAL. 

Description. — Excision  of  ureter,  in  whole  or  in  part.  Partial  ureterec- 
tomy is  the  removal  of  a  portion  of  the  ureter,  followed  by  either  an  uretero- 
ureterostomv  between  the  remaining  ends,  or  an  implantation  of  the  ureter  into 
some  locality.     Complete  ureterectomy  consists  in  the  removal  of  the  entire 

69 


1090  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

ureter — and  implies,  of  course,  the  removal  also  of  the  corresponding  kidney; 
that  is,  nephro-ureterectomy. 

Ureterectomy  may  be  done  extraperitoneally  or  intraperitoneally.  Extra- 
peritoneal ureterectomy  is  generally  done  through  the  oblique  lumbar  incision. 
Intraperitoneal  (transperitoneal)  ureterectomy  is  usually  done  through  an 
anterior  abdominal  section. 

Indicated  in  tuberculosis  and  suppuration  of  the  ureters.  Partial  ureter- 
ectomy is  sometimes  done  accidentally  in  operating  for  other  conditions. 

PARTIAL  URETERECTOMY 

BY  OBLIQUE  LUMBAR  INCISION. 

Description. — The  ureter  is  exposed  extraperitoneally  by  the  above  in- 
cision, and  a  portion  of  its  extent  removed — followed  by  an  uretero-ureteros- 
tomy,  where  the  amount  removed  is  not  too  great — or  by  an  implantation, 
where  the  amount  removed  and  the  site  of  removal  indicate  it.  A  partial 
ureterectomy  is  generally  accidentally  done,  especially  in  intra-abdominal 
operations  for  the  removal  of  tumor. 

Preparation — Position — Landmarks — Incision. — As  for  exposure  of 
the  ureter  extraperitoneally  by  oblique  lumbar  incision,  page  1076. 

Operation. — If  the  ureterectomy  be  deliberately  done — the  kidney  is  ex- 
posed— the  ureter  isolated  by  tracing  downward  from  pelvis  of  kidney — and  is 
then  dissected  up  from  its  bed  by  blunt  dissection  and  by  carefully  peeling  it 
away  from  the  peritoneum.  A  limited  portion  is  now  excised  with  scissors — 
after  ligating  below  the  point  of  division — and  clamping  with  special  clamp 
above.  The  proximal  and  distal  ends  are  then  freed  up  sufficiently  to  enable 
the  gap  formed  by  the  excision  to  be  bridged.  The  ends  are  brought  together 
and  an  uretero-ureterostomy  (preferably  by  Van  Hook's  method,  see  page 
10S2)  is  done — or  an  ureteral  implantation  is  performed. 

TOTAL   URETERECTOMY,   TOGETHER   WITH   REMOVAL   OF  KIDNEY, 

BY  ANTERIOR  MEDIAN  ABDOMINAL  SECTION. 

Description. — Total  Nephro-ureterectomy  consists  in  the  removal  of  the 
kidney  and  of  the  entire  ureter.  Generally  resorted  to  for  tubercular  or  sup- 
purative disease  of  kidney  and  ureter.  The  removal  may  be  made  extraperi- 
toneally by  the  oblique  lumbar  incision,  as  just  described  in  partial  ureterec- 
tomy,— or  intraperitoneally,  by  anterior  abdominal  section  in  the  median  or 
semilunar  line.  The  exposure  of  the  kidney  and  ureter  extraperitoneally 
by  an  oblique  lumbar  incision  has  been  described  and  pictured  at  pages  1053 
and  1055. 

Preparation — Position — Landmarks — Incision. — As  for  median  ab- 
dominal section. 

Operation. — Having  opened  the  abdominal  cavity  and  displaced  the  in- 
testines toward  the  median  line,  divide  the  posterior  peritoneum  upon  the  outer 
aspect  of  the  colon  and  reflect  it  toward  the  spinal  column — thus  exposing  the 
kidney  and  ureter.  The  kidney  is  now  freed  and  its  pedicle  tied  off  as  de- 
scribed under  total  nephrectomy  by  the  abdominal  route.  The  ureter  is  sim- 
ilarly freed  by  blunt  dissection.  All  vessels  are  ligated.  Having  severed  the 
pedicle  of  the  kidney,  except  the  ureter,  the  kidney  is  separated  from  its  bed — ■ 
and,  by  gentle  traction  upon  it  and  the  ureter,  the  ureter  is  traced  down  to  the 
bladder.  The  vesical  end  of  the  ureter  is  doubly  ligated  close  to  the  bladder 
and  divided  between  the  ligatures.     The  free  end  of  the  ureteral  stump  may  be 


SURGICAL  ANATOMY  OF  THE  BLADDER.  1091 

sterilized.  The  posterior  peritoneum  is  dropped  back  into  place  over  the  site 
occupied  by  kidney  and  ureter — and  may  be  sutured  here  and  there  with  in- 
terrupted gut  sutures,  though  it  generally  remains  readily  in  place  and  adheres 
to  the  connective  tissue  from  which  raised.  Temporary  drainage  may  be 
established,  where  specially  indicated — otherwise  the  abdomen  is  closed. 


XIV.  THE  BLADDER. 

SURGICAL  ANATOMY. 

Description. — The  bladder  is  a  musculo-membranous  sac,  mainly  situ- 
ated in  the  pelvic  cavity,  between  pubes  and  rectum  in  male;  and  between 
pubes  in  front,  and  cervix  uteri  and  upper  part  of  vagina  behind,  in  female, — 
entirely  surrounded  by  recto-vesical  fascia,  and  covered  above  by  peritoneum. 
Consists  of  serous  (peritoneal),  muscular,  submucous  (areolar),  and  mucous 
coats.  In  infancy  the  bladder  projects  above  the  os  pubis  and  is  more  of  an 
abdominal  organ  than  in  the  adult.  When  empty — in  the  adult,  the  bladder 
lies  deeply  in  the  pelvis,  flattened  antero-posteriorlv.  When  moderately  dis- 
tended— it  is  rounded  and  still  within  the  pelvis.  When  fully  distended — it  is 
ovoid  and  projects  into  the  abdominal  cavity.  When  greatly  distended — it 
may  extend  nearly  to  the  umbilicus.  The  long  axis  of  the  bladder,  which  in- 
clines to  the  vertical,  runs  from  a  point  between  the  os  pubis  and  the 
umbilicus  (dependent  upon  the  amount  of  distention)  downward  and  back- 
ward toward  the  tip  of  the  coccyx.  The  vertical  axis  is  greater  in  the  male — 
the  transverse  greater  in  the  female. 

Relations. — (1)  Summit : — Connected  with  abdominal  wall  by  urachus 
(remains  of  part  of  allantois),  which  passes  from  apex  of  bladder,  between 
transverse  fascia  and  peritoneum,  to  umbilicus;  obliterated  hypogastric  arteries, 
passing  upward  from  side  of  bladder,  on  each  side  of  urachus.  (2)  Superior, 
or  abdominal  surface  : — Entirely  covered  by  peritoneum,  from  summit  and 
obliterated  hypogastric  arteries  to  base  of  bladder;  sigmoid  flexure  (in  male); 
part  of  vasa  deferentia  (in  male) ;  uterus  (in  female) ;  small  intestines  (in  both 
sexes).  (3)  Antero-inferior,  or  pubic  surface  : — Uncovered  by  perito- 
neum, and  separated  from  the  following  structures  by  the  cavum  Retzii,  or 
prevesical  space;  triangular  ligament;  symphysis  pubis;  levatores  ani  and  in- 
ternal obturator  muscles;  abdominal  wall  (when  distended),  separated  by 
recto-vesical  fascia.  (4)  Lateral  surfaces  : — Upper  part  covered  by  perito- 
neum, above  and  posterior  to  obliterated  hypogastric  arteries, —  lower  part, 
below  and  in  front  of  obliterated  hypogastric  arteries,  is  covered  by  recto- 
vesical fascia,  which  separates  the  lateral  surfaces  from  the  levatores  ani  and 
surrounds  the  vesical  vessels  and  nerves;  obliterated  hypogastric  arteries, 
which  cross  lateral  surfaces  obliquely  from  below  upward  and  forward;  vasa 
deferentia,  arching  from  before  backward  along  subperitoneal  aspect  of  lateral 
surfaces  toward  base,  crossing  obliterated  hypogastric  arteries,  and  passing 
between  ureter  and  wall  of  bladder;  entrance  of  ureter,  at  junction  of  posterior 
and  lateral  surfaces,  about  5  cm.  (2  inches)  above  the  prostate;  levatores  ani 
and  obturator  internus  muscles.  (5)  Postero-inferior  surface,  or  base  : — 
May  be  subdivided  into  two  parts; — (a)  Upper,  Peritoneal  Portion: — Recto- 
vesical pouch  in  male,  generally  from  1.3  to  2.5  cm.  (5  to  1  inch)  from  pros- 
tate, up  to  as  much  as  5  cm.  (2  inches)  in  marked  bladder  distention;  utero- 
vesical  cul-de-sac  in  female: — (b)  Lower,  Non-peritoneal  Triangular  Por- 
tion:— In  Male,  rests  upon  anterior  surface  of  second  part  of  rectum,  inferior 


1092  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

part  of  vasa  deferentia  and  vesiculae  seminales; — its  boundaries  being;  Base, 
reflected  recto-vesical  fold;  Sides,  diverging  vasa  deferentia  and  vesicuJae 
seminales;  Apex,  summit  of  prostate; — In  Female,  adherent  to  anterior  wall 
of  cervix  uteri,  and  to  upper  portion  of  anterior  vaginal  wall; — Neck  of  Blad- 
der, beginning  of  urethra. 

Ligaments. — (a)  Five  true  ligaments: — (1)  Two  pubo-prostatic, — 
recto-vesical  fascia  and  muscular  tissue — from  back  of  pubic  bone  to  antero- 
inferior or  pubic  surface  of  bladder,  passing  over  superior  surface  of  prostate 
gland.  (2)  Two  lateral, — recto-vesical  fascia — from  lateral  aspects  of  pros- 
tate to  sides  of  bladder  and  walls  of  pelvis.  (3)  Superior  ligament,  or  urachus, 
— iibro-muscular  structure  between  summit  of  bladder  and  umbilicus,  (b) 
Five  false  ligaments  (peritoneal  folds): — (1)  Two  posterior,  or  recto-vesical 
folds  of  peritoneum  (in  male), — from  side  of  rectum  to  side  of  bladder.  (2) 
Two  posterior,  or  utero-vesical  folds  of  peritoneum  (in  female), — from  sides  of 
uterus  to  posterior  surface  and  sides  of  bladder.  (The  posterior  false  liga- 
ments form  the  lateral  walls  of  the  recto-vesical  and  utero-vesical  cul-de-sac, 
and  transmit  the  ureters,  obliterated  hypogastric  arteries,  with  vessels  and 
nerves.)  (3)  Superior  ligament, — fold  of  peritoneum  reflected  over  urachus 
and  obliterated  hypogastric  arteries,  from  summit  of  bladder  to  umbilicus. 

Relation  of  Peritoneal  Fold  to  Anterior  Abdominal  Wall. — The  re- 
flection of  peritoneum  is  carried  upward  as  the  bladder  is  distended.  The 
maximum  elevation  of  the  peritoneal  fold  rarely  exceeds  5  cm.  (2  inches). 
Sometimes  it  fails  to  reach  the  upper  border  of  the  symphysis  pubis. 

Space  of  Retzius,  or  Prevesical  Space. — Space  between  the  reflection  of 
peritoneum  above  and  the  symphysis  pubis  below, — and  between  the  bladder 
posteriorly  and  the  symphysis  pubis  anteriorly — and  occupied  by  connective 
tissue. 

Trigonum  Vesicae. — Triangular  smooth  surface  at  base  of  bladder — 
bounded  at  each  posterior  angle  by  the  ureteral  opening — and  at  the  antero- 
inferior angle  by  the  urethral  orifice. 

Orifices  of  Ureters. — Situated  about  3.8  cm.  (1^  inches)  from  base  of 
prostate  gland  and  beginning  of  urethra — and  are  a  little  less  than  5  cm.  (2 
inches)  apart,  at  either  end  of  the  base  of  the  trigone. 

Internal  Urinary  Meatus. — Lies,  in  the  adult  male,  from  2  to  2.5  cm. 
(f  to  1  inch)  posterior  to  the  symphysis  pubis,  and  from  5  to  6.3  cm.  (2  to  2^ 
inches)  above  the  perineum.  It  generally  lies  opposite  some  part  of  the  upper 
half  of  the  symphysis  pubis. 

Arteries. — Superior,  middle,  and  inferior  vesical,  and  branches  from  the 
obturator  and  sciatic,  in  the  male, — and  the  same,  with  additional  branches 
from  the  uterine  and  vaginal,  in  the  female, — all  from  the  anterior  trunk  of  the 
internal  iliac. 

Veins. — Form  plexuses  around  neck,  sides  and  base,  and  end  in  internal 
iliac  vein. 

Lymphatics. — Accompany  the  veins  and  end  in  the  pelvic  glands. 

Nerves. — From  hypogastric  plexus  of  sympathetic,  and  from  third  and 
fourth  sacral  nerves. 

SURFACE  FORM  AND  LANDMARKS. 

In  young  children,  the  apex  of  the  empty  bladder  is  about  25  cm.  (1  inch) 
above  the  level  of  the  symphysis  pubis. 

In  the  adult,  the  apex  of  the  empty  bladder  is  about  on  a  level  with  the 
superior  border  of  the  symphysis  pubis. 


THE  BLADDER— GENERAL  SURGICAL  CONSIDERATIONS.         1093 

In  marked  distention  the  anterior  bladder-wall  comes  closely  into  contact 
with  the  abdominal  parietes — without  the  intervention  of  peritoneum  between 
the  two. 

For  the  normal  extremes  of  the  peritoneal  reflection,  see  Surgical  Anatomy, 
page  1092.  For  the  position  of  the  peritoneal  reflection  under  surgical  dis- 
tention, see  General  Surgical  Considerations,  below. 

The  neck  of  the  bladder  is  on  a  level  with  a  line  extending  horizontally 
backward  from  just  below  the  center  of  the  symphysis  pubis.  Also  see  position 
of  internal  urinary  meatus,  Surgical  Anatomy,  page  1092. 

The  depth  from  the  perineal  skin  to  the  pelvic  floor  generally  averages  from 
5  to  7.5  cm.  (2  to  3  inches)  in  the  posterior  and  external  part  of  the  perineum — 
and  somewhat  less  than  2.5  cm.  (1  inch)  in  the  anterior  part. 

In  the  lithotomy  position  the  bladder  is  about  6.3  or  7.5  cm.  (25  or  3  inches) 
from  the  perineal  surface. 


GENERAL  SURGICAL  CONSIDERATIONS. 

When  both  bladder  and  rectum  are  empty,  the  apex  of  the  bladder  and  the 
peritoneal  reflection  are  slightly  below  the  superior  border  of  the  symphysis 
pubis.  When  the  apex  of  the  bladder  is  as  much  as  5  cm.  (2  inches)  above  the 
svmphysis  and  resting  against  the  anterior  abdominal  wall,  the  peritoneal  re- 
flection is  about  2  cm.  (f  inch)  above  the  upper  border  of  the  symphysis. 

Simple  distention  of  the  rectum  alone  tends  to  elevate  the  base  of  the  blad- 
der without  correspondingly  elevating  the  non-peritoneal  prevesical  space. 

When  the  rectum  is  distended  by  a  rubber  bag  filled  with  air  or  water,  the 
prostatic  portion  of  the  urethra  is  elongated,  and  the  bladder  is  thereby  raised 
out  of  the  pelvic  cavity  and  the  peritoneum  pushed  upward.  The  maximum 
elevation  of  the  non-peritoneal  prevesical  space  is  obtained  by  distending  the 
rectum  first  and  then  distending  the  bladder.  The  rectal  bag  is  first  filled  with 
about  10  or  12  ounces  of  fluid — and  then  the  bladder  is  filled  with  about  8 
ounces.  Thereby  an  additional  space  free  of  peritoneum  is  secured  in  the 
anterior  line.  The  amount  of  space  uncovered  by  peritoneum  which  is  thus 
ordinarily  secured  generally  amounts,  altogether,  to  about  7.5  cm.  (3  inches). 
The  bladder,  however,  is  often  first  filled — and  up  to  15  ounces  may  be  used. 

Grav  states  that  after  distending  the  rectum  with  420  c.c.  water — and  then 
filling  the  bladder  with  500  c.c. — the  bladder  will  be  elevated  by  the  rectum 
sufficiently  to  make  an  interval  between  the  lower  peritoneal  reflection  and  the 
upper  border  of  the  symphysis  equal  to  S.5  cm.  (3yV  inches). 

As  the  point  of  reflection  of  peritoneum,  therefore,  is  not  fixed,  and  as  it 
sometimes  comes  down  to  a  level  with  the  upper  border,  or  even  below,  the 
symphysis  pubis,  it  is  never  absolutely  safe  to  plunge  a  trocar  directly  into  the 
bladder,  even  immediately  above  the  upper  border  of  the  symphysis.  It  is 
always  better  to  expose  the  bladder-wall  by  a  limited  median  incision  before 
using  the  trocar. 

Though  not  to  be  recommended,  the  bladder  may  be  punctured  from  the 
rectum,  in  the  lower,  non-peritoneal  surface  at  the  base  of  the  bladder. 

No  vessels  of  any  size  cross  the  median  line  of  the  abdomen  or  of  the  peri- 
neum— the  two  sites  through  which  cystotomy  is  generally  done. 

The  artery  of  the  bulb,  especially  when  arising  normally,  is  not  generally 
cut  in  perineal  lithotomy.  If  the  artery  of  the  bulb  arises  from  the  accessory 
pudic  it  will  lie  more  anteriorly  than  normal — and  well  out  of  the  way.  If, 
however,  it  arises  from  the  pudic  sooner  than  usual,  it  will  cross  the  perineum 
more  posteriorly  and  will  be  almost  certainly  cut. 


IOQ4  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Perineal  incisions  made  into  the  neck  of  the  bladder  should  not  exceed  the 
limits  of  the  prostate. 

The  prostatic  plexus  of  veins  is  likely  to  be  wounded  in  lateral  perineal 
lithotomy. 

The  ejaculatory  duct  is  apt  to  be  cut  in  the  same  operation  if  the  incision  be 
too  far  posterior. 

INSTRUMENTS. 

Scalpels;  bistouries,  straight  and  curved,  sharp  and  blunt;  lithotomy  knives; 
scissors,  straight  and  curved,  blunt  and  sharp;  forceps,  dissecting  and  toothed; 
artery-clamp  forceps,  long  and  short;  grooved  director;  special  grooved 
directors  and  perineal  guides;  grooved  lithotomy  staffs,  median  and  lateral; 
tenacula;  probe;  retractors,  various;  blunt  dissector;  sponge-holders;  trac- 
tion-loops; Clover's  crutch;  rectal  bag;  catheters;  sounds;  whalebone  guides; 
tunneled  sounds;  lithotomy  forceps;  lithotomy  scoop;  lithotrite;  evacuator; 
irrigating  syringe;  special  bladder  forceps;  cystoscope;  special  electric  illumi- 
nator; trocar  and  cannula;  exploratory  syringe;  needles,  straight  and  curved; 
needle-holder;  ligatures  and  sutures,  silk  and  gut;  drainage-tubing;  gauze. 


INTRODUCTION  OF  SOUND  OR  CATHETER. 

Description. — The  general  method  of  entering  the  male  bladder  by  the 
urethra  is  the  same  in  all  essentials — whether  by  metallic  sounds,  catheters, 
lithotrites,  or  cystoscopes.  Soft  instruments  are  not  subject  to  much  guiding, 
but  generally  enter  the  bladder  by  being  simply  protruded  through  the  urethral 
canal  without  special  effort  to  direct  them  through  the  anatomical  curves.  The 
passage  of  instruments  in  the  female  is  simple. 

Passage  in  the  Male. — (i)  The  glans  and  the  meatal  opening  are  cleansed. 
(2)  The  patient  lies  supine,  near  the  edge  of  the  table — shoulders  slightly 
elevated — thighs  slightly  flexed  and  rotated  outward  by  bending  the  knees  (to 
relax  the  muscular  tension).  The  surgeon  stands  on  the  left,  just  above  the 
hips,  facing  the  patient's  side.  (3)  The  sound,  or  catheter,  warmed,  lubri- 
cated, and  disinfected,  is  held  lightly  in  the  right  hand,  between  thumb  and  first 
two  fingers — the  handle  at  first  parallel  with  the  abdominal  wall.  Thus  held, 
its  point  is  introduced  into  the  meatus,  the  lips  of  which  are  parted  by  the  sur- 
geon's left  index  and  thumb  to  receive  it — the  glans  and  penis  being  held  ver- 
tically in  the  surgeon's  left  fingers.  As  the  instrument  is  pushed  onward  and 
downward,  the  penis  is  correspondingly  drawn  upward  and  over  the  instrument. 
(4)  As  soon  as  the  instrument  is  felt  to  have  entered  about  io  or  13  cm.  (4  to  5 
inches),  and  to  be  rounding  toward  the  subpubic  arch,  the  handle  is  gradually 
elevated  until  the  perpendicular  is  reached — allowing  the  instrument  to  gravi- 
tate through  the  canal  and  beneath  the  pubic  arch.  (5)  As  this  occurs,  the 
handle  is  continued  in  its  sweep  forward,  directing  the  point  through  the  tri- 
angular ligament — onward  through  the  membranous  and  prostatic  urethra — 
until  the  end  is  felt  to  glide  into  the  bladder — when  the  handle  will  be  found 
pointing  directly  away  from  the  bladder  and  slightly  downward — having 
passed  through  a  semicircle  in  the  vertical  plane.  (6)  In  withdrawal,  the 
above  steps  should  be  exactly  reversed. 

Comment. — (1)  The  sound  should  first  hug  the  floor  of  the  spongy  ure- 
thra, until  the  lacuna  magna  (on  the  roof,  2.5  cm.  [1  inch]  from  the  meatus)  is 
passed — and  then  gently  hug  the  roof  for  the  balance  of  the  way  through  the 


PARACENTESIS  YESIC.E.  1095 

spongy,  membranous,  and  prostatic  urethra.  (2)  By  carrying  the  handle  of 
the  instrument  forward  and  between  the  thighs  too  soon,  the  tip  of  the  instru- 
ment is  made  to  hug  the  roof  of  the  urethra  too  suddenly  and  closely,  and  is  apt 
to  lodge  against  the  upper  part  of  the  anterior  aspect  of  the  triangular  ligament, 
and  thus  fail  to  enter  the  membranous  urethra.  (3)  On  the  other  hand,  the 
instrument  sometimes  fails  to  pass  the  triangular  ligament  because  of  lodging 
against  the  lower  part  of  the  anterior  aspect  of  the  triangular  ligament,  the 
handle  not  being  depressed  enough — and,  in  such  cases,  is  made  to  glide  on  by 
depressing  the  handle  more — or  by  lifting  the  lodged  point  upward  by  the  left 
index-finger  in  the  rectum,  or  even  by  pressure  against  the  perineum  behind 
the  scrotum.  (4)  The  instrument  may  be  at  first  introduced  while  held  about 
parallel  with  the  left  Poupart  ligament — that  is,  over  the  left  groin — and  then 
swept  into  the  median  line  as  it  descends.  (5)  If  the  beak  of  the  instrument 
revolves  readily,  the  sound  is  in  the  bladder. 

Passage  of  the  Female  Sound  or  Catheter. — (1)  The  patient  lies  supine, 
with  hips  and  knees  semiflexed,  and  thighs  separated.  (2)  Separate  the  labia 
with  left  thumb  and  index.  Holding  the  instrument  between  the  right  thumb 
and  index,  the  index  extending  beyond  the  end  of  the  instrument,  pass  the  tip 
of  the  right  index  just  within  the  vaginal  orifice — withdraw  the  finger  partly, 
hugging  the  upper  wall  of  the  vagina — and,  as  the  finger  glides  out  of  the 
vagina  upon  the  vestibule,  the  prominent  urethral  papilla  is  felt  (about  1.3 
cm.,  or  h  inch)  above  the  junction  of  the  vagina  and  vestibule — upon  which 
is  situated  the  meatus — into  which  the  instrument  is  then  introduced  and 
protruded  into  the  bladder. 

PARACENTESIS  VESIGE. 

Description. — Puncture  of  the  bladder-wall  by  cannula  and  trocar,  or  by 
aspiratory  syringe.  Indicated  in  retention  of  urine.  The  bladder  may  be 
punctured  immediately  above  the  pubis,  just  below  the  symphysis  pubis, 
through  the  rectum,  or  through  the  prostate  gland.  The  suprapubic  puncture 
is  practically  the  only  method  of  puncture  now  resorted  to — and  will  be  here 
described. 

Preparation. — Ascertain  that  the  bladder  is  well  distended.  Shave  in 
the  region  of  the  median  line,  just  above  the  symphysis  pubis. 

Position. — Patient  supine, — or  sitting  upright,  supported.  Surgeon  on 
patient's  right,  facing  him. 

Point  of  Puncture. — In  median  line,  immediately  above  the  upper  border 
of  the  symphysis  pubis. 

Operation. — Having  outlined  the  distended  bladder  by  percussion — a 
curved  cannula  and  trocar  (which  are  better  than  the  straight)  are  taken  in  the 
operator's  right  hand,  with  the  convexity  upward,  and  so  held,  with  the  index- 
finger  upon  the  shaft  of  the  instrument,  that  the  depth  to  which  it  may  enter  the 
bladder  is  fixed  in  advance.  The  bladder  is  steadied  by  the  surgeon's  left 
thumb  and  index  placed  on  each  side  of  the  median  line.  The  instrument  is 
thrust  sharply  but  gently  into  the  bladder,  entering  in  the  median  line  just 
above  the  symphysis  pubis,  and  directed  backward  and  downward — piercing 
skin,  superficial  fascia,  passing  between  the  inner  borders  of  the  recti  and 
pyramidales  (or  through  their  muscular  substance),  prevesical  space,  anterior 
bladder-wall,  and  into  the  bladder.  The  trocar  is  then  withdrawn  and  the 
cannula  left  in  situ  until  the  urine  has  come  away,  chiefly  of  its  own  accord,  and 
partly  aided  by  gentle  pressure.  Upon  withdrawal  of  the  instrument,  the 
opening  is  at  once  closed  by  sterilized  cotton  and  collodion. 


1096  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

Comment. — (I)  Local  anesthesia  should  he  first  used.  (2)  Incision  of 
skin  may  be  first  made  and  then  trocar  introduced.  This  may  be  done  either 
to  avoid  the  most  difficult  part  of  the  puncture  mechanically,  namely,  the 
penetration  of  the  tough  skin  with  a  comparatively  dull  instrument, — or  it 
may  be  done,  as  mentioned  under  Surgical  Considerations,  for  the  purpose  of 
first  e.xposing  the  bladder  before  puncturing.  (3)  If  the  skin  be  drawn  down- 
ward over  the  symphysis  just  before  puncture,  a  valve-like  opening  will  be 
formed.  (4)  In  those  rare  cases  in  which  the  reflection  of  peritoneum  comes 
very  low  down,  to  or  behind  the  symphysis  pubis,  it  will  almost  certainly  be 
wounded — not  being  possible  to  avoid  it,  except,  were  it  known  in  advance,  by 
exposing  the  area  by  dissection  and  pushing  the  peritoneum  upward  before  the 
puncture.  Puncture  of  the  peritoneum,  however,  is  exceedingly  rare  provided 
the  bladder  be  well  distended,  and  a  curved  instrument  be  used. 


CYSTOTOMY  IN  GENERAL. 

By  Cystotomy  is  meant  the  incision  of  the  bladder.  The  less  correctly  used 
term  "  lithotomy"  (or  "stone-cutting,"  literally)  is  equivalent  to  "Cystotomy 
for  removal  of  calculus." 

Cystotomy  is  indicated  in  calculus,  foreign  body  in  the  bladder,  exploration, 
drainage,  access  to  prostate,  tumors,  diseased  conditions  of  the  mucous  mem- 
brane, catheterization  of  the  ureters  intravesically,  etc. 

Cystotomy  may  be  suprapubic,  median  perineal,  lateral  perineal,  bilateral 
perineal,  medio-lateral  perineal,  medio-bilateral  perineal,  vaginal,  and  by  ex- 
ternal urethrotomy.  The  first  three  of  these  are,  practically,  all  which  are  now 
done — and  of  these  three,  the  suprapubic  is  the  one  which  is  most  frequently 
performed. 

For  the  removal  of  large  stones,  the  suprapubic  route  should  always  be 
chosen — while  it  is  preferable  for  the  removal  of  any  calculus.  For  the  pur- 
poses of  drainage  alone,  not  weighing  other  considerations,  the  perineal  route 
is  the  best. 

SUPRAPUBIC  CYSTOTOMY. 

Description. — Incision  of  the  bladder  above  the  symphysis  pubis,  through 
the  prevesical  space.  Indicated  for  calculi — especially  large  ones — or  encysted 
small  ones;  exploration;  drainage;  tumors;  foreign  bodies;  access  to  prostate 
gland.  Much  more  frequently  performed  than  median  or  lateral  perineal 
cystotomy. 

Preparation. — Pubes  shaved;  rectum  emptied;  rectal  bag  in  rectum,  well 
above  the  sphincters,  in  hollow  of  sacrum,  and  filled  with  10  to  12  ounces  of 
water  (or  with  air);  bladder  irrigated  and  filled  with  8  to  10  ounces  of  water 
(after  the  rectum  has  been  distended) ;  penis  carefully  ligated  with  rubber 
band  to  keep  water  in  bladder. 

Position. — Patient  supine.  Surgeon  on  patient's  right.  Assistant  oppo- 
site. 

Landmarks. — Median  line;  upper  border  of  symphysis  pubis. 

Incision. — About  7.5  cm.  (3  inches)  in  length — placed  in  the  median 
line — beginning  about  6.5  cm.  (2^  inches)  above  the  symphysis  pubis  and  ex- 
tending to  a  point  about  1.3  cm.  {\  inch)  above  the  symphysis.  The  extreme 
upper  and  lower  ends  of  this  incision  are  not  carried  to  the  lowest  depths  of  the 
wound — but  are  only  superficial  and  are  to  allow  for  retraction  of  the  parts. 


SUPRAPUBIC  CYSTOTOMY.  1097 

Operation. — (1)  Divide  the  skin  and  superficial  fascia,  clamping,  if  neces- 
sary, any  bleeding  vessels.  Sometimes  abundant  fatty  areolar  tissue  must  be 
traversed.  The  interval  between  the  inner  borders  of  the  recti  and  pyramidales 
is  sought,  but  is  frequently  not  demonstrated — and,  if  not,  the  muscle  tissue 
is  divided  in  the  line  of  its  fibers,  without  further  needless  search — the  edges 
of  the  wound  being  well  retracted  as  they  are  deepened  (Fig.  803).  (2)  The 
transversalis  fascia  is  encountered  and  similarly  divided  in  the  median  line — 
and  the  prevesical  space  reached.  The  areolar  tissue  overlying  the  prevesical 
space  is  cautiously  divided  in  the  median  line— extreme  care  being  here  used, 
for  the  purpose  of  recognizing  the  lower  reflection  of  peritoneum,  especially  if  it 
be  prolonged  unusually  far  down.  The  peritoneal  fold  must  be  sought  from 
below  (near  the  symphysis)  upward,  the  dissection  beginning  immediately 


Fig. 803.— Suprapubic  Cystotomy  :— A,  Margins  of  recti  and  pyramidales  muscles  ;  B,  B,  Pre\-esi- 
cal  areolar  tissue  freed  and  retracted  from  bladder;  C,  Peritoneum  retracted  upward  (unopened); 
D,  D,  Tenacula  passed  through  serous  and  muscular  coats  of  bladder  and  subsequently  used  to  re- 
tract lips  of  bladder-wound. 

above  the  upper  border  of  the  symphysis.  As  soon  as  encountered,  the  peri- 
toneal fold  is  carefully  pushed  upward,  with  the  left  index,  off  the  front  of  the 
bladder,  so  as  to  be  out  of  the  way  of  injury.  All  the  prevesical  fatty  areolar 
tissue  should  be  divided  accurately  in  the  middle  line,  until  the  bladder-wall  is 
well  exposed — which  is  generally  recognized  by  its  pink  muscular  appearance, 
convex  contour,  fluctuation,  and  elasticity.  The  lips  of  the  wound  should 
be  well  retracted — and  any  bleeding  from  the  prevesical  veins  controlled. 
(3)  The  bladder  is  steadied  by  two  tenacula  passed  transversely  across  the 
median  line  through  the  outer  coats,  at  the  extreme  upper  and  lower  limits 
of  its  exposed  surface,  and  held  in  the  two  hands  of  the  assistant.  When  all 
is  in  readiness,  the  operator,  with  sharp,  narrow  knife,  by  a  quick,  controlled 
thrust,  stabs  through  the  bladder-wall  just  below  the  upper  tenaculum  (in- 


1098  OPERATIONS  UPON  THE  ABDOMINO-PELVIC   REGION. 

suring,  by  this  method,  the  penetration  of  all  coats  of  the  bladder — and  not  the 
protrusion  of  the  muscular  coat  ahead  of  the  knife-point,  as  sometimes  happens 
in  a  slowly  made  incision)  and  cuts  downward  in  the  middle  line  toward  the 
lower  tenaculum,  increasing  the  extent  of  the  incision  as  he  draws  the  knife  out. 
The  contained  fluid  immediately  escapes — but,  owing  to  the  holding  up  of  the 
bladder,  but  a  small  amount  enters  the  prevesical  wound.  Two  silk  retraction- 
sutures  are  now  placed  through  the  center  of  each  lip  of  the  bladder-wound — 
and  the  tenacula  withdrawn.  Some  surgeons,  instead  of  using  the  tenacula 
as  above,  originally  place  these  traction-sutures,  with  a  curved  needle,  passing 
through  the  outer  coats  of  the  bladder,  parallel  with  the  future  incision,  and 
about  1.3  cm.  (h,  inch)  apart.  Hemorrhage  from  the  edges  of  the  bladder- 
wound  may  occur  at  first,  but  generally  is  easily  controlled.  The  ligature 
about  the  penis  is  now  relaxed  and  the  bladder  emptied.  (4)  The  assistant 
who  held  the  tenacula  now  holds  the  bladder-lips  apart  by  traction-sutures. 
The  opening  into  the  bladder  is  enlarged  to  the  desired  extent  in  the  median 
line,  upward  and  downward — carefully  guarding  the  peritoneum  above,  which 
especially  tends  to  prolapse  when  the  bladder  is  empty.  A  finger  is  introduced 
and  the  cavity  of  the  bladder  examined — and  the  special  object  of  the  operation 
accomplished.  If  it  be  a  calculus  to  be  removed,  special  forceps,  guided  by  the 
introduced  finger,  grasps  the  stone  and  withdraws  it.  The  rectal  bag  may  be 
emptied  and  withdrawn  as  soon  as  the  bladder  is  entered — or,  if  not  distended 
before,  may  be  then  distended  to  bring  the  fundus  of  the  bladder  more  into  the 
wound.  (5)  Where  indicated — in  healthy  condition  of  the  parts  and  where 
no  great  traumatism  has  been  done — the  bladder-wound  may  be  closed  at  once. 
In  suturing,  retract  the  upper  and  lower  angles  of  the  bladder-wound  by  wound- 
hooks,  thus  approximating  and  paralleling  the  margins  of  the  vesical  wound. 
Withdraw  the  silk  traction-sutures  as  soon  as  the  wound-hooks  are  in  place. 
The  margins  of  the  bladder  are  then  neatly  and  closely  brought  together  with 
fine  chromic  gut,  upon  a  curved  needle — placed  interruptedly  and  passing 
through  all  the  coats  except  the  mucous  membrane.  It  is  probably  well  to 
reinforce  this  line  of  suturing  with  a  second  tier  of  interrupted  Lemberts  of  silk 
or  fine  gut — the  roughened  connective-tissue  coat  of  the  bladder,  being  ap- 
proximated in  the  Lembert  fashion,  uniting.  Some  surgeons  use  a  first  layer  of 
sutures  through  the  mucous  membrane — and  a  second  layer  through  the  outer 
coats.  Still  others  use  a  row  of  Lemberts  through  the  outer  coats  only.  (6) 
The  superficial  wound  is  now  closed — except  to  a  small  extent  immediately 
over  the  center  of  the  bladder- wound — where  temporary  drainage  is  established 
for  thirty-six  or  forty-eight  hours,  in  case  of  leakage.  Two  tiers  of  sutures  are 
used  in  the  superficial  wound — a  buried  chromic  gut  interrupted  or  con- 
tinuous tier,  uniting  the  divided  muscle  tissue, — and  a  superficial  silkworm- 
gut,  or  silk,  placed  interruptedly  through  the  skin  and  fascia.  The  sutures 
opposite  the  site  of  drainage  may  have  been  placed — and  simply  tightened 
upon  the  withdrawal  of  the  drain. 

Comment. — (1)  The  incision,  superficial  and  deep,  especially  where  done 
for  exploration,  may  be  less  extensive  than  the  above.  (-2)  If  in  doubt  about 
the  position  of  the  bladder,  use  an  exploratory  syringe.  (3)  Avoid  detaching 
the  anterior  bladder-wall  from  the  posterior  surface  of  the  symphysis.  (4)  If 
the  peritoneum  be  accidentally  wounded,  immediately  close  it  with  fine  gut 
sutures  of  the  Lembert  type.  (5)  Special  forms  of  hooked  gorgets  have  been 
made  to  hold  up  the  bladder  while  exploring  or  operating  upon  its  cavity.  (6) 
Use  round  needles  in  suturing  the  bladder.  (7)  In  some  cases,  for  drainage,  or 
other  reason,  the  suprapubic  wound  is  left  open — and  then  the  edges  of  the 
bladder  are  sutured  with  chromic  gut  to  the  deeper  edges  of  the  superficial 


LATERAL  PERINEAL  CYSTOTOMY. 


1099 


wound.  (8)  Some  surgeons  leave  a  catheter  in  the  bladdei  for  two  or  three 
days — to  avoid  overdistention  and  pressure  upon  the  sutures.  (9)  In  children, 
the  bladder  is  naturally  higher  in  the  abdomen. 


LATERAL  PERINEAL  CYSTOTOMY 

FOR  REMOVAL  OF  VESICAL  CALCULUS. 

Description. — Incision  of  bladder  through  left  lateral  region  of  perineum 
— generally  performed  for  the  removal  of  calculi.  The  operation  is  sometimes 
less  correctly  called  Lateral  Lithotomy.  It  is  always  performed  upon  the  left 
side  because  the  manipulations  upon  that  side  are  more  convenient  to  the 
surgeon.  The  operation,  as  here  carried  out,  is  applicable  to  any  purpose  for 
which  it  is  indicated  to  approach  and  open  the  bladder  by  this  route — but  it  is 
generally  done  for  stone,  although  less  frequently  now  than  formerly.  Calculi 
of  moderate,  but  not  the  largest,  size  may  be  removed  by  this  route.  The 
special  instruments  required  are: — a  left  dorso-laterally  grooved  lithotomy 
staff;  probe-pointed  knife  (if  preferred  to  straight-pointed  ) ;  stout  bistoury  with 
cutting  edge  of  about  5  cm.  (2  inches);  Clover's  crutch,  or  some  provision  for 
maintaining  the  lithotomy  position;  wristlets  and  anklets  (may  be  used). 


Fig.  804. — Incisions    for    Perineal    Cystotomy: — A,   Lateral  perineal 

perineal  cystotomy. 


cystotomy  ; 


Median 


Preparation. — Rectum  empty  and  irrigated.  Perineum  shaved.  Rec- 
ognition of  calculus  by  sound. 

Position. — Patient  rests  upon  back,  and,  in  this  position,  is  brought  down 
to  end  of  table,  so  that  buttocks  come  well  over  the  edge  of  the  table.  "While 
steadied  in  this  position,  the  special  staff  is  passed  into  the  bladder  and  given 
into  the  charge  of  an  assistant,  who,  henceforth,  holds  it  steadily  and  unvary- 
ingly in  the  middle  line.  Clover's  crutch  (and  anklets  and  wristlets,  if  de- 
sired) are  then  adjusted,  and  the  thighs  flexed  back  upon  the  abdomen— or  an 
assistant  on  each  side  may  hold  a  limb  in  the  above  position,  without  the  use  of 
the  crutch — and  the  patient  remains  in  the  characteristic  lithotomy  position 
throughout  the  operation.  The  surgeon  sits  at  the  end  of  the  table,  facing  the 
patient's  perineum.  The  assistant,  standing  on  the  left,  who  holds  the  staff  in 
his  right  hand,  holds  up  the  penis  and  scrotum  with  his  left.  Up  to  the  en- 
trance of  the  knife  into  the  groove  of  the  staff,  the  staff  is  held  so  that  its  handle 


iioo  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

is  nearly  parallel  with  the  abdominal  wall,  so  that  its  convexity  causes  the 
membranous  urethra  to  round  out  more  prominently  and  nearer  to  the  peri- 
neum, making  it  more  accessible  to  the  operator.  When  once  the  knife  has 
entered  the  groove  and  the  deeper  part  of  the  incision  is  being  made,  the  staff  is 
held  with  its  handle  perpendicular  and  its  concavity  up  against  the  pubic  arch 
and  its  point  well  in  the  bladder.  When  all  is  ready  for  the  incision,  and  the 
staff  is  in  position,  the  surgeon  should  examine,  by  rectum,  for  staff,  prostate 
and  ischial  tuberosities — and  then  change  gloves. 

Landmarks. — Central  tendinous  point  of  perineum;  median  raphe;  anus; 
ischial  tuberosities. 

Incision. — From  a  point  about  8  mm.  ($  inch)  to  left  of  median  raphe  and 
just  posterior  to  the  central  tendinous  point  of  the  perineum  (which  is  3.2  to  3.8 
cm.,  or  1  \  to  1^  inches,  anterior  to  the  adult  anus) — to  a  point  between  the 
ischial  tuberosity  and  the  posterior  portion  of  the  anus,  and  one-third  nearer  the 


Fig. 805.— Surface  View  of  Perineum  and  Ischiorectal  Regions: — Superficial  structures 
are  seen  on  right,  and  deep  on  left.  A,  Incision  for  lateral  perineal  cystotomy  ;  B,  Incision  for  median 
perineal  cystotomy  ;  C,  Bulb;  D,  Membranous  urethra  ;  E,  Prostate  gland  ;  F,  Vas  deferens,  vesicula 
seminalis,  and  base  of  bladder ;  G,  Internal  pudic  artery  ;  H,  Superficial  perineal  vessels  and  nerves  ; 
I,  Hemorrhoidal  vessels  and  nerves  ;  J,  Anus.     (Modified  from  Gray.) 


tuberosity  than  the  anus  (according  to  others,  midway  between  the  tuberosity 
and  the  anus) — making  a  total  incision  of  from  5  to  7.5  cm.  (2  to  3  inches). 
(See  Fig.  804.  A,  and  Fig.  805,  A.) 

Operation. — (1)  With  the  staff  in  the  first  of  the  positions  indicated  above, 
the  superficial  incision  is  made  in  the  form  of  a  thrust — the  operator  steadying 
the  perineal  tissues  with  his  left  fingers — and  directing  the  point  of  his  knife  at 
a  right  angle  to  the  perineum,  with  its  back  uppermost,  enters  its  point  at  the 
upper  limit  of  the  above  incision — and  aims  directly  for  the  groove  upon  the 
lateral  aspect  of  the  staff,  but  does  not  attempt  to  actually  reach  it,  though  he 
may  do  so  and  enter  it  at  once.  The  incision  is  made  as  the  knife  is  withdrawn, 
following  the  above  line  of  incision — is  about  7.5  cm.  (3  inches)  in  length,  and 
grows  less  deep  as  it  passes  backward  and  outward.  The  structures  cut  in  the 
superficial  incision  are,  in  order — integument;  superficial  and  deep  layers  of 


LATERAL  PERINEAL  CYSTOTOMY.  hoi 

superficial  fascia;  transversus  perinasi  muscle;  transverse  perineal  artery,  veins, 
and  nerves;  lower  margin  of  superficial  layer  of  triangular  ligament;  hemor- 
rhoidal vessels  and  nerves.  (2)  With  the  staff  now  in  the  second  one  of  the 
positions  indicated  above,  the  left  index  is  introduced  into  the  upper  angle  of 
the  wound  and  feels  for  the  staff — and,  with  this  finger  held  in  position  as  a 
guide,  with  the  nail  turned  so  that  it  enters  the  groove,  or  is  directly  over  it,  the 
knife  is  passed,  with  the  back  of  the  blade  uppermost,  along  the  back  of  the 
forefinger  and  nail  straight  into  the  groove — either  the  knife  with  which  the 
superficial  incision  was  made,  or  a  special  probe-pointed  lithotomy  knife. 
The  point  of  the  knife  having  been  well  engaged  in  the  groove  of  the 
staff,  the  second  or  deep  incision  is  now  made — by  pushing  the  knife  down- 
ward and  backward,  depressing  the  handle  as  the  knife  goes  forward  to  pre- 
vent its  leaving  the  groove,  the  point  kept  constantly  in  the  groove,  and  the 


Fig. 806.— Sectional  View  of  Perineal  and  Pelvic  Regions:— The  knife  is  seen  passing 
through  the  perineal  structures,  and  incising  the  membranous  urethra  between  the  bulb,  in  front,  and 
the  prostate  gland,  behind.     (Modified  from  Gray. ) 


sides  of  the  knife  parallel  with  the  edges  of  the  now  deep  wound,  and  inclined 
to  the  left— until  the  lower  end  of  the  knife  passes  through  the  prostate  gland 
and  neck  of  the  bladder — as  evidenced  by  a  gush  of  urine.  The  deep  opening 
into  the  bladder  is  then  enlarged  to  the  extent  considered  necessary  by  bearing 
gently  upon  the  cutting  end  as  the  knife  is  withdrawn — and  ceasing  to  use  pres- 
sure, and,  therefore,  cutting  force,  as  the  knife  reaches  the  more  superficial 
planes  of  the  wound.  The  structures  cut  in  the  deep  incision,  are,  in  order- 
membranous  and  prostatic  parts  of  the  urethra;  superior  or  deep  layer  of  tri- 
angular ligament;  compressor  urethra?  muscle;  anterior  portion  of  levator  ani 
muscle;  left  lateral  lobe  of  prostate  gland.  The  incision  through  the  urethra 
and  prostate  will  be  from  near  the  median  line  obliquely  backward  and  out- 
ward (Fig.  806).     (3)  In  the  case  of  a  stone,  the  lithotomy  forceps  are  intro- 


no2  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

duced  closed,  along  the  finger  in  the  bladder  as  a  guide,  preceded  or  not  by  the 
dilatation  of  the  bladder,  as  indicated — and  the  stone  is  grasped  and  removed, 
aided  or  not  by  the  fingers  in  the  bladder.  (4)  The  interior  of  the  bladder  may 
be  then  irrigated — if  debris  or  other  cause  call  for  it.  (5)  A  perineal  lithotomy 
drainage-tube  is  inserted — and  the  wound  left  open,  or  closed  only  at  its  ex- 
treme ends  by  suture. 

Comment. — (1)  Where  the  calculus  is  lodged  behind  an  enlarged  pros- 
tate gland,  or  held  by  the  bladder-walls  in  some  unusual  position,  or  embed- 
ded, special  manipulations  of  the  lithotomy  forceps  is  necessary.  (2)  Large 
stones  may  be  broken  by  the  lithoclast  and  removed  in  pieces.  (3)  Contra- 
indications to  lateral  perineal  cystotomy  for  the  removal  of  stone,  are — a  large 
stone;  enlarged  prostate,  and  deep  perineum — under  which  circumstances  a 
suprapubic  cystotomy  would  be  done.  (4)  Hemorrhage  during  the  steps  of 
the  operation  is  controlled  by  ligature,  clamping,  pressure,  and  hot  douching. 
(5)  Avoid  cutting  the  bulb  and  its  artery  in  front — the  rectum  behind — and  the 
pudic  artery  laterally.  (6)  Incision  too  far  posteriorly  will  cut  the  ejaculatory 
ducts.  (7)  Draw  the  penis  well  up  over  the  staff  as  the  deep  cut  is  made — so 
as  to  pull  the  bulb  up.  (8)  Incision  through  the  neck  of  the  bladder  should  not 
exceed  about  2  cm.  (f  inch).  (9)  Stick  to  the  groove  in  the  staff,  after  once 
reaching  it.  (10)  Some  difficulties,  peculiar  to  the  smallness  of  the  parts,  are 
encountered  in  lateral  lithotomy  upon  children. 


MEDIAN  PERINEAL  CYSTOTOMY 

FOR  REMOVAL  OF  VESICAL  CALCULUS. 

Description. — Incision  of  bladder  through  median  perineal  region — 
generally  performed  for  the  removal  of  calculi.  The  operation  is  sometimes 
less  correctly  called  Median  Lithotomy.  The  bladder  is  reached  by  incising 
through  the  apex  of  the  prostate  gland  and  the  membranous  portion  of  the 
urethra.  A  less  free  and  extensive  opening  is  thus  given  than  by  either  the 
suprapubic  or  lateral  perineal  cystotomy.  Resorted  to,  especially  formerly, 
for  small  calculi — which  are  generally  now  treated  by  litholapaxy.  The 
special  instruments  required  are: — a  medially  grooved  lithotomy-staff,  and  a 
long,  narrow,  straight  knife  with  a  double  cutting-point.  The  advantages  of 
the  median  over  the  lateral  cystotomy  are  the  following: — smaller  wound;  less 
hemorrhage;  quicker  healing.  There  is  better  drainage  than  in  the  supra- 
pubic operation.  The  disadvantages  are: — that  only  small  calculi  can  be 
removed — and  that  the  bulb  of  the  corpus  spongiosum  and  rectum  are  more 
apt  to  be  injured. 

Preparation. — As  for  lateral  perineal  cystotomy. 

Position. — As  for  lateral  perineal  cystotomy.  The  medially  grooved  staff 
is  held  as  in  the  second  position  assumed  in  lateral  perineal  cystotomy  (see 
page  1099). 

Landmarks. — Central  tendinous  point  of  perineum;  median  raphe;  anus. 
(See  Fig.  804,  B,  and  Fig.  805,  B.) 

Incision. — Begins  at  a  point  about  1.3  cm.  (^  inch)  anterior  to  the  anus, 
in  the  median  raphe — and  extends  upward  for  2.5  cm.  (1  inch). 

Operation. — (1)  The  operator  puts  his  left  gloved  index-finger  into  the 
rectum  and  presses  it  against  the  staff,  which  has  already  been  inserted  and 
held  as  just  mentioned — pressing  against  the  staff  at  the  apex  of  the  prostate 
gland — thereby  steadying  and  recognizing  the  deep  relations,  guarding  the 
rectum,  and  following  the  penetration  of  the  knife.     (2)  The  long,  narrow, 


CVSTORRHAPHV. 


1103 


double-edged  knife,  with  the  main  cutting-edge  upward,  held  at  a  right  angle 
to  the  perineum,  is  first  thrust  directly  inward  and  made  to  at  once  strike  and 
enter  the  grooved  staff  at  the  apex  of  the  prostate,  passing  through  the  apex  of 
the  gland  itself  where  the  finger  steadies  it  within  the  rectum.  The  knife  is 
then  made  to  cut  upward  in  the  groove  of  the  staff — and,  in  the  act  of  with- 
drawal, makes  a  wound  in  the  soft  parts  of  about  2.5  cm.  (1  inch) — depressing 
the  handle  of  the  knife  in  cutting  the  urethra  and  elevating  it  in  cutting  the 
superficial  parts, — incising  the  following  structures: — integument;  both  layers 
of  superficial  fascia;  anterior  portion  of  external  sphincter  ani;  central  ten- 
dinous point  of  perineum;  lower  margin  of  triangular  ligament;  membranous 
urethra ;  compressor  urethra' ;  apex  of  prostate  gland.  (3)  As  the  knife  is  with- 
drawn, the  index-finger  is  introduced  into  the  bladder  directly  upon  the  original 
staff — or  such  an  instrument  as  a  Little's  director  is  introduced  upon  the  staff 
through  the  perineal  wound  and  the  original  staff  then  removed — and  the 
finger  introduced  upon  the  second  director  through  the  neck  of  the  bladder, 
which  is  often  entered  with  difficulty.  The  bladder  cavity  is  thus  examined 
through  the  original  wound — or  the  opening  through  the  neck  of  the  bladder 
may  be  first  dilated,  if  necessary.  (4)  The  special  object  of  the  operation  is 
then  accomplished  in  the  same  manner  as  described  under  the  lateral  perineal 
cystotomy.  (5)  In  completing  the  operation,  a  perineal  lithotomy  drainage- 
tube  is  not  usually  used — the  wound  being  simply  left  open — protected  by  a 
thick  perineal  dressing. 


CYSTORRHAPHY. 

Description. — Suturing  of  bladder.     Indications: — following  cystotomy 
operations  (the  suprapubic  only) ;  wounds,  occurring  during  operation  or  at 
other    times;    rupture   of    the   organ;    etc. 
The  peritoneal   or  non-peritoneal  aspects 
of  the  bladder  may  be  involved — or  both. 

Operation. — The  wound  may  be  con- 
nected with  any  of  the  conditions  men- 
tioned above.  The  exposure  of  the  wound, 
therefore,  will  be  determined  by  the  nature 
of  the  incision  or  injury.  It  will  involve 
either  the  peritoneal  or  the  non-peritoneal 
region  of  the  bladder — or  may  involve 
both.  The  same  form  of  suturing  is  used, 
whether  peritoneal  or  non-peritoneal  sur- 
face be  the  site  of  operation.  Several 
methods  of  approximating  the  edges  are 
in  use: — (a)  The  margins  of  the  bladder- 
wound  are  brought  together  and  carefully 
adjusted  by  means  of  a  single  tier  of  fine 
chromic  gut,  interrupted  or  continuous. 
carried  upon  a  curved  needle,  and  passing 
through  all  the  coats  except  the  mucous, 
(b)  The  mucous  membrane  may  be  first 
united  by  interrupted  or  continuous  gut 
suture — followed  by  the  approximation  of 
the  outer  coats  by  the  stitch  just  described 

under  "a,"  either  fine  gut  or  silk  being  used,     (c)  By  interrupted  chromic 
gut  Lembert  sutures  passing  through  the  outer  coats  only,  extending  slightly 


Fig.  S07.  —  Cystorrhaphy  : — First 
tier  of  sutures  passes  through  outei  coats 
and  involves  edges  of  bladder-wound 
(shown  in  upper  sutures).  Second  tier 
consists  of  Lemberts  through  outer  coats 
(shown  in  lower  sutures-— which  are  here 
also  seen  burying  in  the  first  tier). 


no4  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

beyond  the  wound  at  both  ends.  In  the  case  of  the  peritoneal  surface  of 
the  bladder,  the  serosae  adhere  and  unite.  In  the  case  of  the  non-peritoneal 
surface  of  the  bladder,  the  raw  connective  tissue  covering  the  surface  unites, 
(d)  By  a  combination  of  method  "a"  as  a  first  tier — followed  by  method  "c," 
as  a  second  tier.     (Fig.  807.) 

Comment. — (1)  Method  "a"  is  probably  the  best — or  method  "b."  (2) 
Gut  should  always  be  used  in  sutures  passing  through  the  mucous  membrane. 
(3)  In  no  form  of  suturing  should  the  mucous  membrane  be  included  in  a 
suture  which,  at  the  same  time,  will  pass  through  the  other  coats.  (4)  If  the 
circumstances  of  the  wound  and  the  technic  of  closure  be  such  as  to  make  the 
operator  feel  confident  of  result,  the  external  wound  may  be  closed  as  usual. 
In  all  cases  of  doubt — and  the  safest  in  all  cases — the  external  wound  may  be 
closed  in  greater  part — and  temporary  drainage  be  carried  down  to  the  bladder 
wound.  (5)  The  bladder  may  be  drained  by  the  catheter  for  two  or  three 
days — to  avoid  distention  of  the  organ  and  strain  upon  the  sutures. 


LITHOTRITY. 

Description. — Crushing  of  vesical  calculi  at  one  or  several  intermittent 
sittings  (from  seven  or  eight,  to  three  or  four  days  apart)  without  general 
anesthesia — the  debris  of  the  stone  being  left  to  be  evacuated  by  nature's 
efforts.  The  instrument  used  is  an  ordinary  lithotrite — and  the  manner  of 
using  it  is  the  same  as  in  Litholapaxy,  except  no  evacuator  follows  its  use.  The 
patient  rests  in  bed,  or  may  even  remain  up,  while  the  disturbance  of  each 
sitting  is  passing  by.     The  operation  is  now  almost  obsolete. 


LITHOLAPAXY. 

Description. — Crushing  of  vesical  calculi  and  recrushing  of  the  resulting 
fragments,  followed  by  removal  of  the  debris  by  irrigation,  at  one  sitting,  under 
general  anesthesia.  The  crushing  and  removing  are  accomplished  by  special 
instruments — the  lithotrite  and  evacuator. 

Preparation. — Presence  of  stone  verified  by  sound;  bowels  emptied;  blad- 
der and  urethra  in  an  aseptic  condition  and  bladder  moderately  distended  with 
a  sterile  fluid  (about  4  or  5  ounces). 

Position. — Patient  supine,  with  buttocks  well  raised  by  support,  to  cause 
the  gravitation  of  the  stone  to  the  fundus  of  the  bladder — resting  near  the  right 
edge  of  the  table,  with  thighs  separated.  Surgeon  stands  upon  the  patient's 
right.     Assistant  opposite. 

Operation. — (1)  The  lithotrite,  with  closed  blades,  is  introduced  into  the 
bladder  just  as  a  sound  would  be — with  the  modification  required  by  the 
straighter  instrument  more  abruptly  curved  near  its  end — that  is,  when  the 
bulbous  portion  of  the  urethra  is  reached,  the  handle  of  the  lithotrite,  instead 
of  being  at  once  depressed  (which  would  cause  the  point  of  the  instrument  to 
hook  against  the  roof  of  the  bulbous  urethra  in  front  of  the  triangular  ligament), 
is  held  upright,  so  as  to  allow  its  more  sharply  curved  point  to  gravitate  be- 
neath the  triangular  ligament  and  glide  into  the  membranous  urethra  and 
reach  the  prostate — and  then  only  is  the  handle  depressed,  and  slightly  twisted 
from  side  to  side,  causing  the  tip  to  ride  up  through  the  prostatic  urethra  into 
the  bladder — and  glide  along  the  trigone  to  the  posterior  wall  of  the  organ.  (2) 
Slow,  methodical  movement  in  the  opening  and  closing  of  the  blades,  with  a 


LITHOLAPAXY.  1105 

pause  between  each  movement — together  with  a  systematic  search  of  the  blad- 
der cavity,  should  be  the  method  adopted.  Hurried  movements  cause  bladder- 
currents,  which  generally  keep  the  stone  moving  and  make  the  grasping  of  the 
calculus  difficult.  Irregular,  random  movements  in  directing  the  grasping 
blades  of  the  instrument  are  unsurgical  and  generally  futile.  The  instrument 
mav  encounter  the  stone  immediately — and,  if  so,  its  position  may  be  indicated 
and  the  blades  opened  for  its  seizure.  If  not,  as  the  instrument  rests  quietly  in 
the  middle  line  of  the  base  of  the  bladder,  and  steadily  held  in  the  one  position, 
its  blades  are 'separated  (by  withdrawal  of  the  male  blade) — then  followed  by  a 
few  seconds'  cessation  of  all  movements  (to  allow  stone  to  gravitate  into  the 
grasp  of  the  instrument) — succeeded  by  a  gentle  screwing  back  of  the  male 
blade  (the  instrument  being  kept  steadily,  immovably  in  one  position) — when 


Fig.808.— Litholapaxv  IN  thk  Male: — The  lithotrite  in  position. 


the  stone  will  often  be  felt  in  the  grasp  of  the  separated  blades.  "Open — 
pause — close"  is  the  formula  of  movement.  If  unsuccessful,  open  again — ■ 
turn  blades  to  right  side,  through  an  angle  of  45  degrees  ("right  oblique"),  still 
keeping  the  instrument  in  the  median  line — close.  .  Or  turn  it,  from  a  vertical 
plane,  through  an  angle  of  45  degrees  to  the  left  ("left  oblique") — open — close. 
Thus  the  instrument  may  pass  from  the  vertical  to  a  right  or  left  oblique,  or  a 
right  or  left  horizontal.  It  is  better  to  open  the  blades  before  turning — as  the 
stone  may  be  pushed  away  by  an  opening  blade.  Depress  the  handle,  keeping 
in  the  middle  line  or  turning  laterally — thus  examining  the  anterior  wall  and 
sides  of  the  bladder.  Reverse  the  direction  of  the  blades,  so  that  they  point 
downward,  especially  where  the  prostate  is  enlarged — and  examine  the  floor  of 
the  bladder  and  behind  the  prostate  gland — assuming  the  positions  of  reversed 
vertical,  reversed  right  and  left  horizontal,  and  reversed  right  and  left  oblique. 


no6 


OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 


Thus  the  entire  cavity  of  the  bladder  is  systematically  searched.  (3)  Having 
grasped  a  calculus,  the  male  blade  is  steadily  and  slowly  screwed  down  into  the 
female  blade — until  the  stone  is  felt  to  break  into  two  or  more  pieces.  After 
pausing  a  moment,  the  blades  are  opened,  kept  quietly  apart  a  few  seconds, 
then  closed — when  probably  several  of  the.  fragments  will  be  caught  and  further 
crushed.  This  is  repeated  until  the  debris  are  considered  to  be  fine  enough  to 
come  through  the  tube  of  the  evacuator.  The  blades  of  the  lithotrite  are  then 
closely  approximated  while  in  the  bladder  and  the  instrument  is  withdrawn. 
(Fig.  808.)      (4)  The  tube  of  the  evacuator  is  then  introduced  into  the  bladder 


Fig.  809.— Litholapaxy  in  the  Male  :—The  evacuator  in  position. 


and  the  urine  or  other  fluid  of  the  bladder  is  in  part  withdrawn.  The  opening 
of  the  evacuator  lies  in  the  lowest  part  of  the  fundus  of  the  bladder — so  as  to 
catch  the  gravitating  stones.  The  bulb  of  the  evacuator  is  then  filled  with 
warm  boric  acid  solution  and  attached  to  the  evacuator-tube.  While  the  left 
hand  steadies  the  rigid  tube  in  the  bladder,  the  right  hand  compresses  the  bulb 
and  throws  a  part  of  its  contents  into  the  bladder  (about  2  or  3  ounces).  On 
relaxing  the  bulb,  as  much  fluid  as  was  thrown  in  is  drawn  out  again  (so  that 
the  original  amount  always  remains  in),  and,  with  it,  more  or  less  of  the  debris 
of  stone  are  brought  out  in  the  outflowing  current.     Wait  a  few  moments  and 


LITHOLAPAXV 


1107 


then  repeat  the  evacuating  process — until  all  debris  seem  to  have  come  away. 
If  too  large  a  fragment  remains  for  evacuation,  as  determined  by  its  ineffectual 
clicking  against  the  evacuator,  the  lithotrite  must  be  again  introduced,  the 
stone  recrushed,  and  the  evacuator  reintroduced  and  the  debris  further  re- 
moved. Removal  of  all  debris  is  generally  determined  by  the  absence  of 
clicking — which  is  often  heard  at  a  distance,  but  is  generally  to  be  detected  by 
the  ear  placed  near  the  bladder — and  by  the  coming  away  of  perfectly  clear 
and  clean  water.  The  bladder  may  be  finally  irrigated — and  the  evacuator 
withdrawn  (Fig.  809),  (5)  The  patient  is  generally  kept  quietly  in  bed  for  a 
few  days. 

Comment. — (1)  Avoid  grasping  the  mucous  membrane  of  the  bladder  in 
the  instrument,  the  construction  of  which  usually  makes  it  impossible  or  diffi- 


Fig. 810—  Litholapaxy  in  the  Female  :— The  lithotrite  in  position. 


cult.  At  any  rate,  before  finally  forcibly  closing  the  blades,  always  shift  the 
blades,  so  as  to  feel  that  they  are  free  and  have  not  included  the  bladder-wall. 
(2)  In  evacuating  debris,  the  bladder  should  not  be  allowed  to  get  empty  of 
fluid — as  the  walls  of  the  organ  would  have  a  tendency  to  be  drawn  into  the 
evacuator  by  suction.  (3)  If  air  enter  the  bladder,  depress  the  handle  of  the 
evacuator  so  as  to  raise  its  tip  above  the  level  of  the  bladder  fluid,  and  suck  the 
air  out  with  the  bulb.  (4)  If  the  instrument  clogs  and  cannot,  by  persistent 
though  gentle  effort,  be  freed,  it  must  be  exposed  and  cleared  through  a  supra- 
pubic cystotomy.  (5)  Only  a  lithotrite  with  fenestrated  blade  should  be  used, 
thus  lessening  the  chances  of  clogging.  (6)  It  may  be  necessary  to  slightly 
incise  the  urinary  meatus  in  order  to  get  the  beak  of  the  instrument  to  enter  the 
urethra.     (7)  Instruments  of  special  size,  as  well  as  particular  care,  are  neces- 


no8  OPERATIONS  UPON  THE  ABDOMINO-PELVIC  REGION. 

sary  in  operating  upon  children.  (8)  Litholapaxy  in  women  is  much  more 
easily  performed  than  in  men,  because  of  the  shorter,  larger  urethra  (Fig.  810). 
(9)  A  simple  instrument  has  been  devised  for  combined  crushing  and  evacua- 
tion bv  Chismore. 


VESICAL  DRAINAGE. 

Description. — By  vesical  drainage  is  meant  the  drainage  of  the  bladder 
contents  through  a  natural  or  an  artificial  channel.  While  the  bladder  is  being 
drained  for  consecutive  days,  daily  irrigations  with  aseptic  or  mildly  antiseptic 
solutions  may  be  used.  Where  the  bladder  cavity  is  made  directly  continuous 
with  the  suprapubic  or  perineal  regions,  suprapubic  or  perineal  cystotomy  may 
be  said  to  be  done.  Bladder  drainage  may  be  urethral,  perineal,  or  supra- 
pubic. 

Urethral  Bladder  Drainage. — Consists  in  drainage  by  a  soft  catheter 
passed  through  the  urethra  into  the  bladder.  Indicated  for  only  brief  drainage 
— not  over  three  or  four  days,  the  usual  limit  of  bladder  toleration.  A  soft 
catheter  is  introduced  until  its  eye  has  just  entered  the  bladder,  which  is  as- 
certained by  withdrawing  the  catheter  and  retaining  it  in  the  position  in  which 
it  was  just  before  cessation  of  flow.  Various  devices  are  used  for  holding  the 
catheter  in  the  urethra.  A  1  cm.  (or  h  inch)  widtli  of  rubber-plaster  may  be 
passed  three-fourths  of  the  way  around  the  penis  (to  allow  of  expansion  of  the 
organ)  just  behind  the  corona,  and  to  this  the  tube  may  be  tied  by  silk  suture 
passed  with-a  needle  through  the  outer  wall  of  the  tube  and  upper  border  of  the 
plaster  band. 

Perineal  Bladder  Drainage. — Consists  in  drainage  of  the  bladder  through 
the  perineum  by  means  of  a  tube,  or  through  the  bare  wound  resulting  from 
perineal  cystotomy.  Indicated,  chiefly,  in  operations  upon  the  bladder  by  the 
perineal  route,  and  in  cases  of  impervious  urethra.  Where  the  drainage  is  the 
primary  consideration  (as  in  aggravated  cystitis  and  in  other  conditions  of 
prostate,  bladder  or  urethra)  tire  membranous  urethra  is  opened  by  median 
perineal  incision,  just  as  in  external  urethrotomy  (page  1123) — the  catheter  is 
carried  through  the  prostatic  urethra  into  the  bladder,  until  its  eye  rests  just 
within  the  bladder-cavity — and  is  then  fastened  to  a  T-bandage  by  a  silk  suture 
carried  on  a  needle  through  the  outer  wall  of  the  catheter.  A  long  rubber  tube 
is  then  connected  with  the  catheter  and  carried  to  a  bottle  at  the  foot  of,  or 
under,  the  bed,  and  drains  by  siphonage. 

Suprapubic  Bladder  Drainage. — Consists  in  drainage  of  the  bladder 
through  a  suprapubic  cystotomy  wound.  Indicated  in  some  operations  upon 
the  bladder,  aggravated  cystitis,  etc.  The  drainage  may  be  accomplished  by 
simple  siphonage  by  catheter — or  by  various  devices,  some  mechanical,  and 
others  by  methods  of  suturing,  (a)  By  Siphonage  Tube  ordinarily  Sutured 
into  the  Bladder: — Following  the  suprapubic  cystotomy,  a  pliable  rubber  tube, 
with  large  eye,  is  introduced  through  the  bladder-wound,  which  has  been  partly 
closed  from  both  ends — and  so  adjusted  that  its  lower  end  barely  reaches  the 
lowest  part  of  the  bladder-cavity  but  does  not  press  upon  it.  A  safety-pin 
passed  through  its  outer  wall,  at  the  skin  level,  rests  transversely  across  the  lips 
of  the  partially  sutured  wound  and  maintains  the  fixed  depth  of  the  tube.  A 
large  gauze-pad,  with  central  perforation,  is  then  placed  around  the  tube,  and 
a  second  safety-pin  passed  in  just  above  the  second  pad  to  steady  the  tube. 
The  free  end  is  connected  with  a  rubber  tube,  emptying  into  some  reservoir  for 
drainage.  Where  much  hemorrhage  is  expected,  or,  for  other  reason,  irriga- 
tion is  needed,  two  parallel  tubes  may  be  used — one  serving  the  above  purpose, 


PARTIAL  CYSTECTOMY 


1 109 


and  the  other  being  used  for  throwing  irrigating  fluid  into  the  bladder,  which 
then  siphons  out  by  the  first  tube,  (b)  By  Siphonage  through  a  Tube  in- 
troduced by  Gibson's  Method: — This  is  an  application  of  the  Kader  Gastros- 
tomy method  to  the  bladder  (see  page  964).  The  bladder -wall  is  exposed  as 
in  the  suprapubic  cystotomy — an  opening  is  made  in  the  middle  line  of  the 
bladder  sufficiently  large  to  admit  the  tube 
snugly — in  the  median  line,  in  front  and  be- 
hind the  tube,  a  Lembert  suture  of  chromic 
gut  is  placed  so  as  to  closely  embrace  the 
tube.  These  sutures  form  the  first  tier. 
Then,  a  second  tier  of  four  sutures,  two  in 
front  and  two  behind,  is  applied.  (If  neces- 
sary, a  third  tier  might  be  used.)  The 
tube  is  thus  buried  in — in  a  valve-like  man- 
ner— so  that  when  the  tube  is  removed,  the 
opening  is  closed  by  the  tendency  of  the 
folds — and  can  be  again  readily  re-intro- 
duced. A  long  tube  is  attached  to  this  for 
siphonage  and  conducted  to  a  reservoir,  as  in 
the  other  methods  (Fig.  811). 


PARTIAL  CYSTECTOMY. 

Description. — Removal  of  a  limited  por- 
tion of  the  bladder.  Generally  performed 
for  the  removal  of  a  tumor  involving  a  part 
of  the  bladder-wall.  The  site  of  the  tumor 
may  be  extraperitoneal  or  intraperitoneal — 
or  both. 

Operation. — The  general  features  of  the 
operation  may  be  gotten  from  the  description 
of  the  total  removal  of  the  bladder.  The 
steps  of  the  partial  removal  will  depend  upon  the  site  of  the  growth  demand- 
ing partial  cystectomy.  (1)  When  the  tumor  is  upon  the  upper  part  of  the 
bladder  and  the  peritoneum  can  be  pushed  back,  the  involved  portion  of  the 
bladder-wall  is  excised  with  scissors — and  the  lips  of  the  wound  then  brought 
together  and  sutured  (see  Cystorrhaphy).  (2)  When  the  tumor  is  similarly 
placed  but  its  removal  involves  the  opening  of  the  peritoneal  cavity — the 
peritoneal  wound  is  closed  by  suture  and  the  bladder-wound  dealt  with  as 
just  described.  (3)  If  the  tumor  be  above  the  ureters,  upon  the  posterior 
aspect  of  the  bladder,  it  may  be  exposed  through  a  suprapubic  cystotomy  and 
removed  from  within  the  bladder,  followed  by  the  approximation  and  suturing 
of  the  edges  of  the  wound  left  and  the  establishment  of  drainage.  (4)  When 
the  area  involved  lies  upon  the  anterior  bladder-wall,  behind  the  symphysis, 
partial  resection  of  the  symphysis,  or  symphysiotomy,  may  be  necessary. 
(5)  If  the  involvement  be  at  the  mouth  of  a  ureter,  the  site  should  be  ex- 
cised— the  healthy  ureter,  after  excision  of  its  vesical  end,  should  be  implanted 
into  a  neighboring  part  of  the  bladder — and  the  wound  made  by  the  original 
excision  closed.  (6)  Where  the  base  of  the  bladder  is  involved  and  the  open- 
ings of  the  ureters  are  healthy,  these  should  be  excised,  en  masse,  and  trans- 
planted into  the  rectum — and  the  bladder  removed.  Following  all  partial  ex- 
cisions, the  remainder  of  the  bladder-walls  should  be  brought  together  by 


Fig.  8 1 1. — Suprapubic  Bladder- 
drainage  (Gibson's  Method)  : — The 
first  tier  of  sutures  are  shown  tied. 
The  second  tier  are  placed  ready  to  be 
tied  and  further  bury  in  the  tube.  The 
remaining  structures  are  same  as  given 
in  Fig.  519. 


I  no  OPERATIONS  UPON  THE  ABDOMTNO-PELVIC  REGION. 

suture — temporary  drainage  established  down  to  the  sutured  bladder — and 
a  catheter  introduced  into  the  bladder  for  drainage,  and  to  prevent  overdisten- 
tion  and  tension  upon  the  sutures. 


TOTAL  CYSTECTOMY 

BY  SUPRAPUBIC  MEDIAN  VERTICAL  AND  TRANSVERSE  INCISIONS. 

Description. — Complete  excision  of  the  bladder,  followed  by  implantation 
of  the  ureters.  Indicated  in  malignant  disease  limited  to  the  bladder.  The 
operation  as  performed  by  Tuffier  and  Dujarier  will  be  here  described — con- 
sisting in  an  extraperitoneal  abdominal  excision  of  the  bladder,  followed  by  an 
implantation  of  the  ureters  in  the  sigmoid  colon. 

Preparation. — Bowels  emptied;  pubes  shaved;  bladder  distended  with 
aseptic  fluid  at  an  early  stage  of  the  operation. 

Position. — Patient  in  the  Trendelenburg  position,  near  the  edge  of  the 
table.     Surgeon  on  patient's  left.     Assistant  opposite. 

Landmarks. — Median  line;  symphysis  pubis;  inguinal  canals. 

Incision. — _L-shaped — the  vertical  incision  is  made  in  the  median  line, 
beginning  at  the  symphysis  pubis  and  passing  upward  for  10  to  12.5  cm.  (4  to  5 
inches).  The  transverse  incision  unites  the  inguinal  canals,  along  the  supra- 
pubic border,  to  the  vertical  incision. 

Operation. — (1)  Incise  vertically  carefully  in  the  median  line,  especially 
over  the  position  of  the  peritoneum.  Expose  the  bladder  and  the  reflection 
of  peritoneum — pushing  the  latter  upward  well  off  of  the  bladder.  Clamp  and 
tie  all  bleeding  vessels.  (2)  Make  the  horizontal  incision  from  one  inguinal 
canal  to  the  opposite,  just  above  the  border  of  the  pubic  bone  and  Poupart's 
ligament.  Clamp  or  tie  bleeding  vessels  in  this  line  of  incision.  Dissect  up 
the  rectangular  flaps  thus  outlined — and  retract  them  upward  and  outward  on 
both  sides — thus  giving  free  access  to  the  bladder.  (3)  Separate  the  anterior 
aspect  of  the  bladder  from  the  pubis,  down  to  its  neck,  by  blunt  dissection — ex- 
posing and  isolating  its  neck — moderate  traction  being  exercised  upon  the 
anterior  and  lateral  walls  by  vulsella.  (4)  The  neck  of  the  bladder  is  clamped 
and  divided  above  the  clamps.  (5)  The  peritoneum  is  carefully  peeled  off  of 
the  superior,  posterior,  and  lateral  aspects  of  the  bladder,  avoiding  making  any 
opening  into  the  peritoneal  cavity.  (6)  The  inferior  vesical  arteries  and 
ureters  are  secured  close  to  the  bladder,  in  curved  clamps,  and  divided  en  masse. 
(7)  The  base  of  the  bladder  is  separated  from  its  remaining  connections  and 
the  viscus  removed.  (8)  The  urethral  and  the  ureteral  openings  are  cau- 
terized. (9)  The  vesical  arteries  are  tied  and  the  clamps  relaxed.  (10)  The 
ureters  are  implanted  within  the  sigmoid  colon,  (n)  The  deep  wound  is 
packed  with  gauze — drainage  being  brought  out  just  over  the  symphysis  pubis 
— all  of  the  transverse  and  most  of  the  vertical  incisions  being  sutured. 

Comment. — (1)  Avoid  opening  the  peritoneum  if  possible — and,  if  opened, 
suture  at  once — or,  if  the  opening  be  too  large,  pack  with  gauze.  (2)  The 
authors,  Tufher  and  Dujarier,  made  the  uretero-sigmoidostomy  with  Chalot's 
buttons.     Fowler's  method  (page  870)  may  also  be  used. 


CHAPTER  VI. 

OPERATIONS  UPON  THE  MALE  GENITAL 
ORGANS. 

I.   THE  PENIS. 

SURGICAL  ANATOMY. 

Description. — Consists  of  glans,  body,  and  root.  Body  is  composed  of 
two  corpora  cavernosa  and  the  corpus  spongiosum. 

Corpora  Cavernosa. — Connected,  side  by  side,  in  the  median  line,  for 
their  anterior  three-fourths — an  imperfect  fibrous  septum  intervening.  Sep- 
arated, posteriorly,  to  form  the  crura,  or  roots.  The  crura  are  attached  by 
their  blunt,  fibrous,  posterior  ends  to  the  antero-internal  aspects  of  the  two 
rami  of  the  pubes  and  ischia,  above  the  tuberosities.  The  anterior  ends  of  the 
cavernosa  are  received  into  the  fossa  formed  by  the  base  of  the  glans  penis,  or 
head.  The  superior  median  groove  of  the  corpora  cavernosa  lodges  the  dorsal 
vein  of  the  penis.     The  inferior  median  groove  lodges  the  corpus  spongiosum. 

Corpus  Spongiosum. — Encloses  the  urethra,  which  passes  into  the  bulb 
nearer  its  superior  aspect.  It  is  received  into  the  inferior  median  groove  of  the 
corpora  cavernosa.  It  ends,  anteriorly,  in  the  glans  penis,  or  head  of  the 
organ.  It  ends,  posteriorly,  in  the  bulb  of  the  corpus  spongiosum — between 
the  diverging  crura  of  the  corpora  cavernosa,  and  between  the  deep  layer  of  the 
superficial  fascia  and  the  superficial  layer  of  the  deep  fascia — being  covered  by 
a  fibrous  process  from  the  anterior  layer  of  the  deep  perineal  fascia  and  sur- 
rounded by  the  accelerator  urinae  muscle. 

Suspensory  Ligament  of  the  Penis. — A  fibrous  band  passing  from  the 
front  of  the  symphysis  pubis  to  the  adjacent  portion  of  the  penis,  merging  with 
its  fascial  sheath. 

Muscles  of  Penis. — Erector  penis;  accelerator  urina?;  compressor  ure- 
thra?; transversus  perinrei. 

Arteries. — (a)  Of  the  corpora  cavernosa: — arteries  of  the  corpora  caver- 
nosa; dorsal  arteries  of  the  penis.  All  from  internal  pudic.  (b)  Of  the  corpus 
spongiosum: — artery  of  the  bulb,  from  internal  pudic. 

Veins. — Some  of  the  veins  empty  into  the  dorsal  vein,  which  ends  in  the 
prostatic  plexus.  Other  veins  empty  directly  into  the  prostatic  plexus,  pudic 
plexus,  pudic  veins,  and  obturator  veins.  Others  empty  into  the  cutaneous 
veins  of  the  penis  and  scrotum. 

Lymphatics. — The  superficial  empty  into  the  inguinal  glands.  The  deep 
empty  into  the  pelvic  glands. 

Nerves. — From  the  dorsal  and  superficial  perineal  branches  of  the  pudic 
and  from  the  hypogastric  plexus  of  the  sympathetic. 


INSTRUMENTS. 

Scalpels;  narrow,  straight  bistoury;  scissors;  retractors;  tenacula;  dissecting 
and  toothed  forceps;  artery-clamp  forceps;  blunt  dissector;  periosteal  elevator; 


ii  12  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

rubber  tourniquet  (rubber  catheter);  needles,  straight  and  curved;  needle- 
holder;  ligatures  and  sutures,  silk  and  gut. 


CIRCUMCISION. 

Description. — Removal  of  greater  portion  of  redundant  or  contracted  pre- 
puce. The  amount  of  foreskin  to  be  removed  should  be  so  calculated  that 
two  objects  be  accomplished: — first,  that  enough  foreskin  be  removed  to  insure 
easy  exposure  of  the  entire  glans  penis,  even  during  erection; — secondly,  that 
enough  foreskin  be  left  to  insure  constant  covering  of  the  prominent  corona 
glandis  during  relaxation  of  the  organ,  thereby  securing  retention  of  greater 

sensitiveness  of  the  papillae 
than  when  the  corona  is 
worn  constantly  bare,  and, 
therefore,  dry.  Many  me- 
chanical contrivances  have 
been  devised  for  aiding  in 
circumcision — but  the  oper- 
ation can  generally  be  more 
satisfactorily  done  with  scis- 
sors alone — and,  by  this 
means,  greater  accuracy  is 
usually  obtained  in  provid- 
ing the  exact  amount  of  pre- 
puce which  it  is  well  to  leave. 
Preparation.  —  A  con- 
strictor, usually  a  rubber 
band,  is  applied  around  the 
base  of  the  penis. 

Position.  —  Patient  su- 
pine, near  the  left  edge  of 
table.  Surgeon  on  patient's 
right. 

Landmarks.  —  Position 
of  sulcus  at  junction  of  head 
and  body  of  organ. 

Operation. — (i)  As 
there  will  be  a  much 
greater  tendency  for  the 
skin-aspect  of  the  prepuce 
to  retract  more  than  for  the 
mucous-membrane-aspect,  it 
is  well,  in  all  methods  of  cir- 
cumcision, as  a  preliminary 
step  to  the  actual  division 
of  preputial  tissue,  to  take  the  skin  and  mucous  surfaces  of  the  foreskin  be- 
tween the  left  index  and  thumb  (or  between  the  blades  of  a  pair  of  toothed 
forceps)  and  so  dispose  the  parts  that  the  mucous  membrane  is  drawn  slightly 
forward  and  the  skin  pushed  slightly  backward— so  that  there  will  be  somewhat 
less  disparity  when  the  section  is  made.  (2)  Taking  the  foreskin  in  the  left 
fingers,  the  surgeon  inserts  the  lower  blade  of  a  pair  of  straight  scissors  beneath 
the  upper  aspect  of  the  foreskin,  between  it  and  the  dorsum  of  the  glans— and 


Fig.  812.  — Circumcision  :— I.  Scissor-blade  between 
glans  and  prepuce,  cutting  foreskin  in  median  dorsal  line 
up  to  level  of  its  removal. 


CIRCUMCISION. 


1113 


cuts  through  the  prepuce  with  one  stroke,  up  to  the  height  upon  the  dorsum 
which  it  has  been  calculated  will  leave  sufficient  prepuce  to  cover  the  corona 
during  relaxation  of  the  organ  (Fig.  812).  (3)  The  scissors  are  then  with- 
drawn from  the  vertical  incision — and  the  position  of  the  hands  then  changes. 
The  left  fingers  grasp  the  left  flap,  the  one  nearer  the  surgeon,  and,  holding  it 
slightly  away  from  the  glans,  the  scissors  are  made  to  cut  through  one-half  of 
the  circumference  of  the  organ — the  guide  for  the  cut  being  that  it  should  pass 
about  parallel  with  the  corona  glandis,  crossing  the  median  line  upon  the  under 
aspect  of  the  prepuce  just  in  front  of  (distal  to)  the  fraenum  (Fig.  813).  (4) 
The  right  flap  is  now  dealt 
with  in  the  same  manner — 
completing  the  encircling 
of  the  organ.  The  incision 
will,  therefore,  slope  ob- 
liquely from  above  down- 
ward and  from  behind  for- 
ward. (5)  Four  primary 
chromic  gut  sutures  are 
then  applied  in  the  mid- 
points— above,  below  and 
laterally — closely  approxi- 
mating the  margin  of  mu- 
cous membrane  to  the 
margin  of  skin.  These  are 
followed  by  four  or  eight 
secondary  sutures  evenly 
distributed  between  the 
primary  ones  (Fig.  814). 
(6)  The  dressing  is  so  ap- 
plied as  to  leave  an  opening 
for  urination. 

Comment.  — (1)  The 
usual  error  is  to  remove 
too  much  foreskin.  A  pre- 
puce, appearing  to  be  suffi- 
cient after  the  completing 
of  the  operation,  often  gets 
entirely  and  permanently 
behind  the  corona  in  sub- 
sequent retraction — at  the 
expense  of  considerable 
loss  of  sensitiveness  of  the 
papillae.  (2)  If  any  ques- 
tion arise,  during  opera- 
tion, as  to  the  width  of  the 

opening  being  too  narrow,  the  vertical  incision  may  be  extended  upward  ad- 
ditionally high — the  lateral  incisions  then  being  sloped  downward  so  as  to 
come  just  in  front  of  the  fraenum.  (3)  The  redundancy  of  the  mucous  mem- 
brane is  apt  to  be  much  greater  than  that  of  the  skin.  (4)  In  using  all  forms 
of  circumcision-clamps  too  much  or  too  little  prepuce  is  apt  to  be  cut  away. 
(5)  If  the  penis  is  to  have  a  preliminary  constrictor  applied,  which  would 
tend  to  draw  back  the  foreskin  into  a  somewhat  unnatural  position,  greater 
accuracy  in  measurements  may  be  obtained  by  first  (before  applying  toumi- 


si.3- 


-Circumcision  :— II.  Division  of  the  entire  thick- 
ness of  the  prepuce  transversely,  at  the  upper  limit  of  the 
median  incision.  While  the  entire  redundant  portion  of  pre- 
puce is  being  drawn  downward,  the  left  thumb  and  index  so 
manipulate  the  parts  that  more  of  the  mucous  membrane  than 
of  the  skin  is  removed. 


iii4 


OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 


quet)  marking  the  site  at  which  the  removal  is  desired  with  a  nitrate  of  silver 
stain.     (6)  Sometimes  one  or  more  vessels  have  to  be  twisted  or  gut-ligatured. 

(7)  Do  not  leave  too  great  an  amount 
of  tissue  near  the  fra^num.  (8)  It  may 
be  necessary,  before  suturing,  to  trim  the 
edges  somewhat  with  scissors,  especially 
of  the  mucous  membrane.  (9)  Where 
there  is  firm  adhesion  between  prepuce 
and  glans,  especially  in  children,  the  pre- 
puce must  be  carefully  peeled  off — by 
means  of  the  fingers,  aided  by  toothed 
forceps  and  the  flat  portion  of  a  probe. 
(io)  Often,  in  adherent  prepuces,  no  in- 
strument can  be  slipped  up  between  the 
prepuce  and  glans — and  the  opening  of 
the  prepuce  is  too  small  to  allow  of  re- 
tracting the  membrane  far  backward — in 
which  cases  the  redundant  portion  must 
be  put  upon  tension  and  cut  off  trans- 
versely, after  which  the  separation  of  ad- 
hesions may  be  more  easily  accomplished. 
(ii)  In  operating  in  adherent  cases,  re- 
adhesion  is  prevented  by  removing  an 
excess  of  mucous  membrane  and  leaving 
a  slight  redundancy  of  skin.  In  com- 
pleting the  operation,  the  skin  is  sutured 
to  the  very  short  mucous  membrane — 
and,  being  quite  long,  is  doubled  upon 
itself,  and  the  part  in  contact  with  the 
glans  eventually  becomes  of  the  nature,  somewhat,  of  mucous  membrane. 


Fig.  814.— Circumcision  : — III.  Plac- 
ing of  interrupted  sutures — which  approxi- 
mate the  free  edge  of  the  skin  (A)  to  the 
free  edge  of  the  mucous  membrane  (B). 


PARTIAL  AMPUTATION  OF  PENIS 

BY  FLAP  METHOD. 

Description. — Consists  in  the  amputation  of  more  or  less  of  the  free  por- 
tion of  the  penis  by  a  long  anterior  and  short  posterior  flap — the  freed  urethra 
being  brought  through  and  sutured  into  the  anterior  flap.  The  stump  is  thus 
covered  by  two  bluntly  rectangular  flaps. 

Preparation. — A  rubber  tourniquet  (usually  a  rubber  catheter)  is  placed 
around  the  base  of  the  organ.  A  short  piece  of  soft  catheter  is  passed  into  the 
urethra,  down  to  the  tourniquet,  to  emphasize  the  furrow  between  the  corpora 
cavernosa  and  corpus  spongiosum — or  may  be  passed  just  before  the  trans- 
fixion. 

Position. — Patient  supine,  at  edge  of  table.  Surgeon  on  patient's  right. 
Assistant  opposite. 

Landmarks. — Line  of  section.     Furrow  between  cavernosa  and  spongio- 


Incision. — The  anterior  flap  will  have  a  width  of  one-half  the  circum- 
ference of  the  penis  at  the  line  of  division,  and  a  length  of  about  one  diameter 
of  the  penis.  The  posterior  flap  will  have  the  same  width  of  base,  and  a  length 
of  about  a  half  diameter  of  the  penis. 

Operation. — (1)  Having  decided  upon  the  line  of  section  of  the  penis,  an 


PARTIAL  AMPUTATION  OF  PENIS. 


i"5 


anterior  or  dorsal  flap,  of  skin  and  connective  tissue,  is  cut,  having  a  width  of 
half  the  circumference  of  the  organ  at  the  line  of  division,  and  a  length  about 
equal  to  the  diameter  of  the  organ  (Fig.  815).     This  is  raised  up  by  dissection 


Fig.  815.— Partial  Amputation   of  Penis    by   Flap   Method:— I.  Outlining  of  flaps;  A,  Long 
anterior  flap  ;  B,  Short  posterior  flap. 


Fig  816  -Partial  Amputation  of  Penis  by  Flap  Method  :— II.  Transverse  section  of  stump  ; 
A  Lone  anterior  flap  turned  back,  showing  slit  for  urethra  ;  B.  Short  posterior  flap;  C,  Dorsal  vein 
arid  arteries  ;  D.  Corpora  cavernosa  and  vessels;  E,  Corpus  spongiosum  ;  F,  Urethra  dissected  out, 
and  ready  to  be  sutured  into  slit  of  anterior  flap. 


and  turned  back— the  dorsal  arteries  being  tied  with  gut.  (2)  On  a  level  with 
the  base  of  the  anterior  flap,  the  divisional  groove  between  the  corpora  caver- 
nosa and  corpus  spongiosum  is  recognized,  aided  by  the  soft  catheter  in  the 


OPERATIONS  UPON  THE  WALE  GENITAL  ORGANS. 


urethra.  A  narrow-bladed  knife,  held  flatwise,  with  back  of  blade  backward, 
is  thrust  horizontally  through  the  organ,  between  the  cavernosa  and  spongio- 
sum— and  cuts  its  way  through,  passing  at  first  directly  forward  in  the  groove 
and  then  rounding  abruptly  downward — thus  forming  an  inferior  flap  of  about 
one-half  the  diameter  of  the  penis  in  length,  composed  of  corpus  spongiosum, 
with  its  included  urethra  and  skin.  (3)  The  urethra  is  now  dissected  out  from 
the  small  inferior  flap,  back  to  a  line  with  the  base  of  the  flaps.  (4)  The  cor- 
pora cavernosa  are  divided  transversely  from  within  outward  and  upward,  on  a 

line  with  the  highest  point 
of  transfixion  (base  of 
flaps)  (Fig.  816).  The 
arteries  of  the  corpora 
cavernosa  are  tied  with 
gut,  or  twisted.  (5)  Make 
a  vertical  incision  in  the 
center  of  the  long  anterior 
flap,  opposite  the  urethra 
and  just  large  enough  to 
receive  the  urethra.  The 
urethra  is  then  drawn 
through  this  opening.  If 
the  urethra  be  much  too 
long,  the  redundancy  is 
cut  off,  leaving  a  protru- 
sion of  about  7  mm.  (\ 
inch) — which  is  slightly 
slit  above  and  below— and 
sutured  into  the  margins 
of  the  opening  in  the  ante- 
rior flap.  (6)  The  two 
flaps  are  then  united  by 
suture,  both  where  their  free  ends  meet — and  where  in  apposition  laterally 
(Fig.  817).  (7)  A  dressing  is  applied,  leaving  room  for  urination — at  the 
same  time  exercising  pressure  of  the  flap  against  the  stump  of  the  penis. 

Comment. — The  arteries  of  the  corpus  spongiosum  and  of  the  septa  may 
need  ligating. 


Fig.  817. — Partial  Amputation  of  Penis  by  Flap 
Method: — III.  The  parts  sutured;  A,  Suture-line  of  flaps; 
B,  Urethra  sutured  into  slit  in  long  anterior  flap. 


TOTAL  AMPUTATION  OF  THE  PENIS. 

Description. — In  the  total  amputation  the  entire  organ  is  removed,  ex- 
cept the  posterior  portion  of  the  corpus  spongiosum — the  proximal  portion  of 
the  urethra  being  made  to  open  in  the  perineum. 

Preparation. — Shave  pubis  and  perineal  region. 

Position. — Patient  supine,  at  end  of  table,  in  lithotomy  position.  Surgeon 
between  limbs.     Assistant  to  surgeon's  right. 

Landmarks. — Subpubic  arch;  scrotal  and  perineal  raphe. 

Incision. — The  incision  circularly  surrounds  the  base  of  the  organ,  at  its 
junction  with  the  abdominal  wall — and  is  then  continued  down  the  median  line 
of  the  scrotum  and  into  and  along  the  median  line  of  the  perineum. 

Operation.— (1)  Incise  the  scrotal  tissues  exactly  in  the  median  line,  from 
che  under  surface  of  the  penis,  at  its  junction  with  the  scrotum,  to  and  into  the 
perineum.  Separate  the  two  scrotal  sacs  by  blunt  dissection,  until  the  corpus 
spongiosum  is  reached.     All  bleeding  vessels  are  clamped  and  ligated  as  en- 


TOTAL  AMPUTATION  OF  THE  PENIS.  1117 

countered.  If  a  metallic  sound  be  previously  introduced  through  the  urethra, 
the  incision  and  subsequent  dissection  are  made  easier  (Fig.  818).  (2)  If  a 
sound  have  not  been  previously  introduced,  a  large-sized  metallic  sound  is  now- 
passed  through  the  urethra  up  to  the  triangular  ligament,  to  aid  in  defining  the 
corpus  spongiosum.  The  corpus  spongiosum  is  then  dissected  out  until  free 
in  its  entire  circumference.  The  sound  is  then  withdrawn — and  the  spongy 
urethra  is  divided  well  in  front  of  the  triangular  ligament — and  the  proximal 
end  of  the  spongy  urethra  is  then  freed  back  to  the  triangular  ligament.  (3) 
Carry  the  upper  end  of  the  vertical  incision  circularly  around  the  base  of  the 


Fig. 818.— Total  Amputation  ok  Penis  :— A,  A,  The  two  halves  of  scrotum  split  and  retracted 
outward  ;  B,  Penis  drawn  downward  and  to  one  side,  thus  aiding  separation  of  its  crura  ;  C,  Corpora 
cavernosa  (crura);  D,  Ramus  of  ischium;  E,  Periosteal  elevator  detaching  left  crus  of  penis  from 
ascending  ramus  of  ischium  by  blunt  dissection  ;  F,  Dorsal  vessels  of  penis  divided  and  ligated.  The 
suspensory  ligament  of  penis  and  concavity  of  pubic  arch  are  seen  just  below;  G,  Distal  end  of 
corpus  spongiosum  and  urethra  ;  H,  Proximal  end  of  urethra  dissected  out  and  ready  to  be  sutured 
into  perineum. 


penis.  Divide  the  suspensory  ligament — and  expose  the  corpora  cavernosa. 
(4)  The  corpora  cavernosa  are  to  be  followed  down  to  their  attachment  to  the 
rami  of  the  pubes  and  ischia — and  freed  from  their  attachment  chiefly  bv  blunt, 
but  partly  by  sharp,  dissection.  The  dorsal  arteries  are  tied  after  cutting 
through  the  suspensory  ligament,  and  the  arteries  of  the  corpora  cavernosa 
generally  require  ligation  when  the  cavernosa  are  freed  from  the  bone.  Bleed- 
ing from  the  vesico-prostatic  plexus  of  veins  is  often  considerable,  and  is  to  be 
controlled  by  pressure  and  hot  water.  (5)  The  proximal  end  of  the  urethra  is 
now  turned  downward  and  sutured  into  the  perineum — the  mucous  membrane 
of  the  former  being  sutured  to  the  skin  of  the  lips  of  the  perineal  wound.  If 
necessary,  the  urethra  may  be  split  so  as  to  enable  its  lips  to  be  more  readily 
sutured  into  the  perineal  wound.     (6)   The  remaining  perineal  and  all  the 


iii8  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

scrotal  portions  of  the  wound  and  the  circular  area  formerly  occupied  by  the 
base  of  the  penis,  at  the  peno-abdominal  junction,  are  all  sutured  in  one  straight 
antero-posterior  line  with  continuous  silk  suture.     (Figs.  819  and  820.) 


Fig.819.— Total  Amputation  of  Penis  : — Scrotum  drawn  up  on  to  abdomen  ;  A,  suture-line 
uniting  scrotal  sacs  ;  B,  proximal  end  of  urethra  sutured  into  perineum. 

Fig. 820. — Same;  Scrotum  in  normal  position  (patient  on  back);  C,  suture-line  uniting  scrotal 
sacs  ;  D,  interrupted  sutures  about  to  be  tied,  converting  circular  incision  around  base  of  penis  into  a 
linear  cicatrix  continuous  with  scrotal  suture-line. 

Comment. — (1)  The  urethra  should  be  so  sutured  into  the  perineum  that 
in  the  act  of  urination,  in  a  sitting  posture,  the  urine  will  not  wet  the  scrotum. 
(2)  The  early  passage  of  the  metallic  sound  greatly  aids  in  the  splitting  of  the 
scrotum. 


II.  THE  URETHRA. 
SURGICAL  ANATOMY. 
(A)    Male  Urethra. 

Description. — Extends  from  bladder-opening  to  external  urinary  meatus 
— from  20.5  to  23  cm.  in  length  (8  to  9  inches).  It  consists  of  muscular,  erec- 
tile, and  mucous  tissue.  It  is  divided  into  prostatic,  membranous,  and  spongy 
portions. 

Prostatic  Portion. — About  3.2  cm.  (ij  inches)  long.  Passes  through  the 
prostatic  gland,  near  its  upper  aspect,  from  base  to  apex.  The  following  ob- 
jects are  upon  the  floor  of  the  prostatic  urethra,  from  behind  forward; — (a) 
verumontanum,  an  elevation  of  mucous  membrane  in  the  middle  line; — (b) 
prostatic  sinuses,  one  upon  each  side  of  the  verumontanum,  with  the  orifices 


THE  URETHRA— GENERAL  SURGICAL  CONSIDERATIONS.        1119 

of  the  prostatic  ducts  opening  into  them;— (c)  sinus  pocularis,  a  cul-de-sac 
lying  in  front  of  verumontanum  and  passing  backward  for  about  1.3  cm. 
(J  inch)  into  the  substance  of  the  prostate  gland,  beneath  the  central  lobe;— (d) 
openings  of  the  two  ejaculatory  ducts  into  the  orifice  of  the  sinus  pocularis. 

Membranous  Portion.— Portion  of  urethra  between  the  two  layers  of 
the  triangular  ligament — about  2  cm.  (f  inch)  long  upon  its  anterior,  and  1.3 
cm.  (|  inch)  long  upon  its  posterior  aspect.  Extends  between  apex  of  pros- 
tate gland  and  posterior  aspect  of  bulb  of  corpus  spongiosum.  Its  anterior 
surface  is  about  2.5  cm.  (1  inch)  below  the  pubic  arch — the  dorsal  vessels 
and  nerves  and  some  muscular  fibers  intervening.  It  pierces  both  layers 
of  the  triangular  ligament,  receiving  an  investment  from  each.  It  is  sur- 
rounded by  the  compressor  urethral  muscle. 

Spongy  Portion.— About  15.5  cm.  (6  inches)  in  length.  Extends  entire 
length  of  corpus  spongiosum,  from  bulb  to  external  meatus.  The  portion 
within  the  bulb  is  sometimes  called  the  "bulbous  urethra."  The  ducts  of 
Cowper's  glands  open  upon  the  floor  of  the  bulbous  portion.  The  glands 
of  Littre  open  upon  the  mucous  membrane  of  the  penis,  especially  upon 
the  floor  of  the  spongy  portion.  One  of  these,  the  lacuna  magna,  opens  upon 
the  roof  of  the  fossa'  navicularis,  about  2.5  cm.  (1  inch)  from  the  external 
urinary  meatus.     The  fossa  navicularis  is  situated  within  the  glans  penis. 

Narrowest  Portions  of  Urethra.— At  external  meatus;  in  the  mem- 
branous portion;  at  the  neck  of  the  bladder. 

Vessels  and  Nerves. — See  under  "  Penis." 


(B)    Female  Urethra. 

Description.— About  3.2  to  3.8  cm.  (i|  to  i|  inches)  in  length— from 
neck  of  bladder  to  external  urinary  meatus.  Its  diameter  is  about  6  mm. 
(\  inch),  undilated.  It  pierces  the  triangular  ligament  and  is  directed  upward 
and  backward,  with  concavity  slightly  forward.  It  is  surrounded  anteriorly 
and  laterally  by  a  plexus  of  veins  (plexus  of  Santorini).  It  lies  under  the 
symphysis  pubis — its  posterior  wall  being  closely  connected  with  the  anterior 
wall  of  the  vagina.  The  bladder-opening  lies  about  2  cm.  (f  inch)  behind  the 
center  of  the  symphysis  pubis.  The  external  urinary  meatus  is  a  vertical 
slit  lying  about  2.5  cm.  (1  inch)  posterior  to  the  clitoris,  just  anterior  to  the 
entrance  of  the  vagina,  and  inferior  to  the  lower  edge  of  the  symphysis  pubis. 
The  female  urethra  is  composed  of  muscular,  erectile,  and  mucous  tissue — 
and  is  embraced  by  the  compressor  urethrae  muscle,  between  the  layers  of  the 
triangular  ligament. 

Vessels  and  Nerves. — From  the  same  source  as  those  of  the  vagina  (q.  v.). 


SURFACE  FORM  AND  LANDMARKS. 

The  base  of  the  triangular  ligament  can  be  felt  through  a  thin  perineum. 

The  membranous  urethra  pierces  the  triangular  ligament  about  2  cm. 
(|  inch)  below  the  subpubic  ligament — and  about  2  cm.  (f  inch)  in  front  of 
the  central  tendinous  point  of  the  perineum. 

GENERAL  SURGICAL  CONSIDERATIONS. 

Stricture  never  occurs  in  the  prostatic  urethra — and  is  very  rare  in  the 
membranous — hence  one  may  generally  count  upon  finding  a  patulous  urethra 


H20  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

after  cutting  down  upon  that  portion  emerging  from  the  apex  of  the  prostate 
gland. 

For  other  general  considerations,  see  Urethrotomy. 


INSTRUMENTS. 

Scalpels;  bistouries;  scissors;  forceps,  dissecting,  toothed,  and  artery- 
clamp;  tenacula;  grooved  director;  sounds;  catheters;  filiforms;  tunneled 
sounds;  grooved  and  tunneled  guides;  probe-pointed  scalpels;  sponge-holders; 
retractors;  thread-retractors;  bulbous  bougies;  dilating  bougies;  prostatic 
catheters;  medially  and  laterally  grooved  staffs;  urethrotomes;  Clover's 
crutch,  wristlets  and  anklets;  gorget;  urethral  dilator;  dilating  urethrotome; 
penis  syringe;  female  catheters;  needles,  straight  and  curved;  needle-holders; 
ligatures  and  sutures,  of  silk  and  gut;  silkworm-gut;  drainage-tubing;  gauze. 


INTRODUCTION  OF  SOUNDS  AND  CATHETERS. 

See  Introduction  of  Sounds  and  Catheters  into  the  Bladder,  page  1094. 

MEATOTOMY. 

Description. — Incision  of  external  urinary  meatus.  Indicated  in  con- 
tracted meatus,  especially  in  cases  where  it  is  necessary  to  pass  a  full-sized 
instrument. 

Preparation — Position. — As  for  Internal  Urethrotomy. 

Operation. — The  penis  is  taken  in  the  fingers  of  the  operator's  left  hand 
— the  lips  of  the  meatus  are  parted  by  the  index  and  thumb — a  probe-pointed 
bistoury  is  passed  just  within  the  canal,  its  cutting-edge  downward — and  an 
incision  made,  as  far  as  necessary,  downward  along  the  median  line  of  the 
floor  of  the  meatus,  increasing  the  size  of  the  meatus  to  the  desired  dimen- 
sion. The  lips  of  the  wound,  until  healed,  must  be  kept  apart  with  a  strip 
of  gauze. 

Comment.— The  operation  may  be  done  by  a  meatome,  a  special  instru- 
ment, which  is  inserted  closed  and  the  meatus  is  cut  in  the  act  of  opening  the 
instrument. 

URETHROTOMY  IN  GENERAL. 

Urethrotomy  consists  in  the  incision  of  the  urethra,  generally  in  its  long 
axis. 

Varieties  of  Urethrotomy. — Internal  Urethrotomy  and  External  Urethrot- 
omy. 

Internal  Urethrotomy: — division  of  a  strictured  urethra  from  within  the 
canal,  by  means  of  a  special  instrument,  a  urethrotome,  introduced  into  the 
canal.  Where  simultaneous  dilatation  is  indicated,  a  dilating  urethrotome 
is  used.  Internal  urethrotomy  is  usually  confined  to  the  penile  portion  of 
the  organ,  and  the  incision  is  generally  made  into  the  roof  of  the  urethra. 

External  Urethrotomy: — division  of  a  strictured  urethra  from  without 
inward.  External  Urethrotomy  is  indicated — (a)  In  impermeable  strictures 
anywhere  and  everywhere  in  the  canal — (b)  All  strictures,  whether  permeable 
or  not,  at  or  posterior  to  the  subpubic  urethra. 

Several  grades  of  permeability  of  the  urethra  may  exist — calling  for  ex- 


INTERNAL  URETHROTOMY.  II2I 

ternal  urethrotomies  of  several  grades  of  severity.  These  grades  of  stricture, 
and  the  measures  for  their  relief,  are,  in  order :— (I)  Grooved  staff  can  be 
passed  entirely  through  the  strictured  urethra, — and,  upon  this,  the  stricture 
is  divided — constituting  External  Urethrotomy  by  Syme's  Method.  (2) 
Grooved  staff  cannot  be  passed,  but  a  filiform  guide  can  be  introduced  through 
the  stricture  into  the  bladder,  and,  over  this  guide,  Gouley's  grooved  tunneled 
sound  can  be  carried  down  to  the  stricture  (but  not  through  it), — and,  upon 
this,  the  upper  end  of  the  stricture  is  exposed,  and  the  filiform  followed  into 
the  bladder  and  the  stricture  thus  divided — constituting  External  Urethrotomy 
by  Gouley's  Method.  (3)  Grooved  staff  cannot  be  passed  through  stricture, 
nor  can  filiform  be  passed  through,  but  a  grooved  staff  can  be  passed  down 
to  the  stricture  (not  through  it), — and,  upon  this,  the  urethra  is  opened  just 
in  front  of  the  stricture,  a  fine  grooved  director  passed,  and  the  stricture 
divided  upon  this — constituting  External  Urethrotomy  by  Wheelhouse's 
Method.  (4)  Neither  grooved  staff  nor  filiform  can  be  passed  through  the 
stricture,  the  urethra  being,  practically,  impassable  to  instruments  of  all  kinds 
— therefore  no  attempt  is  made  to  use  any  form  of  guide — the  urethra  is 
opened,  by  the  sense  of  touch  and  relations,  posterior  to  the  stricture  and 
immediately  anterior  to  the  prostate — constituting  External  Perineal  Ure- 
throtomy without  a  guide  (Perineal  Section,  or  Cock's  Operation). 

The  bladder  is  kept  partly  full  in  all  urethrotomy  operations,  in  order 
that  entrance  to  it  may  be  recognized  by  the  escape  of  fluid. 

For  the  anatomy  involved  in  the  perineal  operations,  see  the  description 
of  Median  Perineal  Cystotomy. 


INTERNAL  URETHROTOMY 

BY  DILATING  URETHROTOME. 

Description. — Division  of  a  strictured  urethra  from  within  the  urethra, 
by  means  of  a  special  instrument,  a  dilating  urethrotome,  introduced  into 
the  canal.  If  simultaneous  dilatation  be  not  indicated,  a  plain  urethrotome 
may  be  used.  Internal  urethrotomy  is  generally  confined  to  the  penile  por- 
tion of  the  organ,  and  the  incision  is  usually  made  from  behind  forward,  upon 
the  roof  of  the  urethra. 

Preparation. — Locate  the  exact  position  of  the  stricture  by  a  bulbous 
bougie,  in  the  following  manner, — introduce  the  largest-sized  bulbous  bougie 
which  will  pass  the  stricture — draw  it  back  until  its  shoulder  is  felt  against 
the  posterior  end  of  the  stricture — bend  the  free  portion  of  the  bougie  at  the 
external  meatus — draw  the  instrument  outward  until  the  bulb  slips  through 
the  stricture — then  push  it  back  until  the  tip  of  the  bulb  rests  against  the 
anterior  end  of  the  stricture — then  again  bend  the  free  portion  of  the  bougie 
at  the  external  meatus — and  withdraw  the  instrument  entirely — when  the 
portion  of  the  handle  between  the  two  bends  will  represent  the  extent  and 
distance  of  the  stricture  from  the  meatus.  A  more  accurate  means  of  getting 
the  desired  position  and  extent  of  the  stricture  is  accomplished  by  the  ure- 
thrometer.  The  urethra  should  be  irrigated  with  a  mildly  antiseptic  solution 
before  instrumentalization — and  a  cocain,  or  other  anesthetic  solution,  thrown 
into  the  canal. 

Position. — Patient  supine  at  edge  of  table.  Surgeon  upon  left,  facing 
patient's  penis. 

Landmarks. — Previous  data  gotten  from  urethrometer,  or  bulbous  bougie. 
Known  anatomy  of  urethra. 


H22  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

Operation. — The  dilating  urethrotome,  with  closed  blades  and  concealed 
cutting-edge,  and  well  lubricated  with  aseptic  lubricant,  is  introduced  into 
the  urethra  after  the  fashion  of  a  sound,  until  the  concealed  cutting-edge  has 
passed  directly  opposite  the  posterior  aspect  of  the  stricture,  as  determined 
by  the  previous  measurements  of  the  urethrometer  corresponding  with  the 
measurement  and  distances  marked  on  the  urethrotome.  The  dilating  blades 
ire  then  put  upon  the  stretch  until  the  strictured  urethra  is  tensely  distended 
— then  the  cutting-edge,  turned  toward  the  roof  of  the  urethra,  is  sprung 
by  the  controlling  screw  in  the  handle — and  drawn  through  the  stricture,  to 
its  anterior  limit,  from  behind  forward.  (Fig.  821.)  It  is  then  caused  to 
sink  below   the  blades — and   the  dilating  blades  again  separated.     If  the 


Fig. 821. — Internal  Urethrotomy: — A  dilating  urethrotome  is  shown  within  the  urethra — the 
limbs  of  the  instrument  being  moderately  dilated — and  the  knife-blade  sprung  so  as  to  incise  roof  of 
spongy  urethra  anterior  to  the  triangular  ligament. 


cutting  has  allowed  of  sufficient  dilatation,  it  is  not  repeated — if  not,  while 
the  urethra  is  under  dilatation,  the  blade  is  sprung  a  second  time,  and  again 
caused  to  sink — after  which  the  dilating  blades  are  again  separated,  to  see 
if  sufficient  dilatation  has  been  secured,  as  indicated  by  the  dial  upon  the 
handle.  If  so,  the  blades  are  permanently  closed  and  the  instrument  is 
withdrawn.  If  there  should  be  marked  bleeding,  a  large  sound,  dipped  in 
sterile  cold  water,  is  passed  into  the  urethra  and  the  penis  bound  to  it. 

Comment. — The  incision  may  be  made  from  before  backward — but 
from  behind  forward  is  better.  It  may  also  be  made  upon  more  than  one  site 
of  the  same  stricture,  but  upon  the  roof  generally  suffices,  and  is  safer  than 


EXTERNAL  PERINEAL  URETHROTOMY 


1123 


upon  the  floor.  Several  strictures  may  be  divided  simultaneously.  If  the 
external  meatus  be  too  small  to  admit  the  urethrotome,  meatotomy  should 
be  done.  The  subsequent  passage  of  sounds  is  necessary,  until  healing  is 
complete — and,  at  intervals,  for  a  considerable  time  afterward. 


EXTERNAL  PERINEAL  URETHROTOMY 

UPON  GROOVED  STAFF  —  SVME'S  METHOD. 

Description  — A  grooved  staff  can  be  passed  entirely  through  the  stric- 
ture— and,  upon  this,  the  stricture  is  divided  from  the  perineum. 

Special  Instruments  Required. — Syme's  grooved  staff,  or  an  ordinary 
lithotomv  staff  of  small  size,  grooved  medially  upon  its  convex  aspect.  Gorget, 
or  grooved  director,  for  entering  tHe  bladder  from  the  perineal  wound. 

Preparation — Position. — As  for  median  perineal  cystotomy. 


Fig.  822. — External  Perineal  Urethrotomy: — The  perineum  is  shown  incised  and  retracted. 
A  Syme's  shouldered,  grooved  staff  is  seen  engaged  within  the  membranous  urethra — while  the  edge 
of  a  knife  is  shown  incising  the  constricted  urethra  upon  the  groove  of  the  instrument. 


Landmarks. — Median  perineal  line;  position  of  grooved  staff  in  urethra, 
and  especially  the  position  of  the  stricture  to  be  divided,  as  ascertained  by 
previous  use  of  the  urethrometer,  and  also  verified  by  the  shouldered  portion 
of  the  staff  corresponding  with  the  urethrometer  measurements  and  resting 
against  the  anterior  end  of  the  stricture. 

Incision. — Having  introduced  Syme's  grooved  staff,  or  a  small,  centrally 
grooved  lithotomv  staff,  well  lubricated,  into  the  urethra  and  through  the 
stricture — so  that  its  shouldered  projection  rests  against  the  anterior  aspect 


1 1 24  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

of  the  stricture,  an  incision  is  made  in  the  median  line  of  the  perineum,  so 
placed  that  the  shoulder  of  the  staff  (that  is,  the  anterior  end  of  the  stricture) 
will  be  exposed  in  the  depth  of  the  incision. 

Operation. — (I)  The  steps  of  the  operation  are,  practically,  those  of 
median  perineal  cystotomy,  as  to  structures  incised  and  the  manner  of  dividing 
them.  The  cut  is  made  directly  toward  the  shoulder  of  the  instrument — 
the  groove  is  entered — and,  with  the  back  of  the  point  of  the  knife  in  the  groove, 
its  cutting-edge  is  pushed  in  the  direction  of  the  neck  of  the  bladder,  until 
the  entire  stricture  is  felt  to  be  divided  along  its  floor.  (Fig.  822.)  (2)  A 
gorget,  or  grooved  director,  is  now  passed  along  the  grooved  staff  on  into  the 
bladder — and  the  staff  is  then  withdrawn.  (3)  A  soft-rubber  catheter  is 
passed  through  the  urethra  from  the  meatus — its  end  being  guided  through 
the  perineal  wound  by  the  operator's  fingers  and  on  into  the  bladder,  upon 
the  grooved  director,  on  the  proximal  side  of  the  perineal  gap.  (4)  The 
perineal  wound  is  allowed  to  heal  by  granulation  around  this  catheter — 
being  left  open  in  whole — or  sutured  only  at  the  ends. 

Comment. — (1)  If  the  catheter  cannot  be  constantly  retained,  a  tube  may 
be  carried  into  the  bladder  through  the  perineal  wound.  But  an  instrument 
should  be  daily  passed  from  the  meatus  into  the  bladder  during  healing,  even 
though  a  full-length  instrument  cannot  be  constantly  worn.  (2)  An  ex- 
tensive perineal  wound  should  be  closed  in  part,  from  the  ends — leaving  the 
center  open  for  the  tube  and  drainage. 


EXTERNAL  PERINEAL  URETHROTOMY 

UPON  A  FILIFORM  GUIDE  —  GOULEY'S  OPERATION. 

Description. — In  cases  in  which  the  grooved  staff  cannot  be  passed,  and 
only  a  filiform  whalebone  guide  can  be  made  to  enter  the  bladder — a  grooved 
tunneled  guide  is  carried  over  the  filiform  down  to  the  stricture  (but  not 
through  it) — and,  upon  this  tunneled  guide,  the  upper  end  of  the  stricture 
is  exposed — and  the  filiform  is  then  followed  on  down  into  the  bladder  and 
the  stricture  divided. 

Special  Instruments — Filiform  whalebone  guides;  Gouley's  (or  other) 
grooved  tunneled  staff. 

Preparation — Position. — As  for  median  perineal  cystotomy. 

Landmarks. — Median  raphe;   scroto-perineal  junction ;  anus. 

Incision. — In  median  line,  from  base  of  scrotum  to  a  point  about  1.3  cm. 
(^  inch)  anterior  to  the  anus. 

Operation. — (1)  Having  succeeded  in  getting  a  filiform  whalebone 
guide  into  the  bladder,  Gouley's  tunneled  grooved  staff  is  threaded  upon  this 
and  carried  down  into  the  urethra  upon  it,  with  the  right  hand,  while  the  left 
hand  holds  the  filiform — until  it  is  arrested  at,  or  within,  the  strictured  urethra. 
An  assistant  now  takes  the  filiform  and  metallic  staff  in  his  right  hand,  and 
draws  up  the  scrotum  with  his  left.  (2)  The  surgeon  incises  directly  in  the 
median  line  of  the  perineum,  beginning  at  the  scroto-perineal  junction,  and 
ending  about  1.3  cm.  (^  inch)  in  front  of  the  anus.  The  incision  at  first 
passes  only  through  skin  and  fascia.  The  lower  end  of  the  instrument  in  the 
urethra  is  then  felt  for,  the  surgeon's  left  index  nail  depressing  the  intervening 
structures  over  the  groove — and  all  the  intervening  tissues  are  now  divided 
down  to  and  into  the  groove — in  the  same  manner  and  order  as  in  median 
perineal  cystotomy.  (3)  A  silk  traction-loop  is  placed  in  either  lip  of  the 
urethral  wound  and  the  lips  are  then  drawn  apart — thus  clearly  demon- 


EXTERNAL  PERINEAL  URETHROTOMY.  1125 

strating  the  interior  of  the  urethral  canal,  from  its  normal  lumen  above  to 
where  it  disappears  below  into  an  almost  imperceptible  lumen.  (4)  The 
metallic  staff  is  now  partly  withdrawn  and  steadied  by  an  assistant,  using  care 
to  retain  in  situ  the  filiform,  by  holding  it  in  the  perineal  wound  as  the  staff 
is  withdrawn  over  it.  Nothing  now  remains  at  the  immediate  site  of  the 
operation  but  the  whalebone  guide  passing  into  the  bladder.  (5)  With  a 
probe-pointed  bistoury,  the  filiform  is  carefully  followed  backward  and  the 
stricture  thus  divided  throughout  its  length  and  slightly  beyond.  The  tun- 
neled staff  is  then  thrust  into  the  bladder  over  the  whalebone  guide.  (6)  The 
filiform  is  then  withdrawn.  A  grooved  director  or  gorget  is  passed  into  the 
bladder,  through  the  perineal  wound,  over  the  grooved  staff — and  the  staff 
withdrawn.  (7)  The  remaining  steps  are  the  same  as  in  Syme's  operation 
(see  sections  (3)  and  (4),  including  "  Comment,"  page  11 23). 


EXTERNAL  PERINEAL  URETHROTOMY 

UPON  GROOVED  STAFF  PASSED  DOWN  TO  STRICTURE  — WHEELHOUSE'S 

OPERATION. 

Description. — In  these  cases  the  grooved  staff  cannot  be  passed  through 
the  stricture — nor  can  a  filiform  be  passed  through — but  a  grooved  staff  can 
be  passed  down  to  the  stricture — and,  upon  this,  the  urethra  is  opened  just 
in  front  of  the  stricture  and  a  fine  grooved  director  is  passed  through  it — ■ 
and  the  stricture  is  divided  upon  this  last  director.  The  urethra  is  thus 
opened  in  the  median  line  about  6  mm.  (J  inch)  in  front  of  the  stricture — the 
feature  of  the  operation  being  that  at  least  this  much  of  the  sound  urethra 
should  be  exposed  in  front  of  the  stricture. 

Preparation. — Perineum  shaved.  Lubricated  grooved  sound  introduced 
down  to  the  stricture  and  steadily  held  in  the  median  line. 

Position. — Patient  supine,  in  the  lithotomy  position  at  the  end  of  the 
table.  Surgeon  seated  opposite  the  perineum.  Assistant  on  patient's  left, 
holding  staff. 

Landmarks. — Median  line;  perineo-scrotal  junction;  anus. 

Incision. — From  reflection  of  superficial  perineal  fascia,  at  perineo- 
scrotal junction — to  anterior  border  of  sphincter  ani. 

Operation. — (1)  Incision  is  made  in  the  median  line  to  the  above  extent, 
and  the  tissues  of  the  perineum  are  divided  as  in  median  perineal  cystotomy 
— separating  the  tissues  in  the  direction  of  the  sound  until  the  urethra  is 
reached.  (2)  The  urethra  is  then  divided  to  a  limited  extent  upon  the  grooved 
sound — especial  care  being  taken  that  the  urethra  is  opened  about  6  mm. 
({  inch)  in  front  of  the  stricture — the  opening  not  extending  down  to  the 
stricture.  Looped  silk  traction-ligatures  are  then  put  in  through  the  lips 
of  the  divided  urethra,  upon  either  side,  and  the  two  lips  of  the  urethra  are 
thus  drawn  apart.  (3)  The  grooved  sound  is  then  withdrawn  a  short  dis- 
tance— just  far  enough  to  free  its  end  from  the  remaining  6  mm.  (J  inch)  of 
intact  urethra  in  which  it  had  been,  up  until  then,  engaged — the  sound  is 
then  turned  through  a  half  revolution  upon  its  axis,  so  that  its  extremitv  now 
points  outward — and  thus  hooks  up  upon  its  concavity  the  upper  limit  (angle) 
of  the  urethral  wound.  The  urethral  opening  is  thus  stretched  apart  in  a 
lozenge-shaped  manner,  by  the  hooked  sound  above,  by  the  traction-ligatures 
on  each  side,  and  by  the  attachment  of  the  intact  urethra  below.  (4)  While 
thus  held  apart  and  well  exposed,  a  fine  probe-pointed  grooved  director,  or 
gorget,  is  insinuated  into  and  along  the  strictured  urethra,  with  its  groove 


1 1 26  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

uppermost.  Even  often  when  the  opening  cannot  be  seen,  the  director  will 
find  its  way  toward  the  bladder  among  a  mass  of  distorted  tissue.  (5)  The 
groove  of  the  director  is  now  turned  downward — and  the  strictured  portion 
of  the  urethra  is  divided  upon  its  floor  by  a  knife  passed  along  the  director. 
The  knife  is  withdrawn  and  the  groove  of  the  director,  still  in  the  urethra,  is 
turned  upward — and  a  metallic  catheter,  or  sound,  is  then  passed  from  the 
meatus,  and  is  guided  through  the  opened  urethra  by  the  fingers  in  the  perineal 
wound — and  thence  on  to  the  groove  of  the  director — and  thus  into  the  bladder. 
(6)  The  metallic  instrument  is  allowed  to  remain  in  situ  for  three  or  four  days 
during  granulation  of  the  parts  around  the  new  canal — and  is  then  passed 
daily  until  the  perineal  wound  heals.  (7)  The  perineal  wound  may  be  partly 
closed  by  suture — but  is  left  unsutured  in  part,  at  least,  for  drainage. 

Comment. — If  the  staff  hooked  into  the  incised  urethra  be  in  the  way, 
it  can  be  dispensed  with. 


PERINEAL  SECTION,  OR  EXTERNAL  PERINEAL  URETHROTOMY 

WITHOUT  A  GUIDE  — COCK'S  OPERATION. 

Description. — In  these  cases  neither  a  grooved  staff,  nor  even  a  filiform 
bougie,  can  be  passed  through  the  stricture.  The  urethra  is  practically  im- 
passable to  all  instruments  (from  the  presence  of  several  strictures,  false 
passages,  rupture,  disease,  and  the  like).  No  attempt  is  made  to  use  any 
form  of  guide.  The  urethra  is  opened  posteriorly  to  the  stricture  and  imme- 
diately anteriorly  to  the  prostate.  The  bladder  is  thus  relieved — and  the 
anterior  portion  of  the  urethra  is  subsequently  treated. 

Preparation. — Perineum  shaved.     Bladder  partly  full. 

Position. — Lithotomy  position  at  edge  of  table.  Surgeon  seated  facing 
perineum.     Assistant  holds  penis  and  testes  out  of  the  way. 

Landmarks. — Median  line;  perineo-scrotal  junction;  anus. 

Incision. — In  median  line,  from  perineo-scrotal  junction,  to  within  about 
1.3  cm.  (h  inch)  of  the  anus. 

Operation. — (1)  The  surgeon  introduces  the  left  index-finger  into  the 
rectum,  with  nail  to  the  sacrum,  and  keeps  the  tip  of  his  finger  against  the 
apex  of  the  prostate  gland.  (2)  A  knife  is  then  made  to  cut  directly  and 
boldly,  in  the  median  line  of  the  perineum,  toward  the  tip  of  the  left  index- 
finger — the  entire  cut  being  made  with  one  sweep  of  the  knife,  the  incision 
beginning  above  near  the  perineo-scrotal  junction,  passing  inward  to  the 
prostatic  urethra,  and  ending  below  about  1.3  cm.  (J  inch)  anterior  to  the 
anus.  The  incision  of  tissues  is,  practically,  the  same  as  that  for  median 
perineal  cystotomy.  The  deepest  part  of  this  triangular  incision  will  be  at 
the  apex  of  the  prostate  gland,  and  the  most  superficial  at  the  upper  and  lower 
ends  of  the  base  of  the  triangle  upon  the  perineum.  The  knife  is  at  no  time 
withdrawn  until  the  full  depth  of  the  wound  and  apex  of  the  prostate  gland 
are  reached,  as  its  reinsertion  would  be  uncertain.  In  the  depth  of  the  wound 
the  knife-point  is  guided  by  the  tip  of  the  left  index-finger — and  the  urethra, 
at  the  posterior  part  of  the  membranous  portion,  is  divided  in  its  median 
aspect,  or  slightly  obliquely — the  anterior  part  of  the  prostate  often  also  being 
divided.  (3)  Having  incised  the  urethra,  the  knife  is  withdrawn — but  the 
left  index  is  kept  in  the  rectum  in  contact  with  the  apex  of  the  prostate.  (4) 
While  the  edges  of  the  deep  perineal  wound  are  well  retracted,  a  fine  probe- 
pointed  director  is  inserted  into  the  opened  urethra,  guided  by  a  finger  in  the 
rectum — and  pushed  on  into  the  bladder.     (5)  Perineal  drainage  is  estab- 


URETHROSTOMY.  1127 

lished  by  passing  a  soft  catheter,  through  the  wound  in  the  perineum,  into 
the  bladder — the  catheter  being  held  in  place  by  the  perineal  bandage. 
(6)  This  operation  is  generally  resorted  to  where  the  urethra  is  very  ex- 
tensively involved  or  destroyed.  If,  therefore,  the  perineal  opening  is  not  to 
be  a  permanent  one,  steps  may  be  taken  subsequently,  after  restoration  of 
the  structures  in  whole  or  in  part,  with  reference  to  the  opening  up  of  the 
anterior  portion  of  the  urethra  by  dilatation  or  urethrotomy. 

Comment. — While  the  original  operation  by  Cock  was  done  in  this 
manner,  and  generally  abandoned  if  the  urethra  was  not  reached  in  two  or 
three  attempts,  there  is  no  reason  why  (and  this  is  now  generally  done)  the 
tissues  should  not  be  divided  more  deliberately  and  the  urethra  more  per- 
sistently sought  for.  One  should  be  guided  by  an  intimate  knowledge  of 
the  anatomy  of  the  parts,  in  the  face  of  great  difficulties — for  often  the  struc- 
tures are  unrecognizably  altered. 


URETHRORRHAPHY. 

Description. — Suturing  of  the  urethra.  Indicated  in  incised  and  rup- 
tured wounds  and  in  fistula. 

Preparation — Position. — As  for  Urethrotomy. 

Landmarks — Incision. — Determined  by  nature  and  site  of  wound. 

Operation. — Having  exposed  the  site  of  the  wounded  urethra,  by  ex- 
ternal incision — a  metal  sound  or  soft  catheter  is  passed  through  the  urethra, 
using  special  care  not  to  increase  the  wound.  With  fine  chromic  gut,  or 
fine  silk,  carried  in  a  curved  needle  held  in  a  holder,  the  opposite  edges  of 
the  wounded  urethra  are  united  by  interrupted  sutures  passing  through  the 
entire  thickness  of  the  lips  of  the  wound — except  the  mucous  membrane.  A 
soft  catheter  is  worn  for  two  or  three  days,  until  time  has  been  given  for  the 
shutting-off  of  the  wound  from  the  interior  of  the  urethra,  The  external 
wound  is  left  open,  being  packed  with  gauze  until  the  urethral  wall  has  healed 
— to  avoid  the  danger  of  urinary  infiltration. 

Comment. — There  are  several  plastic  operations  which  may  be  done  for 
urinary  fistula. 

URETHROSTOMY. 

Description. — Making  of  a  more  or  less  permanent  opening  of  the 
urethra  upon  the  perineum.  Indicated  where  the  anterior  portion  of  the 
urethral  canal  is  impermeable,  as  for  stricture, — or  in  case  of  amputation 
of  the  penis. 

Preparation — Position — Landmarks. — As  for  median  perineal  cys- 
totomy. 

Incision. — Determined  by  the  special  circumstances  of  the  case. 

Operation. — (a)  For  the  establishment  of  Urethrostomy  following  ampu- 
tation of  the  penis,  see  section  5,  under  "  Operation,"  page  n  17.  (b)  In  per- 
forming Urethrostomy  in  connection  with  a  strictured  urethra: — Having 
exposed  the  strictured  site,  divide  the  urethra  transversely,  just  behind  the 
stricture,  and  free  the  proximal  end  of  the  urethra  to  a  limited  extent. 
Slit  the  proximal  end  slightly  upon  its  floor,  or  upon  floor  and  roof — and 
suture  the  lips  thus  formed  by  slitting,  into  the  skin  of  the  perineum. 
Suture  up  the  proximal  end  of  the  distal  portion  of  urethra — and  close  the 
wound  up  to  the  margins  of  the  implanted  urethra. 


1128  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 


III.  THE  SCROTUM  AND  TESTES. 

SURGICAL  ANATOMY. 
(A)  The  Scrotum  and  Coverings  of  Testes  and  Cords. 

Description. — The  scrotum  is  a  cutaneo-musculo-areolar  sac,  investing 
the  testes  and  part  of  the  spermatic  cords.  It  is  composed  of  skin  and  dartos 
— the  remaining  layers  mentioned  below  being,  more  properly,  coverings  of 
the  testes  and  cords. 

Skin. — Of  characteristic  appearance.  Continuous  with  the  general 
Integument.  Marked  in  the  middle  line  by  a  raphe,  which  divides  the 
scrotum  into  two  lateral  halves  superficially. 

Dartos. — Proper  tunic  of  the  scrotum — composed  of  reddish,  elastic, 
and  unstriped  muscle  tissue — continuous  with  the  superficial  and  deep  layers 
of  the  superficial  fascia.  Septum  scroti — formed  by  the  dartos — extending 
from  the  raphe  to  the  inferior  surface  of  the  penis — dividing  the  scrotum 
into  two  cavities  for  the  two  testes,  the  left  cavity  being  the  longer. 

Intercolumnar  or  External  Spermatic  Fascia. — Derived  from  borders 
of  pillars  of  external  abdominal  ring.  Continuous  with  superficial  perineal 
fascia  and  superficial  fascia  over  the  symphysis  pubis.  Loosely  (Gray — 
closely,  according  to  Morris)  adherent  to  the  dartos.  Intimately  adherent 
to  the  cremasteric  fascia. 

Cremasteric  or  Middle  Spermatic  Fascia. — Fibro-muscular  layer  de- 
rived from  lower  border  of  internal  oblique  muscle. 

Infundibuliform  Fascia  (Fascia  Propria,  or  Internal  Spermatic 
Fascia). — Connective-tissue  layer  derived  from  both  the  infundibuliform 
process  of  the  fascia  transversalis  and  also  from  the  subperitoneal  connective 
tissue  (which  latter  may  be  considered  a  separate  or  sixth  layer). 

Tunica  Vaginalis. — Closely  connected  with  the  testicles,  with  which  it 
is  described. 

Arteries. — Superficial  and  deep  external  pudic  of  femoral;  superficial 
perineal  of  internal  pudic;  cremasteric  of  epigastric. 

Veins. — Correspond  with  arteries  and  empty  into  pudic,  long  saphenous, 
and  dorsal  vein  of  penis. 

Lymphatics. — End  in  innermost  set  of  inguinal  glands. 

Nerves. — Ilio-inguinal;  superficial  perineal  branches  of  internal  pudic; 
inferior  pudendal  branch  of  small  sciatic;  genital  branch  of  genitocrural. 

(B)  The  Testes. 

Description. — The  testes  consist  of  the  testicles  proper  and  the  epi- 
didymes,  the  latter  also  being  the  beginnings  of  the  vasa  deferentia.  The 
coverings  of  the  testicles  are — the  tunicae  vaginalis,  albuginea,  and  vasculosa. 

Tunica  Vaginalis. — A  closed  serous  sac  originally  derived  from  the 
peritoneum,  surrounding  the  testicle  with  two  layers; — (a)  Visceral  Layer — 
closely  adherent  to  testicle  proper,  to  globus  major,  to  external  part  of  body 
of  epididymis,  and  to  lower  1.3  cm.  (h  inch)  of  spermatic  cord.  Nearly  all 
of  the  globus  minor  and  inner  and  back  parts  of  epididymis  are  uncovered, 
and  here  the  vascular  communications  exist  between  the  testis  and  coverings, 
(b)  Parietal  Layer — continuous  with  and  reflected  from  the  visceral  layer  at 
the  posterior  and  inferior  aspects  of  the  testis  and  at  the  spermatic  cord — 
adherent  to  the  inner  surface  of  the  infundibuliform  fascia,  to  which  it  is 


PARTIAL  EXCISION  OF  THE  SCROTUM.  1129 

attached  by  the  prolongation  from  the  subperitoneal  areolar  tissue — and 
extends  up  upon  the  antero-internal  aspect  of  the  cord  and  below  the  testis, 
(c)  Cavity  of  the  tunica  vaginalis — interval  between  visceral  and  parietal 
layers. 

Tunica  Albuginea. — The  dense,  inelastic  fibrous  covering  of  the  testicle 
— reflected  into  the  interior  of  the  testicle  at  its  posterior  aspect  to  form  an 
incomplete  septum  and  trabecular,  the  mediastinum  testis. 

Tunica  Vasculosa. — A  layer  formed  by  a  plexus  of  vessels  running  in 
the  areolar  tissue.     Lines  the  tunica  albuginea  and  trabecular. 

Lobuli  Testis. — Consist  of  tubuli  seminiferi,  resting  in  the  trabecular 
spaces — forming  the  glandular  structure  of  the  testis. 

Arteries. — Spermatic,  of  abdominal  aorta  (divides  into  branches  which 
pierce  the  tunica  albuginea  at  the  back  of  gland). 

Veins. — Spermatic  (begin  in  testis — leave  it  posteriorly — and  ascend  cord, 
forming  pampiniform  plexus). 

Lymphatics. — Follow  spermatic  vessels  and  empty  into  lumbar  glands. 

Nerves. — From  aortic  and  hypogastric  plexuses. 


PARACENTESIS  TUNIGE  VAGINALIS. 

Description. — Penetration  of  the  tunica  vaginalis  sac  with  a  hollow 
needle  or  an  exploratory  trocar  and  cannula — for  the  purpose  of  withdrawing 
or  injecting  fluid.     Generally  indicated  in  hydrocele. 

Preparation — Position — Landmarks. — As  in  operating  for  Hydrocele. 

Operation. — The  scrotum  is  grasped  posteriorly  by  the  surgeon's  left 
hand  in  such  a  way  as  to  render  the  anterior  aspect  of  the  tumor  tense.  The 
needle  or  trocar  is  so  held  with  the  right  index  near  its  point  as  to  fix  the 
maximum  depth  to  which  it  can  enter.  Thus  held,  it  is  thrust  sharplv  into 
the  antero-inferior  aspect  of  the  sac,  at  about  the  upper  limit  of  its  lower 
third — passing,  at  first  directly  backward — and  then  upward  (thus  missing 
the  testicle).  The  fluid  having  been  withdrawn  (or  injected),  the  instrument 
is  withdrawn — the  opening  sealed  with  sterile  collodion  and  cotton — and 
the  testicle  supported  by  a  compressing  dressing. 

Comment. — The  testicle  usually  lies  posterior  to  a  tunica  vaginalis  filled 
with  hydrocele  fluid — but  sometimes  lies  below — and  sometimes  lies  in  front. 


PARTIAL  EXCISION  OF  THE  SCROTUM. 

Description. — Removal  of  the  lower  portion  of  the  scrotal  tissues.  Gen- 
erally resorted  to  in  relaxation  and  elongation  of  the  scrotum,  and  as  an  aid 
in  varicocele. 

Preparation. — Scrotum  shaved. 

Position. — Patient  supine,  at  edge  of  table.  Surgeon  on  side  of  involved 
sac,  or  on  patient's  right.     Assistant  opposite. 

Landmarks. — Lower  limit  of  testicle. 

Operation. — The  testicle  is  pressed  upward  toward  the  external  abdom- 
inal ring,  to  be  well  above  the  possibility  of  injury.  The  lower  portion  of 
scrotal  tissue  is  clamped  with  special  forceps  (or  clamps),  or  any  pair  of  long 
forceps  whose  blades  will  close  lightly  and  parallel  with  each  other — so  that  the 
lower  border  of  the  clamps  will  be  on  a  level  with  the  line  upon  which  it  is 
desired  to  remove  the  scrotal  sac  (Fig.  823).     Clamp  sufficiently  firmly  to 


ii30 


OPERATIONS    UPON    THE    MALE    GENITAL    ORGANS. 


control  hemorrhage.  Divide  the  scrotal  tissues  with  a  knife,  cutting  along  the 
lower  border  of  the  clamps.  Unclamp  slightly,  to  reveal  the  position  of  bleed- 
ing vessels — which  are  then  ligated  with  gut,  that  no  subsequent  bleeding  may 


Fig.  823. — King's  Scrotal  Clamp. 

take  place  into  the  loose  tissues.  While  the  edges  are  still  held  in  the  clamps, 
they  are  sutured  together,  interruptedly  or  continuously — after  which  the 
clamps  are  relaxed.  No  drainage  is  used.  The  part  is  well  supported  and 
compressed  by  the  dressing. 


Fig.  824. — Partial  Excision  of  the  Scrotum: — The  lateral  aspects  of  the  scrotum  are 
held  apart  by  traction  sutures.  Interrupted  through-and-through  sutures  prevent  the  testicles 
from  escaping  from  the  scrotum  and  also  partly  control  hemorrhage.  The  overhand  sutures 
of  the  free  margins  complete  the  operation,  also  controlling  hemorrhage.  (Redrawn  from 
Hartmann.) 

Comment. — The  first  and  second  fingers  of  an  assistant's  right  and  left 
hands,  separated  to  clasp  the  scrotum,  the  index-fingers  crossing  each  other  in 
front,  and  the  second  fingers  crossing  each  other  behind,  the  scrotum,  make 
satisfactory  clamps.  The  operation  may  be  done  without  any  form  of  clamp 
by  first  introducing  retention  and  hemostatic  sutures,  as  shown  in  Fig.  824. 


OPERATION    FOR    HYDROCELE. 


1131 


OPERATION  FOR  HYDROCELE 

BY  INCISION  OF  TUNICA  VAGINALIS  —  VOLKMANN'S  OPERATION. 

Description. — The  tunica  vaginalis  is  incised  vertically  in  its  anterior 
aspect  and  stitched  to  the  scrotal  skin — its  cavity  being  then  packed  with 
gauze  and  allowed  to  heal  by  granulation. 

Preparation. — Scrotum  shaved.  Penis  wrapped  in  gauze  and  held  away 
from  the  field  of  operation. 

Position. — Patient  supine,  at  edge  of  table.  Surgeon  on  side  of  opera- 
tion.    Assistant  opposite. 

Landmarks. — Position  of  the  testicle  proper. 


Fig. 825.— Volkmann's  Operation  for  Hydrocele: — A,  Lip  of  scrotal  wound;  B,  Tunica 
vaginalis,  incised  ;  C,  Testis  ;  D,  Suture  passing  through  tunica  vaginalis  and  entire  thickness  of  lip  of 
scrotal  wound. 


Incision. — About  5  cm.  (2  inches)  in  length — along  the  anteroinferior 
aspect  of  the  tumor. 

Operation. — (1)  The  assistant  so  grasps  the  tumor  as  to  render  tense 
and  prominent  its  anterior  aspect — and,  at  the  same  time,  keeps  the  testicle 
out  of  the  way  of  injury.  (2)  An  incision  of  about  5  cm.  (2  inches)  in  extent 
is  made  along  the  anteroinferior  aspect  of  the  tumor — passing  through  the 
tissues  overlying  the  tunica  vaginalis  (skin,  dartos,  intercolumnar  fascia, 
cremasteric  fascia,  and  infundibuliform  fascia)  through  the  tunica  vaginalis 
and  into  its  cavity.  (3)  After  the  escape  of  the  hydrocele  fluid  the  edges  of 
the  tunica  vaginalis  are  sutured  to  the  edges  of  the  scrotal  skin  by  from  four 
to  eight  chromic  gut  sutures — and  the  cavity  itself,  of  the  tunica  vaginalis, 
is  packed  with  gauze — and  heals  by  granulation,  thus  obliterating  the  cavity. 
The  scrotum  is  well  supported  and  compressed  by  the  dressing.     (Fig.  825.) 


117,2  OPERATIONS    UPON   THE    MALE    GENITAL    ORGANS. 


OPERATION  FOR  HYDROCELE 

BY    EVERSION  AND   SUTURING   OF   THE   TUNICA    VAGINALIS — JABOULAY's 

METHOD. 

Description. — After  having  freed  the  testicle  from  the  tunica  vaginalis, 
the  edges  of  the  tunica  are  displaced  backward  and  sutured  behind  the  testicle. 

Preparation — Position — Landmarks — Incision. — As  for  Volkmann's 
operation,  page  1131. 

Operation. — Having  incised  the  tunica  vaginalis  longitudinally,  the 
testicle  proper  is  pressed  forward  in  such  a  way  as  to  evert  the  entire  vaginal 
tunic.  The  everted  sac  is  then  displaced  backward  and  its  margins  sutured 
behind  the  testicle  in  such  a  manner  as  to  bring  the  serous  surface  of  the 
tunica  vaginalis  everywhere  into  contact  with  the  tunica  dartos  (Fig.  826). 


Fig.  826. — Operation  for  Hydrocele  by  Eversion  of  the  Tunica  Vaginalis: — 
The  incised  tunic  is  everted  and  its  margins  sutured  together  behind  the  testicle  and  cord. 
(Redrawn  from  Hartmann.) 

The  testicle  and  everted  tunica  vaginalis  are  then  replaced  within  the  scrotum 
and  the  skin  wound  sutured.  Thus  the  cavity  of  the  tunica  vaginalis  is 
entirely  obliterated. 

Comment. — (1)  Care  is  to  be  exercised  that  the  structures  of  the  cord  be 
not  too  tightly  compressed  in  the  act  of  suturing  the  everted  tunic  around  it. 
(2)  It  has  happened  that  the  everted  tunic  has  gone  on  secreting  its  fluid  into 
the  scrotal  tissues.  (3)  Andrews  incises  the  tunica  vaginalis  anteriorly — 
and  in  the  act  of  expressing  the  testicle  through  this  opening  he  everts  the  tunic 
■ — which  remains  everted  without  suturing. 


OPERATIOX    FOR    HYDROCELE. 


^33 


OPERATION  FOR  HYDROCELE 

BY  INCISION,  WITH  PARTIAL  EXCISION  OF  TUNICA  VAGINALIS— VON  BERGM ANN'S 

OPERATIOX. 

Description. — Incision  of  the  tunica  vaginalis,  with  removal  of  its  parietal 
layer,  followed  by  closure  of  the  scrotal  wound,  with  or  without  drainage. 

Preparation — Position — Landmarks — Incision. — As  for  Volkmann's 
operation. 

Operation. — (i)  While  the  scrotum  is  held  as  in  Volkmann's  operation, 


Fig. 827.— Von  Bekgmann's  Operation  for  Hydrocele  :— A,  Margin  of  incised  tunica  vagi- 
nalis ;  B,  Testis  ;  C,  Portion  of  visceral  layer  of  tunica  vaginalis  being  excised  with  curved  scissors, 
while  being  drawn  upon  with  forceps  ;  D,  Inner  aspect  of  scrotal  sac  from  which  tunica  vaginalis  has 
been  separated. 


an  incision  is  made  over  its  antero-external  aspect,  about  7.5  cm.  (3  inches) 
in  length,  down  to  the  tunica  vaginalis.  (2)  The  tunica  vaginalis  is  then 
incised  in  the  same  line,  at  first  to  the  extent  of  about  1.3  cm.  (\  inch). 
Through  this  opening  the  finger  is  introduced  and  the  cavity  of  the  tunica 
vaginalis  and  the  position  of  the  testicle  examined.  (3)  The  collapsed  tunica 
vaginalis  is  then  incised  to  the  full  extent  of  the  external  wound  with  scissors. 
All  bleeding  vessels  are  clamped  and  tied.  (4)  The  parietal  layer  of  the  tunica 
vaginalis  is  seized  and  partly  peeled,  partly  dissected  away  from  the  scrotum, 
by  fingers  and  forceps — nearly  up  to  the  epididymis,  externally — and  nearly 


"34 


OPERATIONS    UPON    THE    MALE    GENITAL    ORGANS. 


up  to  the  testicle  internally — along  which  lines  it  is  cut  away  with  scissors. 
Bleeding  from  this  step  is  controlled  by  pressure,  hot  douching,  and  gut- 
ligature.  (Fig.  827.)  (5)  A  drainage-tube  is  then  usually  inserted  into  the 
cavity  and  the  lips  of  the  scrotal  wound  closed  by  suturing  up  to  the  drainage- 
tube.  Drainage  may  be  omitted  in  favorable  cases.  The  scrotum  is  well 
supported  by  the  dressing. 

ORCHIDECTOMY. 

Description. — Orchidectomy,  or  castration,  consists  in  the  incision  of 
the  scrotum,  followed  by  excision  of  the  testicle  and  the  structures  of  the 
lower  part  of  the  cord — and  closure  of  the  scrotal  wound. 

Preparation. — Scrotum  and  pubis  shaved. 


Fig. 828. — Orchidectomy: — A,  Superficial  vessel  in  lip  of  incised  scrotum;  B,  Testis;  C,  Sper- 
matic artery  and  pampiniform  plexus  of  veins,  ligated  ;  D,  Vas  deferens  and  artery,  ligated  ;  E,  Cre- 
masteric artery  and  posterior  spermatic  veins,  ligated. 


Position. — Patient  supine,  near  edge  of  table,  with  thighs  separated. 
Surgeon  to  patient's  right,  in  operating  upon  either  side.     Assistant  opposite 

Landmarks. — Testicle;  cord;  external  ring. 

Incision. — Vertical  incision,  from  just  below  the  external  abdominal  ring 
to  the  lower  end  of  the  scrotum,  upon  the  antero-external  aspect  of  the  cord — 
the  scrotum  being  held  in  the  palm  of  the  left  hand,  with  the  index  and  thumb 
extending  upward  on  either  side  and  rendering  the  parts  slightly  tense.  Where 
redundant  or  diseased  tissue  exists,  an  elliptical  incision  may  be  made — in- 
cluding and  removing  the  redundant  or  involved  tissue. 

Operation. — (1)  The  vertical  incision  above  described  is  made  directly 


SURGICAL    ANATOMY    OF    THE    SPERMATIC    CORD.  II35 

down  through  the  overlying  parts  (skin,  dartos,  intercolumnar  fascia,  cremas- 
teric fascia,  infundibuliform  fascia)  to  the  cord  and  tunica  vaginalis.  (2)  By 
blunt  dissection,  the  testicle,  surrounded  by  the  unopened  tunica  vaginalis,  is 
shelled  out  of  its  bed.  The  structures  of  the  cord  are  similarly  isolated,  en 
masse,  chiefly  by  blunt  dissection,  as  high  up  as  necessary — generally  about 
2.5  cm.  (1  inch)  below  the  external  abdominal  ring.  (3)  The  component 
structures  of  the  cord  (see  anatomy  of  the  cord,  page  1135)  are  now  ligated — 
which  is  best  done  by  teasing  them  apart  to  the  extent  of  dividing  them  up  into 
three  or  four  bundles  of  vessels  and  ligating  each  bundle  separately  with 
chromic  gut,  independently  of  whether  composed  of  arteries,  veins,  or  vas 
deferens.  This  is  better  than  to  include  the  entire  mass  in  one  or  even  in 
two  ligatures,  and  is,  practically,  as  satisfactory  as  attempting  to  recognize  and 
tie  the  vessels  separately.  (Fig.  828.)  (4)  All  bleeding  vessels  are  con- 
trolled by  clamping  or  ligation  with  gut — and  are,  usually,  the  superior  ex- 
ternal pudic,  inferior  external  pudic,  superficial  perineal,  and  artery  of  the 
septum  scroti.  (5)  The  scrotal  wound  is  then  put  upon  a  slight  stretch 
and  sutured  throughout,  so  approximating  the  edges  as  to  prevent  in-turning 
— using  interrupted  sutures  of  chromic  gut  or  silkworm-gut.  If  indicated, 
temporary  drainage  may  be  used  in  the  lower  part  of  the  scrotal  wound. 
The  scrotum  is  well  supported  by  dressing. 

Comment. — (i)  The  tunica  vaginalis  is  frequently  opened  before  removing 
the  testicle,  for  the  purpose  of  examination.  (2)  In  other  cases  the  testicle  and 
visceral  layer  are  cut  away  from  the  parietal  layer  of  the  tunica  vaginalis  and 
removed,  leaving  the  latter.  (3)  The  cord  may  first  be  clamped  and  cut — and 
the  vessels  tied  later.  (4)  If  the  arteries  can  be  recognized  and  separately  tied, 
it  is  somewhat  more  surgical. 


IV.  THE  SPERMATIC  CORD. 

SURGICAL  ANATOMY. 

Structures  of  Cord. — Consist  of  the  vas  deferens  (which  begins  in  the 
globus  minor  of  the  epididymis),  arteries,  veins,  lymphatics,  nerves,  processus 
vaginalis,  and  internal  cremaster  of  Henle — all  connected  by  areolar  tissue  and 
surrounded  by  the  fascia:  which  descend,  together  with  the  testes,  from  the  in- 
ternal abdominal  rings,  through  the  inguinal  canals,  into  the  scrotum  to  the 
summit  of  the  testes. 

Arteries  of  the  Cord. — Spermatic,  of  abdominal  aorta — lying  anterior 
to  vas  deferens  and  surrounded  by  pampiniform  plexus  of  veins;  artery  of  vas 
deferens,  of  superior  or  inferior  vesical — accompanying  vas  deferens  upon  its 
lateral  aspect;  cremasteric  artery,  of  deep  epigastric — lying  superficially  and 
upon  the  external  aspect. 

Veins. — Most  of  the  spermatic  veins  pass  through  the  inguinal  canal  and 
emptv  into  the  inferior  vena  cava  on  the  right — and  into  the  renal  vein  on  the 
left.  They  may  be  divided  into  three  sets;— (1)  Anterior  Set— much  larger, 
form  pampiniform  plexus,  accompany  the  spermatic  artery  and  ascend  the 
cord  anterior  to  the  vas;— (2)  Posterior  Set — much  smaller,  surround  the  vas 
deferens  and  accompany  the  artery  of  the  vas;— (3)  Some  independent 
veins. 

Lymphatics. —Empty  into  the  Lumbar  Glands. 

Nerves. — From  the  spermatic  and  pelvic  plexuses. 


1 136  OPERATIONS    UPON    THE    MALE    GENITAL    ORGANS. 

Vas  Deferens. — Lying  posteriorly  and  recognized  by  its  cord-like  feeling. 

Processus  Vaginalis. — Remnant  of  obliterated  tube  of  communication 
between  tunica  vaginalis  and  peritoneum. 

Internal  Cremaster  of  Henle.— Scattered  bundles  of  muscle-fibers. 

Fatty  Areolar  Tissue. — Connecting  constituent  structures  of  cord. 

Epididymes. — Formed  by  vasa  efferentia — which  pierce  the  tunica  al- 
buginea  and,  becoming  convoluted  into  the  coni  vasculosi,  form  the  globus 
major,  at  the  upper,  inner  aspect  of  the  testicle.  The  vasa  efferentia  thus  unite 
to  form  the  body  of  the  epididymis,  along  the  inner  aspect  of  the  testicle — end- 
ing below  in  the  globus  minor,  at  the  lower  inner  aspect  of  the  testicle — which 
terminates  in  the  vas  deferens. 

Vasa  Deferentia. — Continuation  of  the  epididymes — extending  from  the 
globus  minor  to  the  prostatic  urethra.  Ascends  on  the  inner  side  of  the  epididy- 
mis and  back  of  the  testis — passing  vertically  up  the  cord,  posterior  to  the  sper- 
matic vessels — enters  the  external  abdominal  ring — runs  through  the  inguinal 
canal — emerging  from  the  internal  abdominal  ring,  it  passes  around  the  outer 
side  of  the  origin  of  the  deep  epigastric  artery  and  runs  downward  and  inward, 
crossing  the  external  iliac  vessels  into  the  pelvis  to  the  side  of  the  bladder, 
running  under  the  peritoneum — thence  curves  backward  and  downward  to  the 
postero-lateral  surface  of  the  bladder — crossing  over  the  cord  of  the  obliterated 
hypogastric  artery,  and  lying  internal  to  the  ureter,  passing  between  the  ureter 
and  bladder — thence  it  ceases  to  be  covered  by  peritoneum,  running  forward 
to  the  base  of  the  prostate,  lying  between  the  bladder  and  rectum  and  attached 
to  the  former  (bladder) — being  placed  internal  to  the  vesiculae  seminales. 
Near  the  base  of  the  prostate,  each  vas  enlarges  somewhat  (ampulla)  and  joins 
the  duct  of  the  corresponding  seminal  vesicle,  to  form  the  ejaculatory  duct  of 
that  side — the  ejaculatory  duct  opening  into  the  sinus  pocularis  of  the  pros- 
tatic portion  of  the  urethra.  After  the  vas  ceases  to  be  subperitoneal,  it  is 
invested  by  recto-vesical  fascia  and  a  prolongation  of  the  subperitoneal  tissue. 
The  efferent  ducts  consist  of  cellular,  muscular,  and  mucous  coats.  Its  artery 
is  the  artery  of  the  vas  deferens,  a  branch  of  the  superior  vesical  of  the  internal 
iliac.  Its  lymphatics  end  in  the  iliac  glands.  The  angle  of  approximation  of 
the  ejaculatory  ducts  lies  immediately  above  the  prostate.  For  the  anatomy  of 
the  ejaculatory  ducts,  see  the  vesiculae  seminales. 


INSTRUMENTS. 
See  those  mentioned  under  the  urethra  and  penis. 

PARTIAL  VASECTOMY. 

Description. — A  division  of  the  vas  deferens,  with  a  limited  excision  of  its 
trunk.     Sometimes  resorted  to  in  cases  of  hypertrophy  of  the  prostate  gland. 

Preparation — Position — Landmarks. — As  in  operating  for  varicocele. 

Incision. — In  the  course  of  the  spermatic  cord,  beginning  just  below  the 
external  abdominal  ring  and  extending  downward  for  about  4  cm.  (i-J-  inches). 

Operation. — Incise  skin  and  fascia — clamp  and  ligate  superficial  vessels. 
Expose  the  spermatic  cord  just  below  the  external  abdominal  ring — locate  the 
vas — and  isolate  it  from  the  accompanying  structures.  Place  two  gut  ligatures 
upon  it,  about  2  cm.  (f  inch)  apart,  and  excise  about  1.3  cm.  (h  inch)  of  its 
length.     Close  the  wound  with  gut  or  silkworm-gut. 


OPERATION    FOR    RADICAL    CURE    OF    VARICOCELE. 


"37 


OPERATION  FOR  THE  RADICAL  CURE  OF  VARICOCELE. 

BENNETT'S  MODIFICATION  OF  HOWSE'S  OPERATION. 

Description. — Consists  in  an  incision  of  the  scrotum  and  cord,  with  a 
partial  excision  of  the  pampiniform  plexus  of  veins  (which  is  the  set  chiefly 
involved  in  varicocele) — followed  by  suturing  of  the  proximal  and  distal  ends 
of  the  severed  plexus  together. 

Preparation. — Pubis  and  scrotum  shaved. 


Fig.  829. — Bennett's  Modification  of  House's  Operation  for  Varicocele  : — Between 
retracted  lips  of  scrotal  wound  are  seen  two  stumps  left  by  excision  of  bulk  of  scrotal  veins.  A,  One 
end  of  upper  ligature  being  threaded  through  upper  stump  laterally  ;  B,  Same  of  lower  stump  and 
ligature.  The  long  limbs  of  this  ligature  are  tied  together — and  the  short  limbs  together.  C,  Suture 
carried  through  the  stumps  antero-posteriorly  and  tied.  The  stumps  are  approximated  by  tightening 
the  sutures. 


Position. — Patient  supine,  at  edge  of  table.  Surgeon  on  side  of  operation. 
Assistant  opposite. 

Landmarks. — Site  of  varicose  tumor.  Position  of  testicle  and  cord.  Ex- 
ternal abdominal  ring. 

Incision. — Longitudinal  incision,  about  4  to  5  cm.  (i\  to  2  inches)  in 
length,  made  over  the  structures  of  the  cord,  with  its  center  over  the  site  of  the 
greatest  varicosity. 

Operation. — (1)  As  soon  as  the  incision  is  made  through  skin  and  fascia, 
the  bleeding  vessels  are  damped  and  tied — and  two  silk  retraction-loops  are 
put  into  the  lips  of  the  wounds  and  these  lips  well  retracted — thus  exposing  the 


1 138  OPERATIONS    UPON    THE    MALE    GENITAL    ORGANS. 

structures  of  the  cord.  (2)  The  vas  deferens  is  the  first  structure  of  the  cord 
to  be  identified — and  this  is  done  for  the  purpose  of  henceforth  avoiding  in- 
juring it  This  structure  and  its  artery,  and  the  posterior  set  of  veins  accom- 
panying it,  are  kept  as  much  out  of  the  field  as  possible.  (3)  The  pampini- 
form plexus  of  veins,  together  with  the  surrounding  fascia  especially  preserved 
and  unopened,  are  isolated  from  the  more  important  structures  and  are  freed 
for  about  4  to  5  cm.  (15  to  2  inches),  according  to  the  size  of  the  varicocele,  by 
blunt  dissection.  (4)  Strong  chromic  gut  ligature  is  carried,  up  on  an  aneu- 
rism-needle, around  the  lower  portion  of  the  freed  part  of  this  plexus  of  veins 
and  tied  tightly,  both  ends  being  left  long.  The  same  is  then  done  at  the  upper 
portion  of  the  freed  part — the  ligatures  being  about  4  cm.  (i\  inches)  apart. 
About  2.5  cm.  (1  inch)  in  extent  of  this  venous  plexus  is  now  removed  with 
scissors,  which  cut  about  6  mm.  (j  inch)  from  each  ligature.  (5)  One  of  the 
free  ends  of  each  ligature  is  now  threaded  and  carried  through  its  own  end,  so 
as  to  come  out  opposite  the  knot.  The  two  ends  which  were  threaded  are  then 
tied  together.  The  other  two  ends  are  similarly  treated  and  tied.  The  free 
ends  of  the  venous  plexuses  left  by  the  excision  are  thus  approximated,  together 
with  their  sheaths  of  surrounding  fascia — thus  shortening  the  cord  and  partially, 
perhaps,  taking  the  weight  of  the  lower  part  of  the  cord  from  the  scrotum.  (6) 
The  wound  is  then  gut-ligatured  throughout.     (Fig.  829.) 

Comment. — (1)  As  much  in  length  of  the  plexus  may  be  removed  as  con- 
sidered necessary  in  the  special  case.  (2)  Isolation  of  the  veins  to  be  ligated 
is  aided  by  passing  a  director  above,  and  one  below,  between  the  veins  to  come 
away  and  the  structures  to  remain — and  then  separate  the  parts  upward  and 
downward  in  this  line.  (3)  Especially  avoid  opening  the  fascial  sheath  sur- 
rounding the  veins  of  the  pampiniform  plexus  to  come  away — as  they  are 
much  more  readily  manipulated  when  intact.  (4)  Avoid  cutting  the  cremas- 
ter  muscle.  (5)  Avoid  removing  an  excess  of  vascular  structures — for  fear 
of  damaging  the  blood-supply  of  the  part  too  greatly. 


V.  THE  VESICULiE  SEMINALES  AND  EJACULATORY  DUCTS. 

SURGICAL  ANATOMY. 

(A)  Vesicul/E  Seminales. 

Description. — Two  diverticular,  membranous,  seminal  reservoirs  placed 
between  the  bladder  and  the  rectum — lying  external  to  the  ampulla?  of  the  vasa 
deferentia — their  upper  extremities  being  subperitoneal.  They  average,  in 
length,  about  6.3  cm.  (2^  inches) — breadth,  about  1  cm.  (y^-inch) — thickness, 
about  6  mm.  (\ inch). 

Relations. — Superiorly;  base  of  bladder,  from  near  entrance  of  ureters 
to  base  of  prostate  gland.  Inferiorly;  rectum,  with  the  recto-vesical  fascia 
intervening.  Anteriorly;  converging,  unite  with  vasa  deferentia  (which 
lie  to  their  inner  side)  to  form  the  ejaculatory  ducts.  Posteriorly ;  the  free 
ends  diverge,  overlapping  the  ureters,  which  pass  between  the  vesiculae  semi- 
nales and  the  bladder.  The  recto-vesical  pouch  of  peritoneum  covers  the 
upper  part  of  the  posterior  aspect  of  the  seminal  vesicles. 

(B)  Ejaculatory  Ducts. 

Description. — Formed  by  union  of  vasa  deferentia  and  vesicula?  seminales 


TOTAL    EXCISION    OF    VESICUL^    SEM1NALES.  1 139 

of  each  side.  They  are  about  2  cm.  (f  inch)  in  length.  Beginning  at  base  of 
prostate,  they  pass  forward  and  downward  between  the  middle  and  lateral 
lobes — perforate  the  prostatic  fissure — and  empty  at  or  within  the  margins  of 
the  sinus  pocularis,  in  the  prostatic  portion  of  the  urethra.  Its  coats  are 
fibrous,  muscular,  and  mucous. 

Arteries  of  Vesiculae  Seminales  and  Ejaculatory  Ducts. — Artery  of  vas 
deferens,  of  superior  vesical  branch  of  internal  iliac;  inferior  vesical,  of  internal 
iliac;  middle  hemorrhoidal,  of  internal  iliac;  middle  vesical,  of  internal  iliac. 

Veins. — Accompany  arteries. 

Lymphatics. — End  in  pelvic  glands. 

Nerves. — From  hypogastric  plexus. 


INSTRUMENTS. 
See  those  used  in  operating  upon  the  bladder. 


TOTAL  EXCISION  OF  VESICUL^     SEMINALES  AND    PART  OF    EJAC- 
ULATORY DUCTS 

F.V  SUPRAPUBIC  RETROCVSTIC  EXTRAPERITONEAL  ROUTE  —  YOUNG'S  OPERATION 

Description. — The  total  excision  of  the  seminal  vesicles  (Spermatocys- 
tectomy)  and  the  partial  excision  of  the  ejaculatory  ducts,  by  a  suprapubic 
T-shaped  incision.  The  posterior  aspect  of  the  bladder  is  exposed  by  a  median 
suprapubic,  incision,  with  the  addition  of  a  transverse  incision  at  its  upper  end. 
Through  this  incision,  which  does  not  pass  into  the  peritoneal  cavity,  the 
peritoneum  is  peeled  away  from  the  posterior  wall  of  the  bladder,  until  the 
vesicular  seminales  are  exposed.  The  seminal  vesicles  are  then  removed — and 
the  ejaculatory  ducts  are  traced  to  the  internal  abdominal  rings  and  also  re- 
moved at  this  point. 

Preparation. — Bowels  emptied.  Bladder  partly  filled.  Pubic  and  supra- 
pubic regions  shaved. 

Position. — Patient  in  Trendelenburg  position.  Surgeon  to  patient's  left. 
Assistant  opposite. 

Landmarks. — Symphysis  pubis;  median  line;  known  relations  of  the  parts. 

Incision. — T-shaped.  The  median  suprapubic  incision  is  made  from 
just  above  the  umbilicus  to  the  symphysis  pubis.  The  transverse  incision, 
about  7.5  cm.  (3  inches)  in  length,  extends  across  the  upper  end  of  the  vertical 
incision,  just  above  the  umbilicus  and  in  the  linea  transversa.  The  median 
incision  passes  between  the  recti  muscles — and  the  transverse  incision  divides 
them  as  far  as  it  extends. 

Operation. — (I)  The  median  incision  is  carried  down  in  the  median  line 
just  as  in  median  abdominal  section- — passing  through  the  fascia  posterior  to 
the  recti — down  to  but  not  through  the  peritoneum.  (2)  The  peritoneum, 
having  been  exposed,  is  carefully  separated  from  the  posterior  wall  of  the  blad- 
der in  the  median  line — keeping  comparatively  near  the  median  line,  to  avoid 
severing  many  of  the  nutrient  vessels  of  the  bladder  by  separating  the  perito- 
neum too  far  laterally.  Upward  traction  of  the  posterior  bladder-wall — while, 
at  the  same  time,  pressing  backward  the  rectum — aids  the  separation  of  the 
peritoneum  from  the  back  of  the  bladder.     (3)  The  vasa  deferentia  are  thus 


U40  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

exposed  and  freed  from  the  bladder  by  blunt  dissection — during  which  the 
vesiculae  seminales  are  encountered,  lying  slightly  to  the  outer  side,  and  are 
similarly  freed.  (4)  Both  vesiculae  seminales  and  vasa  deferentia  are  divided 
by  blunt  dissection  close  to  the  upper  border  of  the  prostate  gland.  The  vasa 
deferentia  are  then  traced  on  outward  over  the  lateral  aspects  of  the  bladder 
to  the  internal  abdominal  rings — and  there  ligated  and  divided.  (5)  In  con- 
cluding the  operation,  the  transversely  divided  recti  are  repaired  with  chromic 
gut.  The  longitudinal  wound  is  sutured  as  in  abdominal  section — leaving  the 
lower  portion  open — through  which  a  temporary  gauze  drainage  is  usually 
conducted. 

Comment. — (1)  Hemorrhage  is  controlled  by  gut-ligaturing  and  gauze- 
packing.  (2)  Briefly  summarizing  the  operation,  the  steps  are: — Separation 
of  peritoneum  from  base  of  bladder — Separation  of  rectum  from  base  of  blad- 
der— Excision  of  vesiculae  seminales  and  of  the  vasa  deferentia  as  far  out  as  the 
internal  abdominal  rings.  (3)  Guard  the  ureters  by  adhering  to  the  area  as 
near  the  middle  line  as  possible.  They  are  made  easier  of  detection  by  up- 
ward traction  upon  the  bladder.  (4)  A  sound  introduced  into  the  bladder 
during  the  progress  of  the  operation  will  often  be  of  aid.  (5)  The  incision  may 
pass  through  the  upper  half  of  the  prostate  and  a  portion  of  the  prostate  be  thus 
removed,  attached  to  the  seminal  vesicles — which  is  accomplished  by  an  in- 
cision beginning  at  the  upper  part  of  the  prostate,  anterior  to  its  junction  with 
the  vesiculae  seminales,  and  passing  obliquely  posterior  to  the  urethra  and 
terminating  about  the  center  of  the  posterior  aspect  of  the  prostate.  (6)  The 
seminal  vesicles  may  be  exposed  by  a  transverse  perineal  incision — and  also  by 
the  sacral  route,  as  in  the  operations  for  excision  of  the  rectum. 


VI.  THE  PROSTATE  GLAND. 

SURGICAL  ANATOMY. 

Description. — A  fibro-muscular  glandular  body  in  front  of  the  neck  of  the 
bladder  and  surrounding  the  beginning  of  the  urethra,  placed  posteriorly  and 
inferiorly  to  the  symphysis  pubis  and  posteriorly  to  the  triangular  ligament,  and 
resting  upon  the  rectum.  Its  measurements  are  the  following: — transversely 
at  base,  about  4  cm.  (1^  inches);  antero-posteriorly,  about  2.5  cm.  (1  inch); 
depth,  about  2  cm.  (f  inch).  The  prostatic  urethra  pierces  the  gland  generally 
one-third  nearer  the  posterior  than  the  anterior  aspects, — though  it  sometimes 
passes  nearer  the  anterior  aspect, — and  sometimes  only  the  inferior  three- 
fourths  of  the  urethra  is  surrounded  by  the  prostate.  The  ejaculatory  ducts 
pierce  the  gland  obliquely  forward  between  the  middle  and  lateral  lobes,  open- 
ing into  the  prostatic  portion  of  the  urethra.  The  glands  of  the  prostate 
open  into  the  prostatic  sinuses.  The  prostatic  sinuses  lie  upon  either  side 
of  the  verumontanum,  in  the  prostatic  part  of  the  urethra. 

Capsule  of  Prostate  Gland. — Firm,  thin,  fibrous  membrane  derived  from 
the  recto-vesical  portion  of  the  pelvic  fascia — separated  from  the  superior  layer 
of  the  deep  perineal  fascia  by  a  plexus  of  veins. 

Divisions  of  Prostate  Gland. — (1)  Two  Lateral  Lobes — deeply  notched 
posteriorly  and  slightly  furrowed  anteriorly.  (2)  Middle  Lobe — a  small,  ir- 
regularly shaped  prominence  upon  the  posterior  aspect  of  the  gland,  between 
the  two  lateral  lobes,  lying  above  the  sinus  pocularis  and  between  the  ejacu- 
latory ducts — and  placed  directly  under  the  neck  of  the  bladder,  posterior  to 
beginning  of  urethra. 


PROSTATECTOMY,  IN  GENERAL.  1141 

Fixations. — Held  in  place  by  the  anterior  or  pubo-prostatic  ligaments  of 
bladder;  by  the  superior  layer  of  the  triangular  ligament;  and  by  the  anterior 
part  of  the  levatores  ani. 

Base  of  Prostate. — Directed  upward  and  backward.  Lies  somewhat 
above  level  of  center  of  symphysis  pubis,  resting  upon  and  connected  with  neck 
of  bladder. 

Apex. — Directed  downward  and  forward,  resting  upon  superior  layer  of 
triangular  ligament.  Lies  about  1.3  cm.  (h  inch)  behind  and  slightly  inferior 
to  the  subpubic  angle.  By  rectal  examination,  about  3  cm.  (ij  inches)  above 
the  edge  of  the  an  is. 

Anterior  Surface. — Convex.  Lies  about  2  cm.  (f  inch)  posterior  to  lower 
aspect  of  symphysis.  Covered  by  prostatic  plexus  of  veins,  by  pubo-prostatic 
ligaments,  and  by  vesico-pubic  muscle. 

Posterior  Surface. — Flattened.  Rests  upon  anterior  aspect  of  rectum, 
some  dense  connective  tissue  and  muscular  fibers  intervening. 

Lateral  Surfaces. — In  relation  with  superior  surfaces  of  levatores  ani  and 
the  lateral  portions  of  the  venous  plexuses.  Extend  upward  as  two  indistinctly 
defined  lobes. 

Arteries. — branches  of  inferior  (and  probably  middle)  vesical,  from  an- 
terior trunk  of  internal  iliac;  branches  of  hemorrhoidal  arteries;  branches  of 
internal  pudic. 

Veins. — Receive  dorsal  vein  of  penis  and  form  plexuses  about  anterior  and 
part  of  lateral  aspects  of  gland — and  empty  into  branches  of  internal  iliac 
vein . 

Lymphatics. — End  in  pelvic  glands. 

Nerves. — Form  hypogastric  plexus. 


INSTRUMENTS. 
See  those  used  in  operating  upon  the  Bladder. 


PROSTATOTOMY. 

Description. — Incision  of  prostate  gland.  Indicated  in  abscess — and 
sometimes  resorted  to  for  division  of  the  prostatic  bar  or  collar  at  neck  of 
bladder. 

Operation. — While  the  prostate  gland  may  be  exposed  by  a  median  peri- 
neal incision,  as  in  Cock's  operation  for  perineal  section,  a  more  complete  and 
satisfactory  exposure  may  be  obtained  by  the  transversely  curved  perineal  in- 
cision described  under  proctatectomy.  For  the  exposure  of  the  prostate  by 
either  of  these  incisions,  therefore,  see  pages  11 26  and  1143. 


PROSTATECTOMY,  IN  GENERAL. 

Description. — Consists  in  the  removal  of  part  or  the  entire  prostate  gland. 
Indicated  chiefly  in  marked  hypertrophy  of  the  prostate.  Prostatectomy 
may  be  complete  or  partial — dependent  upon  the  amount  of  gland  removed. 

Varieties  of  Prostatectomy. — (1)  Suprapubic — applicable  to  smaller 
growths,  and  especially  applicable  to  enlargement  of  the  middle  lobe  alone,  or 
to  enlargement  of  middle  lobe  together  with  the  intravesical  part  of  the  lateral 
lobes.  (2)  Perineal  Prostatectomy — applicable  to  larger  involvements,  and 
especially  of  the  lateral  lobes  and  to  sub-urethral  growths.     Affords  excellent 


1 142  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

drainage.  (3)  Combined  Suprapubic  and  Perineal  Prostatectomy — giving 
freest  access  to  largest  growths.  This  method  is  probably  the  best.  Even  if 
the  perineal  operation  be  done  immediately  after,  a  suprapubic  cystotomy 
enables  the  vesical  aspect  of  the  prostate  to  be  thoroughly  examined. 


SUPRAPUBIC  PROSTATECTOMY 

BY  MEDIAN  VERTICAL  INCISION. 

Description. — Consists  in  the  removal  of  the  prostate  gland  through  a 
median  suprapubic  incision.  This  operation  is  frequently  only  a  partial  pros- 
tatectomy,  consisting  in  the  removal  of  the  median  lobe  of  the  prostate  and  the 
intravesical  parts  of  the  lateral  lobes. 

Preparation — Position — Landmarks — Incision. — As  for  suprapubic 
cystotomy  (page  1096). 

Operation. — (1)  Having  irrigated  the  bladder,  and  partly  filled  the  rectal 
bag  with  fluid  (which  should  not  be  more  than  six  or  eight  ounces  if  the  pros- 
tate be  large  and  hard),  the  operation  is  conducted  precisely  as  in  suprapubic 
cystotomy,  up  to  the  opening  of  the  bladder,  control  of  hemorrhage,  and  re- 
traction of  the  lips  of  the  bladder-wound  with  silk  traction-loops.  (2)  This 
much  having  been  accomplished,  the  condition  of  the  prostate  and  urethral 
opening  are  carefully  examined  with  the  finger — using  great  care  in  all  manip- 
ulations not  to  detach  the  bladder  from  its  connective-tissue  plane.  (3) 
Enucleation  of  the  enlarged  prostate  accessible  from  the  bladder  is  now  ac- 
complished by  fingers,  blunt  dissector,  curved  blunt  scissors,  a  curette,  and 
forceps  (the  instruments  all  having  long  handles).  The  mucous  membrane 
overlying  the  hypertrophied  middle  lobe  is  incised  vertically  with  scissors — and 
the  enlarged  growth  is  shelled  out  of  its  bed.  The  mucous  membrane  should 
be  divided,  as  nearly  as  possible,  in  the  median  line,  to  allow  of  subsequent 
suturing,  where  feasible,  though  suturing  is  not  absolutely  necessary.  Often 
pedunculated  parts  are  simply  cut  away  at  their  pedicles.  Where  a  collar-like 
bar  of  hypertrophied  gland  around  the  beginning  of  the  urethra  is  encountered, 
it  is  divided  by  inserting  a  blade  of  the  scissors  into  the  urethra  and  severing  it 
by  closure  of  the  blades  (if  special  scissors  with  serrated  edges  be  used,  hem- 
orrhage will  be  less) — the  forefinger  is  then  inserted  into  the  wound  thus  made 
— and,  while  an  assistant  pushes  the  prostate  upward  into  the  bladder  by 
counter-pressure  from  the  perineum,  the  surgeon  continues  the  process  of 
enucleation,  removing  as  much  of  the  lateral  lobes  as  possible,  in  mass  or  in 
piecemeal — and  as  much  of  the  sub-urethral  prostate  as  can  be  reached  and 
removed  by  sweeping  the  finger  around  the  urethra  and  enucleating  from  be- 
tween the  urethral  wall  and  capsule  of  the  gland.  (4)  At  the  end  of  the  opera- 
tion, the  edges  of  the  mucous  membrane  should  be  sutured  with  catgut,  if 
possible.  If  inaccessible,  or  too  much  torn  up,  they  may  be  dropped  into  place 
without  suturing.  Patency  of  the  urethra  should  be  ascertained  by  the  passage 
of  a  sound  through  the  meatus  and  by  digital  examination  of  the  prostatic 
urethra.  (5)  A  large  drainage-tube  is  inserted  into  the  bladder  through 
the  suprapubic  wound — around  which  the  edges  of  the  abdominal  wound 
are  closed  as  in  suprapubic  cystotomy. 

Comment. — (1)  The  Trendelenburg  position  is  convenient  after  opening 
the  bladder.  (2)  Intravesical  hemorrhage  is  controlled  by  hot  douching  and 
gauze  pressure.  In  some  cases  excessive  hemorrhage  may  necessitate  the 
packing  of  the  bladder  with  gauze.  (3)  The  operation  should  be  planned  so 
as  to  secure  a  level,  low  floor  at  the  bladder  opening  of  the  prostatic  urethra. 


PERINEAL  PROSTATECTOMY 


"43 


(4)  Some  operators  make  a  counter-opening  in  the  perineum  after  the  opera- 
tion— which  should  be  resorted  to  if  much  damage  have  been  done — and  both 
perineal  and  suprapubic  drainage  be  used. 


PERINEAL  PROSTATECTOMY 

BY  TRANSVERSE  CURVED  INCISION'. 

Description. — The  prostate  is  exposed  by  a  transversely  curved  incision — 
the  capsule  of  the  gland  being  divided  transversely  and  the  gland  tissue  enu- 
cleated with  the  finger. 

Preparation — Position. — As  for  perineal  cystotomy  (page  1102). 

Landmarks. — Ischial  tuberosities;  subpubic  arch. 

Incision. — Extends  from  one  ischial  tuberosity  to  the  opposite,  curving 
convexly  forward  toward  the  inferior  margin  of  the  subpubic  arch  (Fig.  830,  A). 

Operation. — (1)  Incise  the  skin  and  superficial  fascia — divide  the  ischio- 
rectal fattv  areolar  tissue  in  the  line  of  incision,  passing  clown  to  the  levatores 
ani.  (2)  Retract  forward  the  superficial  perineal  vessels  and  nerves,  the 
artery  and  nerve  to  the  bulb,  and  the  transversus  perinaei  muscle — and  retract 
backward  the  inferior  hemorrhoidal  vessels  and  nerves — clamping  and  tying 
bleeding  vessels.     (3)   Recognize  the  bulb  and  central  tendinous  point  of  the 


Fig. 830.— Perineal  Routes  for   Exposing   Prostate  Gland: — A,  Transverse  curved  incision; 

B,  Median  perineal  incision. 


perineum  (from  which  latter  the  transverse  perineal  muscles  extend  outward), 
all  exposed  in  the  wound.  Divide  transversely  the  external  sphincter  just 
posterior  to  its  junction  with  the  accelerator  urinas  at  the  central  tendinous 
point.  Retract  the  bulb,  transverse  perineal  muscles,  and  central  tendinous 
point  all  forward.  (4)  Incise  more  deeplv  still  along  the  transverse  curved 
incision — and  expose  the  compressor  urethra1  muscle,  surrounding  the  mem- 
branous urethra  from  the  prostate  behind,  to  the  bulbous  urethra  in  front. 
Above  the  compressor  urethra?  lies  the  inferior  aspect  of  the  prostate  gland, 
surrounded  by  dense  connective  tissue  continuous  with  the  pelvic  fascia  and 
forming  a  portion  of  the  capsule  of  the  gland.  (5)  Draw  this  fascia  downward 
and  the  rectum  backward,  and  incise  the  capsule  of  the  prostate  transversely, 
thereby  exposing  the  posterior  surface  of  the  prostate  gland.  (6)  The  index- 
finger  is  then  inserted  through  the  incised  capsule  and  the  process  of  enucleation 


1 144  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

of  the  gland  substance  from  below  upward  to  its  upper  border  is  accomplished 
in  the  same  general  manner  as  in  Alexander's  operation  (paragraph  6,  page 
1 145).  (7)  The  vasa  deferentia  lie  a  little  deeper — and  the  vesiculse  seminales 
lie  just  to  the  outer  sides  of  the  vasa  deferentia — both  of  which  structures  may 
be  exposed  and  removed  by  this  incision.  (8)  The  prostate  having  been  enu- 
cleated, a  sound  is  passed  through  the  entire  urethra  from  the  meatus — and 
especially  the  condition  of  the  prostatic  urethra  examined.  The  urethra  is  not 
opened  up,  supposedly,  by  the  perineal  manipulations.  (9)  Drainage  through 
the  perineal  wound  is  established — the  lateral  extensions  of  the  wound  being 
sutured  from  either  end  toward  the  median  line. 


PROSTATECTOMY  BY  THE  COMBINED  METHOD 

BY  MEDIAN   SUPRAPUBIC   AND   MEDIAN    PERINEAL   INCISIONS  — ALEXANDER'S 

OPERATION. 

Description. — The  prostate  is  first  exposed  through  a  regular  suprapubic 
incision,  for  the  purpose  of  examining  the  gland  and  to  enable  downward  dis- 
placement of  the  prostate  during  the  perineal  operation — and  the  gland  is  then 
removed,  as  far  as  required,  through  the  median  perineal  incision.  The  ob- 
jects of  the  operation  are  to  remove  the  obstructing  portions  of  the  prostate 
with  the  minimum  damage  to  the  bladder  and  urethra,  and  to  furnish  good 
drainage.  The  special  method  of  Alexander  involves  the  following  anatomical 
features  emphasized  by  its  author  (whose  writing  is  largely  followed  in  the  sub- 
sequent description): — (a)  The  prostatic  urethra  consists  of  two  parts; — (1) 
Vesical  portion — which  lies  above  the  openings  of  the  seminal  ducts  into  the 
prostatic  urethra;  and  which  has  thicker,  stronger  walls,  permitting  the  freeing 
of  the  prostate  without  damage  to  the  urethral  mucous  membrane.  (2)  Ure- 
thral portion — which  lies  below  the  openings  of  the  seminal  ducts  into  the 
prostatic  urethra;  and  which  has  thinner,  weaker  walls,  largely  supported  by 
prostatic  tissue,  (b)  Fibrous  trabecular  extend  from  the  central  fibrous  part 
of  the  prostate,  behind  the  urethra,  laterally  outward  to  the  fibrous  capsule — 
dividing  the  lateral  lobes  into  anterior  and  posterior  parts  by  forming  cleavage 
lines  between  them.  (1)  Anterior  portion — placed  in  front  of  the  fibrous 
trabecular,  at  the  side  of  the  urethra — which  are  the  only  parts  of  the  lateral 
lobes  whose  hypertrophy  causes  interference  with  urination.  (2)  Posterior, 
or  inferior,  portion — placed  posterior  to  the  fibrous  trabecular,  posterior  and 
inferior  to  the  urethra  and  seminal  ducts — the  hypertrophy  of  which  does  not 
cause  interference  with  urination,  (c)  Summary — the  anterior  portions  of  the 
lateral  lobes,  whose  hypertrophy  causes  urinary  obstruction,  may,  therefore, 
be  enucleated  en  masse,  without  injury  to  the  posterior  portions  or  to  the 
capsule. 

Preparation. — Bowels  emptied.  Bladder  irrigated  and  then  distended 
with  8  or  10  ounces.     Pubic  and  perineal  regions  shaved. 

Position. — Patient  as  for  suprapubic  cystotomy,  during  the  opening  of  the 
bladder — and  in  the  lithotomy  position  during  the  perineal  incision.  Surgeon 
to  patient's  left  at  first — and  then  seated  opposite  the  perineum.  Assistant  at 
first  opposite  surgeon  and  then  to  his  right. 

Landmarks- — Those  for  suprapubic  cystotomy  (page  1096)  and  for 
median  perineal  cystotomy  (page  1102). 

Incisions. — Same  as  for  median  suprapubic  cystotomy  (page  1096)  and 
for  median  perineal  section  (page  11 23).     (Fig.  830,  B.) 

Operation. — (1)   A  median  suprapubic   cystotomy  is  done — making  an 


PROSTATECTOMY  BY  THE   COMBINED  METHOD.  1145 

opening  into  the  bladder  large  enough  to  insert  the  index-finger.  The  lips  of 
the  bladder  wound  are  temporarily  sutured  to  the  lips  of  the  abdominal  wound, 
by  one  or  two  stitches  on  each  side.  The  intravesical  portion  of  the  prostate  is 
examined.  The  bladder  wound  is  then  protected  with  gauze.  (2)  A  fairly 
large,  centrally  grooved  sound  is  then  passed  into  the  bladder  from  the  meatus 
of  the  penis — and  steadily  held  in  the  middle  line  by  an  assistant.  (3)  The 
median  perineal  section  is  made  just  as  in  Syme's  operation  (page  1123) — ex- 
posing the  membranous  urethra.  Its  floor  is  divided  upon  the  grooved  sound, 
from  just  posterior  to  the  bulb  in  front,  to  the  apex  of  the  prostate  gland  be- 
hind. (4)  As  the  sound  is  being  withdrawn,  the  finger  is  passed  into  the 
bladder  through  the  prostatic  urethra,  which  is  dilated  by  the  finger.  (5)  The 
left  index  is  introduced  through  the  suprapubic  wound  into  the  bladder — and 
presses  the  prostate  firmly  toward  the  perineum,  to  bring  it  as  fully  into  the 
perineal  wound  as  possible.  (6)  The  right  index  passes  through  the  perineal 
wound  into  the  prostatic  urethra  and  begins  the  enucleation  of  the  prostatic 
gland  tissue — beginning  by  feeling  along  the  lateral  aspect  of  the  prostatic 
urethra  for  the  prominence  caused  by  the  inward  bulging  of  the  enlarged  lateral 
lobe.  The  mucous  membrane  is  broken  through  by  the  finger  just  in  front  of 
this  eminence  caused  by  the  intrusion  of  the  lateral  lobe.  The  finger  then 
works  its  way  along  the  cleavage  line  of  the  fibrous  trabecular,  between  the 
anterior  and  posterior  parts  of  the  lateral  lobe.  The  obstructing  part  of  the 
lateral  lobe  is  separated  with  comparative  ease  laterally  and  posteriorlv  from 
the  posterior  portion  of  the  gland  and  capsule.  The  obstructing  mass  is  then 
separated  from  the  mucous  membrane  at  the  neck  of  the  bladder  and  from  the 
superior  part  of  the  prostatic  urethra — aided  by  being  grasped  with  forceps  and 
drawn  toward  the  perineal  wound — while  the  left  index  in  the  bladder  aids 
in  guarding  the  mucous  membrane  against  being  torn.  (7)  The  procedure 
just  described  upon  one  lateral  lobe  is  repeated  upon  the  other  lateral  lobe,  if 
indicated.  (8)  If  an  enlarged  "middle  lobe"  exist,  it  is  pressed  down,  by  the 
finger  in  the  bladder,  into  the  perineal  wound,  into  the  area  formerlv  occupied 
by  the  enucleated  lateral  lobes,  when  it  is  also  enucleated  in  the  same  way  from 
beneath  the  mucous  membrane  and  without  further  injury  to  the  mucous  mem- 
brane— by  sweeping  the  finger  around  through  the  space  left  by  enucleating  the 
lateral  lobes.  Thus  the  only  part  of  the  urethra  which  is  torn  during  the  opera- 
tion is  that  portion  just  anterior  to  the  opening  of  the  seminal  ducts.  And  no 
injury  is  done  to  the  bladder  or  urethral  mucous  membrane  except  that  done  to 
the  mucous  membrane  of  the  prostatic  urethra  above  the  openings  of  the  vesi- 
cular seminales.  (9)  Hemorrhage  is  controlled  by  hot  water  and  gauze  pres- 
sure. The  bladder  and  perineal  wounds  are  irrigated  with  hot  salt  solution. 
A  stout  rubber  catheter  is  passed  into  the  bladder  through  the  perineal  wound — 
and  another  rubber  drainage-tube  is  inserted  into  the  bladder  through  the 
suprapubic  wound.  The  suprapubic  bladder  wound  is  sutured  about  the  tube 
by  Gibson's  method  (page  nog) — .similar,  in  principle,  to  Kaders  gastrostomy 
method.  The  perineal  wound  is  partly  closed  by  suture.  The  bladder  is  ir- 
rigated daily.  The  suprapubic  tube  is  generally  removed  in  four  days  and  the 
perineal  in  seven — complete  healing  of  both  wounds  being  expected  in  about 
five  weeks. 

Comment. — (1)  The  perineal  hemorrhage  may  require  temporary  gauze 
packing.  (2)  Guard  against  injury  to  the  rectum,  especially  during  work  near 
the  anterior  portion  of  the  prostatic  urethra.  (3)  In  conjunction  with  the 
regular  suprapubic  cystotomy,  some  surgeons  make  the  transverse  curved 
perineal  incision.  The  prostate  is  exposed  through  the  suprapubic  bladder 
wound  and  depressed  through  the  bladder  into  the  perineum.     The  capsule  of 


1 146  OPERATIONS  UPON  THE  MALE  GENITAL  ORGANS. 

the  gland  is  then  divided  transversely  through  the  perineal  wound  and  enu- 
cleated by  this  route. 

NOTE. 

Other  operations  upon  the  Penis,  Urethra,  Scrotum,  Testes,  Spermatic 
Cord,  Vesicula?  Seminales,  Ejaculatory  Ducts,  and  Prostate — as  well  as  the 
operations  upon  the  Epididymis,  Vasa  Deferentia,  and  Cowper's  Glands — be- 
longing more  particularly  to  special  Genito-Urinary  Surgery,  will  not  be  con- 
sidered here. 


CHAPTER  VII. 

OPERATIONS  UPON  THE  FEMALE  GENITAL 

ORGANS. 

I.  THE  UTERUS. 
SURGICAL  ANATOMY. 

(i)   Uterus. 

Description. — Situated  in  pelvic  cavity,  between  bladder  and  rectum, 
supported  by  its  ligaments — its  cervix  projecting  into  superior  part  of  vagina, 
downward  and  backward — and  its  base  upward  and  forward.  Communicates 
with  fallopian  tubes  and  vagina.  Consists  of  serous,  muscular,  and  mucous 
coats.  Length,  about  7.5  cm.  (3  inches) — breadth,  about  5  cm.  (2  inches) — 
thickness,  about  2.5  cm.  (1  inch).  Its  divisions  are — fundus,  body,  cervix, 
uterine  cavity,  internal  and  external  os,  and  openings  of  fallopian  tubes. 

Relations  of  Fundus  and  Body. — Anteriorly;  covered  by  peritoneum 
and  separated  from  posterior  aspect  of  bladder  by  utero  vesical  peritoneal 
pouch  (generally  occupied  by  coils  of  intestine).  Posteriorly;  covered  by 
peritoneum  and  separated  from  anterior  aspect  of  rectum  by  recto-uterine 
pouch  of  peritoneum  (in  which  are  generally  some  coils  of  intestines).  Lat- 
erally; broad  ligaments;  fallopian  tubes  (above);  round  ligament  (below); 
ligaments  of  ovaries  (behind).     Superiorly;  covered  by  peritoneum. 

Relations  of  Cervix  Uteri. — (1)  Intravaginal  Portion; — surrounded  by 
vagina,  which  extends  higher  posteriori}-  than  anteriorly — and  presents  opening 
of  os  externum.  (2)  Supravaginal  Portion ; — one-half  of  entire  cervix  is  supra- 
vaginal posteriorly,  and  two-thirds  anteriorly.  Presents  opening  of  internal  os. 
The  relations  of  supravaginal  portion  are  the  following: — Anteriorly;  bladder 
(areolar  tissue  intervening).  Posteriorly;  peritoneum  of  Douglas's  pouch. 
Laterally;  broad  ligament;  uterine  vessels;  ureters  (which  are  about  1.3  cm., 
or  ^  inch,  away).  (3)  Vaginal  Portion;  zone  of  vaginal  attachment — oblique 
— higher  posteriorly  than  anteriorly. 

Relations  of  Peritoneum. — Invests  whole  of  posterior  aspect  of  uterus, 
but  only  upper  three-fourths  of  anterior  aspect. 

Ligaments. — Three  pairs  peritoneal — four  pairs  muscular  (three  of  latter 
lying  between  folds  of  broad  ligament  and  one  between  folds  of  posterior  liga- 
ment). Two  Lateral  or  Broad  Ligaments  (peritoneal): — duplication  of 
peritoneum  extending  transversely  outward  from  sides  of  uterus  and  vagina  to 
sides  of  pelvis — the  two  peritoneal  layers  being  continuous  above  at  free  bor- 
der, but  diverging  below  and  laterallv,  and  including  various  structures  be- 
tween their  folds  (v.  Broad  Ligament,  page  1148).  Two  Anterior,  or  Vesico- 
uterine (peritoneal) : — reflected  from  top  of  bladder  to  anterior  wall  of  uterus, 
at  junction  of  supravaginal  cervix.  Two  Posterior,  or  Recto-uterine  (peri- 
toneal):— peritoneal  folds  reflected  backward  from  intraperitoneal  part  of  cer- 
vix and  vagina,  on  to  second  part  of  rectum — forming  lateral  boundaries  of 
Douglas's  pouch.     Two  Utero-sacral   (muscular): — muscular  bands  lying 

1147 


1 148     OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 

between  folds  of  the  posterior  or  recto-uterine  ligaments.  Extend  from  second 
and  third  pieces  of  sacrum  forward  and  downward  to  sides  of  uterus  at  junc- 
tion of  body  and  supravaginal  cervix  (opposite  os  internum),  crossing  the  sides 
of  the  rectum  opposite  the  junction  of  its  first  and  second  parts.  Two  Utero- 
pelvic  Ligaments  (muscular) : — muscular  expansions,  extending  between 
folds  of  broad  ligaments,  from  fascia  over  obturator  internus  muscles  to  sides 
of  uterus  and  vagina,  surrounding  the  utero-vaginal  vessels  and  nerves.  Two 
Utero-ovarian  Ligaments  (Ligaments  of  the  Ovaries)  (muscular) : — pro- 
longations of  uterine  muscular  fibers  in  the  form  of  round  cords,  extending 
between  folds  of  broad  ligaments,  from  upper  angles  of  uterus  to  inner  aspects 
of  ovaries.  Two  Round  or  Utero-inguinal  Ligaments  (muscular) : — fibro- 
muscular  cords,  10  to  12.5  cm.  (4  to  5  inches)  long,  placed  between  folds  of 
broad  ligaments,  extending  from  superior  angles  of  uterus  through  inguinal 
canals  to  labia  majora  (v.  Round  Ligaments,  page  1149). 

Arteries. — Ovarian,  of  abdominal  aorta — carried  into  broad  ligament  by 
infundibulo-pelvic  ligament — divides  into  tubal  artery  and  ovarian  artery 
proper.  Uterine,  of  internal  iliac — runs  downward  along  pelvic  wall  to  base  of 
broad  ligament — thence  inward  near  floor  of  pelvis  toward  cervix,  which  it 
reaches  at  junction  of  vagina,  passing  in  front  of  ureter — and  runs  up  side  of 
cervix  and  uterus  between  folds  of  broad  ligament,  communicating  with  oppo- 
site uterine  and  branches  of  ovarian. 

Veins. — Correspond  with  arteries.  Veins  from  ovarian  plexuses  empty — 
right,  into  inferior  vena  cava — left,  into  left  renal.  Veins  from  uterine  plexuses 
empty  into  internal  iliac  veins. 

Lymphatics. — Those  from  body  empty  into  lumbar  glands — and  those 
from  cervix  into  pelvic  glands. 

Nerves. — From  third  and  fourth  sacral — and  from  hypogastric  and  renal 
plexuses. 

(2)   Broad  Ligament.* 

Description. — Duplicative  of  peritoneum,  extending  transversely  from 
sides  of  uterus  and  vagina  outward  to  sides  of  pelvic  wall — the  two  layers  being 
continuous  superiorly  at  their  free  border — and  diverging  laterally  and  infe- 
riorly  to  envelop  various  structures  (v.  i.). 

Relations. — Superior  or  free  Border  (mesosalpinx): — summit  of  dupli- 
cative, where  it  envelops  fallopian  tube.  Extends  from  side  of  uterus  toward, 
pelvic  wall,  to  beyond  the  fimbriated  extremity  of  fallopian  tube.  Infundibulo- 
pelvic  ligament — that  portion  of  superior  border  of  broad  ligament  between 
fimbriated  extremity  of  fallopian  tube  and  lower  attachment  of  broad  ligament 
— a  concave,  rounded  border — the  ovarian  vessels  being  conveyed  in  this  liga- 
ment. Inferior  Border : — attached  to  levator  ani  muscle  and  recto-vesical 
fascia.  Ureters,  vessels,  and  nerves  pass  through  the  subperitoneal  areolar 
tissue  between  its  layers.  Internal  Border : — attached  to  lateral  walls  of 
uterus  and  vagina.  Utero-vaginal  vessels  and  muscular  bands  pass  between 
the  two  lamina?.  External  Border : — In  contact  with  obturator  fascia. 
Transmits  uterine  vessels  and  round  ligament. 

Structures  between  Two  Layers  of  Broad  Ligament. — Ovary — pro- 
jects from  posterior  lamina.  Ligament  of  ovary — from  angle  of  uterus  to 
lower  or  internal  aspect  of  ovary.  Fallopian  tube — in  upper  free  margin. 
Round  ligament — forms  a  ridge  beneath  anterior  lamina,  on  its  way  to  inguinal 
canal.  Parovarium  (fetal  relic) — between  ovary  and  outer  part  fallopian  tube. 
Duct  of  Gaertner;  hydatid  of  Morgagni;  small  cysts — all  fetal  relics.     Uterine, 

*  Here  described  because  involved  in  Hysterectomy. 


SURGICAL  ANATOMY  OF  THE  VAGINA.  1149 

ovarian,  and  funicular  vessels;  lymphatics;  and  uterine  plexus  of  nerves.  Sub- 
peritoneal fatty  areolar  tissue.  Involuntary  muscular  fibers — from  obturator 
fascia  to  sides  of  uterus  and  vagina. 

Broad  ligament  divides  pelvic  cavity  into : — Anterior  part — containing 
bladder,  urethra,  and  vagina; — Posterior  part — containing  rectum. 

Boundaries  of  Douglas's  Recto-uterine  Pouch. — Anteriorly;  posterior 
wall  of  uterus,  supravaginal  cervix,  upper  fourth  of  vagina.  Posteriorly; 
rectum,  sacrum.  Laterally;  sacro-uterine  ligaments.  Superiorly;  small  in- 
testines. 

(3)   Round  Ligaments.* 

Description. — Two  flat,  cord-like  bundles  of  muscular,  fibrous,  and  areo- 
lar tissue,  vessels  and  nerves,  continuous  with  uterine  fibers,  attached  to  supe- 
rior angles  of  uterus  just  below  and  in  front  of  fallopian  tube — each  passes 
upward,  outward,  and  forward  between  layers  of  broad  ligaments  to  pelvic 
wall,  raising  the  anterior  layer  of  broad  ligament  into  a  fold — curves  around 
deep  epigastric  artery  on  inner  side  of  external  iliac  artery — enters  internal 
abdominal  ring — passes  through  inguinal  canal — emerges  from  external  ring 
— its  fibers  then  becoming  lost  in  tissues  of  labia  majora  and  mons  veneris. 
May  be  accompanied  by  an  invagination  of  peritoneum,  the  canal  of  Nuck 
(analogous  to  pouch  of  peritoneum  accompanying  descent  of  testes),  which 
may  remain  patulous.  Receives  fibers  in  transit  through  inguinal  canal — and 
gives  off  few  fibers  to  pillars  of  ring.  Average  length — 10  to  12.5  cm.  (4  to  5 
inches).     Supplied  by  funicular  branch  of  superior  vesical  of  internal  iliac. 

(4)  Vagina. 

Note. — Vagina  is  here  described  in  connection  with  Vaginal  Hysterectomy. 

Description. — Extends  from  orifice  below  through  an  opening  in  tri- 
angular ligament,  to  neck  of  uterus  above— completely  surrounding  the  cervix. 
Extends  upward  much  further  beyond  posterior  lip  of  uterus  (about  2  cm., 
or  f  inch)  than  beyond  anterior  lip.  Length  of  anterior  wall,  about  6.3  cm. 
(2^  inches), — posterior  wall,  about  9  cm.  (3^  inches).  Fornices,  anterior  and 
posterior — consist  of  angles  of  reflection  of  vaginal  on  to  uterine  mucous  mem- 
brane. Transverse  section  of  vagina  is  H-shaped,  when  collapsed.  Struc- 
ture— fibrous,  muscular,  and  mucous  coats. 

Relations. — Anteriorly;  Base  of  bladder — loose  subperitoneal  fascia 
intervening.  Urethra — subperitoneal  areolar  tissue  intervening  in  upper  one- 
third,  but  closely  connected  in  lower  two-thirds.  Ureters — which  enter  blad- 
der 3.2  cm.  (i|  inches)  below  level  of  os  uteri.  Posteriorly ;  Rectum — Doug- 
las's peritoneal  cul-de-sac  intervening  for  about  2.5  cm.  (1  inch)  above — and 
subperitoneal  areolar  tissue  intervening  lower.  Perineal  body — below  (sepa- 
rating vagina  and  rectum).  Laterally: — Vaginal  branch  of  uterine  artery. 
Subperitoneal  venous  plexus  at  base  of  broad  ligament.  Ureters  crossing 
upper  third  obliquely.     Levatores  ani,  in  relation  with  lower  two-thirds. 

Arteries. — Vaginal,  internal  pudic,  vesical,  and  uterine  branches  of  in- 
ternal iliac;  external  pudic  branches  of  femoral. 

Veins. — Correspond  with  arteries — but  form  vaginal  plexuses  on  each  side 
of  vagina. 

Lymphatics. — Empty  chiefly  into  pelvic — some  into  inguinal  glands. 

Nerves.- — From  fourth  sacral  and  pudic  nerves — and  from  hypogastric 
plexus. 

*  Here  described  because  involved  in  Hysterectomy. 


1150 


OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 


Fig. 831. — Diagram  Showing  Some  of  the  Relations  of  the  Uterus: — A,  Uterus;  B,  Os 
uteri;  C,  Vagina  ;  D,  Ovary;  E,  Utero-ovarian  ligament;  F,  Fallopian  tube;  G,  Round  ligament; 
H,  H,  Ureters;  I,  Ovarian  artery;  J,  Internal  iliac  artery;  K,  Uterine  artery;  L,  L,  L,  Vaginal 
arteries;  M,  Infundibulo-pelvic  portion  of  broad  ligament.  The  position  of  the  ligatures  about  the 
vessels  and  broad  ligament  is  shown  (here  shown  as  interlocking,  which  is  unessential)  as  applied 
in  total  abdominal  hysterectomy. 


SURFACE  FORMS  AND  LANDMARKS. 

Utero-vesical  fold  of  peritoneum  is  about  on  a  level  with  the  internal  os 
uteri. 

Utero-rectal  fold  of  peritoneum  is  reflected  for  nearly  2.5  cm.  (1  inch)  on 
the  posterior  wall  of  the  vagina. 

The  cervix  may  be  divided  into  three  zones: — the  lower  third  is  intra- 
vaginal; — middle  third  is,  anteriorly,  supravaginal  (united  to  base  of  bladder) 
— and  intravaginal  posteriorly; — upper  third  is  supravaginal — united  to  blad- 
der anteriorly — and  in  relation  with  peritoneum  posteriorly. 

The  ureters,  in  the  case  of  a  normal  uterus,  with  empty  bladder,  lie  nearly 
1.3  cm.  (J  inch)  from  the  cervix.  They  pass  parallel  with  the  cervix  and  nearly 
1.3  cm.  (J  inch)  away — running  through  the  plexus  of  uterine  veins  and  under- 
neath the  broad  ligament — and,  continuing  near  the  vagina,  run  between  the 
vagina  and  bladder,  and  enter  the  bladder  about  on  a  level  with  the  center  of 
the  anterior  wall  of  the  vagina.  The  uterine  arteries  run  over  them,  upon  their 
inner  aspect.  For  further  description  of  the  female  ureter,  see  page  1074. 
For  the  course  of  the  uterine  and  ovarian  arteries,  see  page  1148  (also  see 
Fig.  831,  H,  H). 


INSTRUMENTS. 

See  those  given  under  Abdominal  Section  (page  801) — in  addition  to  which, 
may  be  mentioned: — vaginal  retractors;  broad  ligament  clamps;  vulsella  for- 
ceps; pedicle  clamps;  pedicle  needles,  straight  and  laterally  curved;  aneurism- 
needles,  straight  and  laterally  curved;  tenaculum-forceps;  long  artery-clamp 
forceps;  long  scalpels;  long  scissors,  straight  and  curved;  long  forceps,  toothed 
and  dissecting;  uterine  sound;  urethral  catheters. 


PARTIAL  ABDOMINAL  HYSTERECTOMY. 


PARTIAL  ABDOMINAL  HYSTERECTOMY,  TOGETHER  WITH  REMOVAL 
OF  OVARIES  AND  TUBES. 

I  PARTIAL  ABDOMINAL  HYSTERO-SALPINGO-OOPHORECTOMY.) 

Description. — The  supravaginal  portion  of  the  uterus,  together  with  the 
ovaries  and  tubes,  are  removed  through  a  median  abdominal  incision.  In 
Partial  Abdominal  Hysterectomy  the  supravaginal  portion  of  the  uterus  only 
is  removed,  and  the  vagina  is  not  opened.  In  Total  Abdominal  Hysterectomy 
the  entire  uterus,  including  the  cervix,  is  removed,  and  the  vaginal  vault  is 
opened.  The  ovaries  may  or  may  not  be  removed,  in  either  case — thev  should 
be  left  when  possible. 

Preparation. — Bowels  and  bladder  emptied.  Median  line  and  pubis 
shaved. 

Position. — An  upward  tilt  of  patient's  pelvis,  of  about  30.5  cm.  (12  inches), 
in  the  Trendelenburg  position  aids  by  causing  the  intestines  to  fall  awav  from 
the  uterus.  Surgeon  stands  on  patient's  right  during  most  or  the  entire  opera- 
tion.    Assistant  opposite. 

Landmarks. — Median  line;  navel;  symphysis  pubis;  position  of  bladder 
and  ureters. 

Incision. — In  median  line,  extending  from  umbilicus  downward  towards 
symphysis  pubis.  It  may  be  extended  above  the  umbilicus,  passing  directly 
through  the  navel,  or  may  pass  around  it  to  the  left.  It  averages  from  10  to 
15  cm.  (4  to  6  inches)  in  length. 

Operation. — (1)  Median  Abdominal  Section: — Perform  a  median  abdo- 
minal section  in  the  usual  manner — control  hemorrhage — retract  the  edges  of 
the  abdominal  wound — displace  the  small  intestines  and  the  sigmoid  coil  of  the 
large  intestine  and  keep  them  out  of  the  pelvis  with  gauze  pads,  aided  bv  the 
Trendelenburg  position.  Examine  the  contents. of  the  pelvic  cavity  and  learn 
the  condition  of  the  organs  and  the  presence  and  extent  of  adhesions.  (2) 
Freeing  Uterus,  Tubes,  and  Ovaries  from  Adhesions: — The  weakest  adhesions 
are  separated  by  the  fingers — firmer  adhesions  by  scissors — the  most  extensive 
are  divided  between  double  chromic  gut  ligatures,  as  near  the  uterus  as  possible. 
The  fundus  of  the  uterus  is  seized  with  vulsella  and  drawn  toward  the  pubis, 
and  the  rectum  displaced  backward,  while  freeing  the  posterior  aspect — then 
to  the  right,  while  freeing  the  left  aspect  of  the  uterus,  ovary,  tube,  and  broad 
ligament, — and  to  the  left  while  freeing  the  right  aspect  of  the  same  structures. 
Dense  adhesions  are  sometimes  more  easily  broken  up  by  following  down  the 
fallopian  tubes  and  working  up  under  the  tube  and  ovary,  than  from  above 
downward.  Free  more  closely  to  the  organ  to  be  removed  than  to  the  struc- 
tures to  be  left.  A  sound  in  the  uterus  will  often  aid  in  outlining  the  cleavage- 
lines  of  dense  adhesions,  along  which  separation  must  be  accomplished  by  dis- 
section with  knife  and  forceps,  or  scissors.  If  completion  of  the  freeing  of 
adhesions  in  the  usual  way  offers  insuperable  difficulties,  it  is  sometimes  best  to 
stop  and  ligate  the  ovarian  vessels  and  round  ligament  (in  the  manner  and 
order  described  below)  and  divide  the  upper  part  of  the  broad  ligament,  making 
it  possible  to  reach  and  free  the  tube  and  ovary  from  in  front.  (3)  Enuclea- 
tion : — (a)  Ligate  the  left  ovarian  vessels  with  silk,  at  the  outer  end  of  the  broad 
ligament,  beneath  the  sigmoid  colon — either  dividing  them  between  two  silk 
ligatures,  or  between  a  clamp  on  the  uterine  and  a  ligature  upon  the  pelvic  side 
— cutting  obliquely  across  the  broad  ligament  to  the  round  ligament,  (b)  The 
round  ligament  is  similarly  ligated  with  chromic  gut,  or  clamped  and  ligated, 
and  divided  about  1.3  cm.  (h  inch)  from  the  uterus,     (c)  The  vesico-uterine 


1152  OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 

peritoneum  is  detached  from  the  uterus,  by  first  incising  the  peritoneum  along 
the  concave  line  of  its  reflection,  from  left  round  ligament  to  right  round  liga- 
ment. While  the  uterus  and  adnexa  are  drawn  up  and  to  the  opposite  side,  the 
vesical  peritoneum  is  pushed  off  of  the  cervix  with  gauze  or  sponge  grasped  in  a 
holder  — thus  separating  bladder  from  cervix  and  baring  the  latter  for  about 
3  cm.  (ij  inches)  and  exposing  the  uterine  vessels,  (d)  Grasp  the  cervix  be- 
tween the  left  index  and  thumb,  and  verify  its  lower  termination  and  the  site 
of  the  uterine  arteries  on  each  side.  Ligate  the  left  uterine  vessels  by  silk  liga- 
ture carried  under  them  upon  a  curved  aneurism-needle,  passing  from  before 
backward  and  near  to  the  cervix — but  not  carried  too  deeply  alongside  of  the 
cervix,  for  fear  of  including  the  ureter.  Place  a  clamp,  or  a  second  ligature, 
on  the  uterine  side,  and  divide  between  them,  (e)  Amputate  the  cervix  trans- 
versely, just  above  the  vaginal  attachment — so  as  to  leave  the  stump  of  the 
cervix  cupped  antero-posteriorly  and  laterally.  Protect  the  cut  uterine  canal 
with  gauze  from  emptying  its  contents  into  the  wound  site.  Cauterize  the 
cervical  canal — and  stuff  with  gauze  down  into  the  vagina,  (f)  The  uterus 
is  drawn  upward  and  to  the  opposite  side — the  right  uterine  vessels  are  exposed 
and  are  ligated  and  divided  as  on  the  left  (or  may  be  clamped  at  first  and  tied 
later),  (g)  The  uterus  is  still  further  drawn  up  and  to  the  opposite  side — and 
the  round  ligament  ligated  as  on  the  left  and  divided  (or  may  be  first  clamped, 
and  ligated  later),  (h)  Cut  obliquely  across  the  broad  ligament  to  the  right 
ovarian  vessels  in  the  infundibulo-pelvic  ligament — ligating  and  dividing  them 
(or  clamping  first,  and  ligating  later).  The  enucleation  is  now  complete — and 
there  is  left  a  crescently  denuded  area  in  the  pelvic  cavity,  broadest  at  its  center, 
opposite  the  cervical  stump,  and  coming  to  points  at  the  brim  of  the  pelvis,  on 
either  side,  where  the  ovarian  vessels  were  ligated.  (4)  Closure  of  the  Cer- 
vical Canal: — The  cupped  surface  of  the  cervical  stump  is  sutured  with  chro- 
mic gut  in  such  a  way  as  to  approximate  the  anterior  and  posterior  aspects  by 
from  four  to  six  interrupted  sutures — entering  the  anterior  lip  exclusive  of  the 
vesical  peritoneum,  and  emerging  from  the  anterior  lip  anterior  to  the  cervical 
canal — then  passing  over  the  cervical  canal  and  entering  the  posterior  lip  just 
behind  the  cervical  canal  and  emerging  on  the  posterior  peritoneal  aspect  of  the 
cervical  stump — thus  closing  the  cervical  canal,  approximating  the  lips  of  the 
cervical  stump,  and  controlling  hemorrhage.  The  sutures  are  cut  short  and 
the  stump  dropped  back  into  place.  (5)  Repair  of  the  Pelvic  Floor: — Having 
seen  that  all  bleeding  vessels  are  ligated  (with  chromic  gut) — the  denuded  sur- 
faces are  entirelv  covered  in,  by  suturing  together  the  peritoneal  surfaces  with 
continuous  gut — uniting  the  edges  of  the  anterior  peritoneal  layer  of  the  broad 
ligament  and  reflected  vesical  peritoneum  in  front,  to  the  edges  of  the  posterior 
peritoneum  behind — beginning  and  ending  at  the  stumps  of  the  ovarian  vessels 
— and  suturing  the  vesical  peritoneum  opposite  the  cervical  stump  to  the  pos- 
terior peritoneum  which  has  been  included  in  the  stitches  which  closed  in  the 
cervical  canal.  (6)  Closure  of  the  Abdominal  Wound: — The  abdominal 
wound  is  closed  as  usual — without  drainage,  unless  specially  indicated. 

Comment. —  (1)  The  broad  ligament  is  everywhere  divided  between  liga- 
tures. Where  the  ligatures  for  the  ovarian  vessels,  round  ligament,  and  uterine 
vessels,  above  mentioned,  do  not  extend  entirely  across  the  broad  ligament,  in- 
tervening separate  ones  are  placed.  (2)  Especially  guard  against  injuring 
the  ureters  while  ligating  the  uterine  arteries  (see  Anatomy,  pages  1074  and 
1 150). 


TOTAL  VAGINAL  HYSTERECTOMY.  1153 


TOTAL    ABDOMINAL    HYSTERECTOMY,    TOGETHER    WITH    REMOVAL 
OF  OVARIES  AND  TUBES. 

(TOTAL  ABDOMINAL  HYSTERO-SALPINGO-OOPHORECTOMV.) 

Description. — The  entire  uterus,  including  the  cervix,  as  well  as  the 
ovaries  and  tubes,  are  removed,  and  the  vaginal  vault  opened — all  through  a 
median  abdominal  section.     The  ovaries  should  be  left  when  possible. 

Preparation — Position — Landmarks — Incision. — As  for  Partial  Abdo- 
minal Hysterectomy. 

Operation.— The  technic  is  so  similar  to  that  for  Partial  Abdominal 
Hysterectomy  that  only  those  points  will  be  mentioned  in  which  the  technic 
of  Total  Abdominal  Hysterectomy  differs  from  the  operation  just  described. 

(1)  The  lips  of  the  cervix  are  closed  with  strong  silk  sutures  applied  through 
the  vagina,  before  the  operation  is  begun — to  protect  the  abdominal  cavity 
from  infection.  The  vagina  is  packed  with  gauze.  (2)  When  the  peritoneal 
reflection  has  been  pushed  away  from  the  supravaginal  part  of  the  uterus,  and 
the  uterine  arteries  tied,  as  described  in  Partial  Hysterectomy  (clown  to  3 — d, 
page  1 15 1) — instead  of  cutting  through  the  cervix  transversely,  the  upper  limits 
of  the  vagina,  anteriorly  and  posteriorly,  are  determined — and  the  vaginal 
vault  is  then  opened  in  front,  about  1  to  2  cm.  (f  to  f  inch)  below  the  vaginal 
attachment  of  the  uterus,  by  means  of  the  thermocautery  or  scissors — aided 
by  a  vaginal  sound  passed  into  the  anterior  fornix,  if  necessary — the  incision 
being  continued  around  each  side  until  the  cervix  is  freed.  The  margin  of  the 
cut  vagina  isligated.  pari  passu,  with  chromic  gut  at  a  right  angle  to  its  long 
axis,  using  interlocking  ligatures  if  necessary — the  sutures  being  placed  parallel 
with  and  at  a  short  distance  from  its  margin.  The  sites  of  the  ligatures  re- 
quired in  total  abdominal  hysterectomy  are  shown  in  Fig.  831.  All  exposed 
areas  are  protected  with  gauze.  (3)  The  anterior  and  posterior  edges  of 
peritoneum  bordering  the  denuded  area  are  sutured  with  continuous  gut  in  a 
transverse  line  from  one  pelvic  brim,  across  the  pelvic  floor,  to  the  opposite 
pelvic  brim,  thus  repairing  the  floor  of  the  pelvis.  The  peritoneal  edges  are 
closed  over  the  vaginal  opening — but  the  opening  in  the  vaginal  vault  is  not 
sutured  together — but,  instead,  a  loose  gauze  pack  is  pushed  through  the 
opened  vaginal  vault  up  to  the  sutured  overlying  peritoneum.  (4)  The 
abdominal  wound  is  closed  in  the  ordinary  manner. 

Comment. — (1)  If  ureteral  catheters  are  passed  into  the  ureters  prior  to 
the  operation,  the  positions  of  the  latter  are  made  more  evident  during  opera- 
tion. (2)  The  uterine  arteries  may  be  ligatecl  further  back  in  the  pelvis,  nearer 
their  origin  from  the  anterior  branches  of  the  internal  iliacs — first  assuring  one's 
self  of  the  position  of  the  ureters  by  [ticking  up  the  uterine  artery  and  parallel 
tissues  between  the  index  and  thumb — and  then  allowing  them  to  slip  out  of 
the  grasp.  If  this  be  done,  the  artery  is  caught  and  drawn  up  and  the  dis- 
section of  the  connective  tissue  is  carried  on  down  to  the  uterus.  (3)  Veins, 
large  single  ones,  and  in  plexuses,  are  apt  to  be  encountered  in  the  broad  liga- 
ment and  on  the  pelvic  floor. 


TOTAL  VAGINAL  HYSTERECTOMY. 

Description. — Removal  of  entire  uterus  through  the  vault  of  the  vagina — 
the  incision  being  made  from  within  the  vagina.  Indicated  chiefly  for 
malignant  growth  of  the  cervix,  or  for  malignant  disease  limited  to  cervix 

and  fundus. 


i  '54 


OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 


Preparation. — Pubis,   labia,   and   perineum   shaved.     Vagina    cleansed. 
Bowels  and  bladder  emptied. 

Position. — Patient  supine,  at  end  of  table,  in  lithotomy  position.     Surgeon 
sitting  at  foot  of  table.      Assistant  to  surgeon's  right,  retracting  posterior  vagi 
nal  wall  with  large   Sims   or  other  retractor — while  the  lateral  vaginal  walls 
are  retracted  by  lateral  vaginal  retractors. 

Landmarks. — Anterior  and  posterior  vaginal  fornices;  known  position  of 
ureters  and  uterine  vessels. 

Operation. — (i)  The  lips  of  the  cervix  are  caught  and  drawn  down  with 


Fig. 8^52. — Vaginal  Hysterectomy: — I.  A,  Sutures  closing  lips  of  uterus  and  serving  as  trac- 
tion-loops, by  which  uterus  is  drawn  out  of  vagina  ;  B,  Knife  making  incision  through  mucous  mem- 
brane around  cervix,  at  level  with  vaginal  vault;  C,  Irrigator  washing  away  blood.  Vaginal  walls 
are  well  retracted  by  four  retractors.     (Modified  from  Kelly.) 


vulsella,  or  tenaculum-forceps — and  are  sutured  together  with  strong  silk  (to 
prevent  escape  of  contents).  The  silk  ligatures  may  be  left  as  long  traction- 
loops.  The  uterus  is  thus  drawn  well  down  into  the  outlet  (by  forceps  or 
loops) — while  the  vaginal  walls  are  retracted  downward  and  outward,  as  de- 
scribed above  (Fig.  832).  (2)  With  a  knife,  or  sharp  curved  scissors,  an  in- 
cision is  made  entirely  around  the  cervix,  passing  through  the  thickness 
of  the  vaginal  vault  down  upon  the  substance  of  the  cervix.  (3)  With 
the  right  index,  the  cellular  tissue  plane  is  opened  up  in  front  (between  uterus 


TOTAL  VAGINAL  HYSTERECTOMY 


"55 


and  bladder)  and  behind  (between  uterus  and  Douglas's  cul-de-sac) — by  push- 
ing up  and  peeling  back  the  tissues  with  the  pulp  of  the  finger  always  directed 
against  the  cervix,  to  prevent  the  fingers  from  slipping  off  violently  in  the 
wrong  direction  (Fig.  833).  This  separation  is  done  anteriorly  and  posteriorly 
— but  not  done  laterally,  where  the  vessels  enter  from  the  broad  ligament. 
Posteriorly,  Douglas's  cul-de-sac  is  recognized  by  a  slight  amount  of  fluid 
present  within  its  cup-like  cavity  and  by  the  smooth  surfaces  gliding  over  each 
other.     This  is  caught  with  forceps,  drawn  down  and  incised  with  sharp 


Fig. 833 —Vaginal  Hysterectomy  :— II.  Index-finger  opening  up  cellular  tissue  plane  between 
uterus  and  bladder,  anteriorly  ;  and  between  uterus  and  Douglas's  cul-de-sac,  posteriorly.  (Modified 
from  Kelly.) 


scissors  to  a  slight  extent,  the  opening  being  increased  to  the  broad  ligaments 
on  each  side  by  two  fingers  introduced  and  separated.  Anteriorly,  the  sepa- 
ration is  continued  until  the  anterior  vesico-uterine  peritoneal  fold  is  reached — ■ 
which  is  recognized  by  its  gliding  surfaces — and  which  is  drawn  down  with 
forceps  and  incised  with  sharp  scissors  to  a  limited  extent — the  opening  being 
increased  to  the  broad  ligament  on  each  side  by  fingers  introduced  and  sepa- 
rated, guided,  if  necessary,  by  a  sound  in  the  bladder.  The  peritoneal  cavity 
is  thus  opened  in  front  and  behind  and  the  uterus  is  left  hanging  from  the  broad 


1156 


OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 


ligaments  (4)  The  broad  ligaments  are  now  tied  off.  The  uterus  is  drawn 
well  down  and  to  the  side  opposite  that  upon  which  the  ligature  is  to  be  passed, 
while  the  corresponding  vaginal  wall  is  retracted.  The  left  index-finger  is 
passed  in  through  the  posterior  opening  behind  the  broad  ligament  and  near 
the  cervix.  A  strong  silk  ligature,  carried  by  a  laterally  curved  aneurism- 
needle,  is  passed  from  before  backward,  and  from  above  downward,  and  about 
1  cm.  (f  inch)  to  the  outer  side  of  the  cervix,  and  including  about  1  cm.  (f  inch) 
of  broad  ligament  tissue  (Fig.  834).  The  ligature  is  firmly  tied  and  the  broad 
ligament  included  is  immediately  divided  with  scissors,  rather  nearer  the 


Fig. 834. — Vaginal  Hysterectomy: — III.  Ligating  off  the  left  broad   ligament.     (Modified  from 

Kelly.) 


uterus — being  careful  not  to  make  the  division  higher  than  the  ligature  has 
gone.  Two  or  three  ligatures  can  generally  be  applied  to  one  side  before  plac- 
ing the  same  number  on  the  opposite  side,  during  downward  traction  of  the 
uterus  to  the  side  where  the  first  ligating  was  done  (always  drawing  it  to  the 
side  opposite  the  one  upon  which  the  greatest  exposure  is  wished).  Or  the 
ligating  may  be  continued  up  one  side  as  far  as  convenient,  even  to  the  cornu 
of  the  uterus,  and  then  upon  the  other  side.  The  uterine  vessels  are  generally 
included  in  the  second  or  third  ligature,  being  found  close  to  the  cervix  uteri 
near  the  os  internum.     The  position  of  the  uterine  artery  should  be  determined 


TOTAL    VAGINAL    HYSTERECTOMY. 


"57 


as  soon  as  the  opening  through  the  posterior  fornix  is  made.  Especial  care  is 
here  taken  to  avoid  the  ureter  (see  Surgical  Anatomy,  pages  1074  and  n 50). 
When  the  ligating  and  division  have  progressed  nearly  to  the  cornu  of  that  side, 
the  finger  can  be  passed  in  behind  and  hooked  over  the  remaining  broad  liga- 
ment, fallopian  tube,  and  round  ligament,  and  these  brought  down  and  ligated 
— this  last  ligature  being  tied  particularly  well  and  the  tissues  cut  at  a  distance. 
Often  it  is  easier  to  alternate — by  tying  two  or  three  ligatures  on  one  side — then 
on  the  opposite,  and  so  on.  'When  all  of  one  side  and  nearly  all  of  the  oppo- 
site broad  ligament  has  been  tied,  the  finger  may  be  introduced  and  hooked 
around  the  fundus  of  the  uterus  and  the  organ  delivered  sidewise — the  remain- 


Fig. 835.— Vaginal  Hysterectomy  :— IV.  Delivering  the  uterus  by  means  of  a  finger  introduced 
from  behind  and  below.  The  right  broad  ligament  has  been  entirely  ligated  and  cut.  (Modified 
from  Kelly.) 


ing  ligatures  being  applied  either  from  below  upward  or  from  above  downward, 
as  most  convenient,  while  the  organ  lies  in  the  vulval  fissure  (Fig.  835).  Or, 
after  progressing  a  part  of  the  way,  the  fundus  may  be  brought  down,  carrying 
the  cervix  up  into  the  pelvic  cavity  and  doubling  the  broad  ligament  upon 
itself — and  thus  applying  the  remaining  ligatures  in  the  reverse  direction.  But 
it  is  better,  and  more  surgical,  to  deliver  the  uterus  in  its  normal  axis — continu- 
ing the  ligating  and  division  upon  the  two  sides  as  first  described.  (5)  The 
right  and  left  groups  of  sutures  are  separated  and  held  aside  and  the  lower  pel- 
vic cavity  irrigated  and  mopped  or  sponged  out.  Each  line  of  broad  ligament 
ligatures  must  be  inspected — suspicious  ones  replaced — and  additional  ones 


u?8 


OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 


applied  where  indicated.  The  ligatures  of  each  side  are  tied  together  in  one 
group  and  cut  near  the  knot,  closely  within  the  vagina.  (6)  The  cut  edge  of 
the  vesico-uterine  peritoneal  fold  in  front  is  sutured  at  its  middle  with  gut  to  the 
middle  of  the  cut  edge  of  the  utero-rectal  peritoneal  fold  behind — either  by  a 
single  mattress  suture  bringing  the  central  portions  of  the  two  peritoneal  folds 
together,  or  by  a  continuous  suture  bringing  together  the  central  portion — 
leaving,  in  either  case,  a  gap  at  either  side  for  possible  drainage  in  cases  where 
the  vaginal  vault  is  not  sutured,  or  only  sutured  in  part.  Where  the  vaginal 
vault  is  entirely  sutured,  the  two  edges  of  the  peritoneum  should  be  sutured 
together  throughout.     (7)  The  vaginal  vault  may  be  left  entirely  unsutured — 


Fig. 836.— Vaginal  Hysterectomy: — V.  Peritoneal  and  vaginal  suturing;  A,  Vesico-uterine 
peritoneal  fold  ;  B,  Utero-rectal  peritoneal  fold.  A  transverse  line  of  interrupted  sutures  unites  the 
central  portion  of  these  folds.  C,  C,  Vessels  and  broad  ligament  ligated.  D,  Vault  of  vagina  ;  E, 
Sutures  approximating  cut  edges  of  anterior  and  posterior  vaginal  fornix,  thus  repairing  dome  of 
vagina  ;  F,  Each  lateral  vaginal  suture  also  passes  through  broad  ligament  stump,  and  thus  brings  it 
into  lip  of  vaginal  wound.     (Modified  from  Kelly.) 


in  which  cases  it  is  packed  loosely  with  gauze,  and  the  vagina  is  then  packed 
rather  snugly.  In  other  cases,  which  method  is  to  be  preferred,  the  vaginal 
vault  is  entirely  closed  by  a  line  of  continuous  or  interrupted  gut  sutures  bring- 
ing the  cut  edges  of  the  fornices  together  and  crossing  the  dome  of  the 
vagina  from  before  backward.  But  at  each  side  the  lower  portion  of  the  ligated 
broad  ligament  is  caught  and  drawn  down  into  the  upper  part  of  the  vagina, 
and  the  sutures  which  pass  through  the  lips  of  the  vaginal  vault  also  pass 
through  and  include  some  of  the  broad  ligament  stump — the  stumps  on  the 
two  sides  thus  projecting  into  the  vagina,  thus  insuring  drainage.     (Fig.  836.) 


SURGICAL  ANATOMY  OF  THE  OVARIES.  1159 

Comment. — (1)  Up  to  the  opening  of  the  peritoneal  cavity,  blood  is  re- 
moved by  constant  irrigation  through  a  special  glass  tube  held  just  above  the 
vulva, — after  opening  the  peritoneum,  by  gauze  mops.  (2)  Catheters  passed 
into  the  ureters  before  the  operation  enable  the  position  of  the  ureters  to  be 
readily  made  out  and  guarded  during  operation.  (3)  If  it  be  found,  during 
operation,  that  it  is  desirable  to  remove  the  tubes  and  ovaries,  ligatures  are 
placed  on  the  outer  side  of  these.  These  ligatures  are  somewhat  more  difficult 
to  apply  and  tighten  than  the  others.  (4)  Especially  guard  the  ureters  near 
the  cervix  and  behind  the  uterine  arteries,  while  working  near  the  cervix. 


II.  THE  OVARIES. 

SURGICAL  ANATOMY. 

(1)    Ovaries. 

Description. — Placed  one  on  each  side  of  the  pelvis — connected  with  the 
posterior  layer  of  the  broad  ligament,  posterior  and  inferior  to  the  fallopian 
tubes.  Rests  against  the  lateral  wall  of  pelvis,  with  long  axis  nearly  vertical 
in  erect  position  of  body  (His).  Length,  about  3.8  cm.  (ih  inches) ; — breadth, 
about  2  cm.  (f  inch); — thickness,  about  1.3  cm.  (J  inch).  Position  of  ovary 
corresponds  with  a  point  about  5  cm.  (2  inches)  internal  to  the  anterior  superior 
iliac  spine.  In  the  position  and  relations  given  by  His,  the  fallopian  tube  and 
fimbria  almost  completely  envelop  the  ovary.  In  structure,  the  ovary  con- 
sists of  peritoneal  serous  covering  and  stroma. 

Relations. — Mesial  Surface; — Is  free.  Fimbriated  extremity  of  fallo- 
pian tube  is  in  contact  to  various  extent.  Mesosalpinx  is  also  in  relation. 
Coils  of  jejunum  and  ileum  often  to  inner  side  of  right  ovary.  Sigmoid  colon 
may  be  to  inner  side  of  left  ovary.  Lateral  Surface  ; — Lies  in  fossa  ovarii,  a 
peritoneal  depression  upon  the  lateral  pelvic  wall,  generally  just  below  the 
external  iliac  vessels — with  the  ureter  often  bounding  the  fossa  below  and  be- 
hind. Posterior  Border; — Is  free.  Directed  toward  rectum.  Partly  em- 
braced by  fimbriated  end  of  fallopian  tube.  Anterior  Border; — Furnishes 
attachment  to  broad  ligament.  Presents  hilum  (between  two  layers  of  broad 
ligament)  for  entrance  of  vessels  and  nerves.  Fallopian  tube.  Upper  Ex- 
tremity; — Ovarian  fimbria  of  fallopian  tube  are  attached.  Ligamentum  sus- 
pensorium  ovarii  (ligamentum  infundibulo-pelvicum)  passes  from  brim  of 
pelvis  to  upper  extremity — conveying  the  ovarian  vessels  and  nerves.  Lower 
Extremity ; — Ligament  of  ovary — from  angle  of  uterus  to  lower  or  inner  end 
of  ovary. 

Arteries. — Ovarian  of  abdominal  aorta;  anastomotic  branches  of  uterine 
and  internal  iliac.  The  ovarian  artery,  crossing  brim  of  pelvis,  enters  broad 
ligament  and  runs  in  infundibulo-pelvic  ligament — and,  passing  between 
layers  of  broad  ligament,  runs  to  the  ovary  and  upper  part  of  uterus. 

Veins. — Follow  the  arteries — and  form  the  pampiniform  plexus. 

Nerves. — From  ovarian  plexus;  from  pelvic  plexus;  from  uterine  nerves. 

Lymphatics. — Empty  into  prevertebral  glands,  in  front  of  aorta  and  vena 
cava. 

(2)    Fallopian  Tubes. 

Description. — Average  length,  10  to  12.5  cm.  (4  to  5  inches).  Begin  at 
superior  angle  of  uterus  and  extend — enclosed  in  upper  free  border  of  the 


u6o     OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 

broad  ligament — to  the  sides  of  the  pelvis,  ending  in  the  fimbriated  extremities, 
which  are  in  relation  with  the  corresponding  ovaries.  After  enveloping  the 
fallopian  tubes,  the  layers  of  the  broad  ligament  are  continued  down  to  the 
ovary.  The  tubes  are  made  up  of — the  isthmus  (inner  third) — ampulla  (from 
isthmus  to  neck) — neck  (or  ostium  abdominale) — and  fimbriated  extremity. 
They  are  composed  of  serous,  muscular,  and  mucous  coats. 

Course  and  Relations. — From  the  superior  angles  of  the  uterus,  the}'  run 
nearly  horizontally  outward,  for  about  1.3  to  2.5  cm.  (J  to  1  inch)  to  the 
pelvic  wall — thence  ascend,  sometimes  tortuously,  anteriorly  to  their  ovaries — 
then  curve  backward  over  the  ovaries,  lying  internal  to  the  suspensory  liga- 
ment— and  end  by  passing  downward  along  the  inner  and  posterior  borders 
of  the  ovaries.  Ileo- jejunal  convolutions  are  sometimes  above  and  to  inner 
side  of  right  fallopian  tube.  Sigmoid  rectum  is  sometimes  in  the  same  relation 
to  the  left  tube. 

Artery. — Tubal  branch  of  ovarian. 


OVARIECTOMY,    OR    OOPHORECTOMY,    WITH    REMOVAL    OF    FALLO- 
PIAN TUBE. 

(SALPINGO-OVARIECTOMY,  OR  SALPINGO-OOPHORECTOMV.) 

Description. — Ovariectomy  (or,  less  correctly,  Ovariotomy)  consists  in  the 
removal  of  the  ovary  through,  generally,  an  abdominal  section.  When  the 
fallopian  tube  is  simultaneously  removed,  the  operation  becomes  Salpingo- 
ovariectomy,  or  Salpingo-oophorectomy.  The  ovary  may  be  removed  alone, 
or  the  tube  may  be  removed  alone.  In  the  operation  here  described, 
the  following  structures  will  be  removed: — entire  ovary,  entire  fallopian  tube, 
part  of  utero-ovarian  ligament,  and  the  arteries,  veins,  lymphatics,  and  nerves 
belonging  to  these  structures. 

Preparation. — Median  line  and  pubis  shaved.  Bowels  and  bladder 
emptied. 

Position. — Patient  supine  near  edge  of  table  at  first — and  subsequently 
elevated  into  slight  Trendelenburg  position  after  the  abdomen  is  opened.  Sur- 
geon on  side  of  operation — or  always  on  patient's  right,  independently  of  ovary 
operated  upon — or  may  prefer  to  cut  upward,  and  then  stands  on  patient's  left 
in  both  cases.     Assistant  opposite. 

Landmarks. — As  for  median  abdominal  section  (page  801). 

Incision. — In  median  line — about  5  to  10  cm.  (2  to  4  inches)  in  length — 
extending  upward  from  a  point  about  2.5  cm.  (1  inch)  above  the  symphysis 
pubis. 

Operation. — (1)  Perform  a  median  abdominal  section — control  hemor- 
rhage— and  retract  lips  of  abdominal  wound.  (2)  Pass  the  first  and  second 
fingers  into  the  wound,  with  the  back  of  the  hand  to  the  abdomen — follow 
down  the  under  surface  of  the  abdominal  parietes  to  the  symphysis — thence 
down  on  to  the  bladder  and  uterus — and  thence  out  laterally  over  the  superior 
cornu  of  the  uterus,  with  the  palm  of  the  hand  still  downward,  to  and  along  the 
broad  ligament — along  the  posterior  superior  aspect  of  which  the  fallopian  tube 
is  found — and,  just  posterior  to  the  tube,  the  ovary.  These  structures  are 
drawn  toward  the  median  line,  into  an  accessible  position  in  the  abdominal 
wound.  (3)  The  ovarian  artery  and  veins  are  first  tied,  with  silk — the  ligature 
being  carried,  upon  a  laterally  curved  aneurism-needle,  through  the  clear  space 
of  the  broad  ligament  and  tied  over  the  top  of  the  infundibulo-pelvic  ligament, 
outside  of  the  fimbriated  end  of  the  fallopian  tube,  and  close  to  the  brim  of  the 


OVARIECTOMY. 


1161 


pelvis  (Fig.  837).  (4)  The  utero-ovarian  ligament,  lying  behind  the  fallopian 
tube,  is  ligated  with  chromic  gut,  rather  nearer  the  uterus,  carried  upon  a  later- 
ally curved  aneurism-needle.  (5)  The  inner  end  of  the  fallopian  tube  and  the 
upper  free  part  of  the  broad  ligament  are  ligated  with  silk  near  the  horn  of  the 
uterus — which  ligature  also  controls  the  branches  from  the  uterine  artery.  (6) 
The  structures  are  now  removed  by  cutting  through  the  broad  ligament  well 
within  the  outer  ligature  of  the  ovarian  vessels — and  cutting  through  the  fallo- 
pian tube  and  ovarian  ligament  well  to  the  outer  side  of  their  ligatures — and 


Fig.  837.—  Ovariectomy,  with  Removal  of  Fallopian  Tube:  — A,  Uterus;  E,  Aneurism- 
needle  carrying  ligature  around  utero-ovarian  ligament;  C,  Ligature  passing  through  broad  liga- 
ment and  surrounding  fallopian  tube  and  ovarian  artery ;  D,  Ligature  passing  through  broad 
ligament  and  over  top  of  infundibulo-pelvic  ligament  and  surrounding  ovarian  artery;  E,  Round 
ligament;  F,  Bladder  ;  G,  Colon. 


carrying  the  incision  through  the  broad  ligament  well  below  the  hilum  of  the 
ovary.  Any  doubtful  ligature  is  strengthened,  and  any  bleeding  point  is  sur- 
rounded by  an  additional  gut  ligature.  (7)  The  edges  of  the  anterior  and  pos- 
terior layers  of  the  broad  ligament,  left  by  the  removal  of  the  above  structures, 
are  sutured  together  with  gut.  The  patient  is  lowered  to  the  horizontal  posi- 
tion— and  the  intestines  and  omentum  are  replaced.  (8)  The  abdomen  is 
closed,  as  after  median  abdominal  section. 

Comment. — (1)  The  main  danger  in  the  operation  is  from  uncontrolled 


n62  OPERATIONS  UPON  THE  FEMALE  GENITAL  ORGANS. 

hemorrhage.  Where  there  is  any  danger  of  a  ligature  slipping,  one  end  of  the 
ligature  may  be  carried  through  neighboring  tissue  and  knotted  to  the  oppo- 
site end.  (2)  The  non-vascular  portion  of  the  broad  ligament  between  the 
ligatures  of  the  special  structures  may  be  left  free — or,  if  ligated,  should  be  so 
ligated  as  not  to  bind  the  pelvic  and  uterine  aspects  of  the  broad  ligament 
together. 

NOTE. 

Other  operations  upon  the  Uterus  and  Ovaries,  and  the  operations  upon 
the  Fallopian  Tubes,  Broad  Ligaments,  Round  Ligaments,  Labia  Majora  and 
Minora,  Clitoris,  Hymen,  Glands  and  Ducts  of  Bartholin,  Bulbi  Vestibuli, 
Vagina,  Female  Perineum,  Female  Bladder,  Female  Urethra,  and  Female 
Ischio-rectal  regions — all  belonging  more  particularly  to  special  Gynecological 
Surgery,  will  not  be  considered  here. 


CHAPTER  VIII. 

OPERATIONS  FOR  HERNIAE. 

I.    INGUINAL  HERNIA. 

SURGICAL  ANATOMY. 

The  structures  encountered  in  the  operations  for  inguinal  hernia?  and 
those  in  the  immediate  neighborhood  of  the  site  of  operation,  will  be  here 
briefly  described — chiefly  in  the  order  encountered,  from  without  inward. 

Superficial  Fascia. — Divisible  into  two  layers,  between  which  lie  super- 
ficial arteries,  veins,  lymphatics,  and  nerves  of  the  inguinal  region. 

Superficial  Layer  of  Superficial  Fascia. — Continuous  with  superficial 
fascia  of  abdomen,  thigh,  penis,  scrotum,  labia,  and  perineum. 

Superficial  Arteries. — Superficial  epigastric  branch  of  femoral.  Super- 
ficial circumflex  iliac  of  femoral.     Superficial  external  pudic  of  femoral. 

Superficial  Veins. — Accompany  arteries  and  end  in  internal  saphenous 
vein. 

Superficial  Lymphatics. — Superior  group,  along  Pouparfs  ligament. 
Inferior  group,  around  saphenous  opening. 

Superficial  Nerves. — Hypogastric  branch  of  Iliohypogastric,  Ilio-inguinal. 

Deep  Layer  of  Superficial  Fascia  (Scarpa's  Fascia). — Attached  to 
linea  alba — continuous  with  superficial  fascia  over  trunk — connected  with 
fascia  lata — helps  form  dartos — continuous  with  deep  layer  of  superficial  fascia 
of  perineum. 

External  Oblique  Muscle. — 

Pcupart's  Ligament. — That  portion  of  aponeurosis  of  external  oblique 
extending  from  anterior  superior  iliac  spine  to  spine  of  os  pubis. 

Gimbernat's  Ligament. — That  portion  of  aponeurosis  of  external  oblique 
which  is  reflected  from  Poupart's  ligament,  at  spine  of  os  pubis,  along  the 
pectineal  line. 

Triangular  Ligament. — That  portion  of  aponeurosis  of  external  oblique 
which  is  reflected  from  Gimbernat's  ligament,  at  the  pectineal  line,  upward  and 
inward  beneath  the  spermatic  cord  and  behind  the  internal  pillar  of  the  ex- 
ternal ring  and  in  front  of  the  conjoint  tendon,  to  the  linea  alba,  where  it  inter- 
laces with  its  fellow  of  opposite  side. 

External  or  Superficial  Abdominal  Ring. — A  triangular  opening  in 
aponeurosis  of  external  oblique  immediately  above  and  just  external  to  crest  of 
os  pubis.  Bounded,  interiorly,  by  crest  of  os  pubis, — Superiorly,  by  inter- 
columnar  fibers,  strengthened  by  intercolumnar  fascia, — Internally,  by  inner 
or  superior  pillar, — Externally,  by  outer  or  inferior  pillar.  Transmits  sper- 
matic cord  in  male,  and  round  ligament  in  female. 

Internal  Oblique  Muscle. — 

Conjoint  Tendon  of  Internal  Oblique  and  Transversalis. — Inserted 
into  crest  of  os  pubis  and  pectineal  line,  directly  behind  external  abdominal 
ring. 

Cremaster  Muscle. — Corresponds  with  inferior  fibers  of  internal  oblique 

1163 


1164  OPERATIONS  FOR   IIKRM.K. 

— arising  from  center  of  Poupart's  ligament,  where  they  are  continuous  with 
the  interno-inferior  aspect  of  that  muscle — descend  along  external  and  anterior 
aspect  of  spermatic  cord — curve  around  testicle — and,  ascending  along  inner 
aspect  of  cord,  are  inserted  into  crest  of  os  pubis  and  anterior  surface  of  sheath 
of  rectus.     The  fascia  cremasterica  increases  the  strength  of  these  fibers. 

Transversalis  Muscle. — 

Transversalis  Fascia. — 

Inguinal  Canal. — Transmits  spermatic  cord  in  male — and  round  ligament 
in  female.  Extends  obliquely  downward  and  inward  for  about  3.8  cm.  (1^ 
inches) — parallel  with  and  slightly  above  Poupart's  ligament — beginning  at  the 
internal  abdominal  ring  and  ending  at  the  external  abdominal  ring.  Anterior 
boundaries, — skin;  superficial  fascia;  aponeurosis  of  external  oblique  (through- 
out);  internal  oblique  (outer  third).  Posterior  boundaries, — triangular  liga- 
ment; conjoint  tendon  of  internal  oblique  and  transversalis;  transversalis  fascia; 
subperitoneal  fat;  peritoneum.  Superior  boundaries, — curved  fibers  of  in- 
ternal oblique  and  transversalis.  Inferior  boundaries,- — junction  of  fascia 
transversalis  and  Poupart's  ligament. 

Internal  or  Deep  Abdominal  Ring. — An  oval  opening  lying  in  the  trans- 
versalis fascia,  half-way  between  the  anterior  superior  iliac  spine  and  symphy- 
sis pubis,  and  about  1.3  cm.  (^  inch)  above  Poupart's  ligament.  Superior  and 
External  boundary, — curved  fibers  of  transversalis.  Inferior  and  Internal 
boundaries, — deep  epigastric  vessels.  Transmits  spermatic  cord  in  male — and 
round  ligament  in  female.  Infundibuliform  process  of  fascia  transversalis 
strengthens  its  opening. 

Subperitoneal  Areolar  Tissue. — 

Deep  Epigastric  Artery,  of  External  Iliac. — 

Other  anatomical  points,  necessary  to  the  thorough  understanding  of  the 
Inguinal  Hernia?,  are  given  under  General  Surgical  Considerations. 


GENERAL  SURGICAL  CONSIDERATIONS. 

Definition  of  Inguinal  Hernia. — Hernia  passing  through  the  abdominal 
wall  in  the  inguinal  region. 

Varieties  of  Inguinal  Herniae. — (1)  External  or  Oblique  Inguinal 
Hernia, — neck  of  sac  lies  external  to  deep  epigastric  artery, — follows  course  of 
spermatic  cord  through  inguinal  canal.  (2)  Internal  or  Direct  Inguinal 
Hernia, — neck  of  sac  lies  internal  to  deep  epigastric  artery, — hernia  pene- 
trates some  portion  of  abdominal  wall  internal  to  deep  epigastric  artery. 

(a)  Oblique  or  External  Inguinal  Hernia. — 

Coverings  of  Oblique  Inguinal  Hernia  : — The  hernia  enters  the  external 
inguinal  fossa  (v.  i.) — and,  passing  down  from  the  abdominal  cavity,  receives 
the  following  coverings,  in  order; — (1)  At  Internal  Abdominal  Ring: — perito- 
neum; subserous  areolar  tissue;  infundibuliform  process  of  fascia  transversalis; 
■ — (2)  In  Inguinal  Canal: — (passes  under  curved  fibers  of  internal  oblique 
and  transversalis,  but  does  not  receive  a  covering  from  them);  cremaster 
muscle; — (3)  At  External  Abdominal  Ring: — intercolumnar  fascia; — (4)  In 
Scrotum: — superficial  fascia;  skin. 

Position  of  Oblique  Inguinal  Hernia. — This  variety  of  Inguinal  Hernia 
always  lies  to  the  outer  side  of  the  deep  epigastric  artery — and  generally  lies 
anterior  to  the  vessels  of  the  spermatic  cord — and  rarely  descends  below  the 
the  testis  (because  of  adhesion  of  the  hernial  coverings  to  the  tunica  vaginalis). 


INGUINAL  HERNIA— GENERAL  SURGICAL  CONSIDERATIONS.   1 165 

Seat  of  Stricture  in  Oblique  Inguinal  Hernia. — Most  frequently  at  the 
internal  ring, — may  occur  at  the  external  ring, — or  may  occur  in  the  canal,  by 
fibers  of  internal  oblique  and  transversalis. 

(b)  Direct  or  Internal  Inguinal  Hernia. — A  correct  understanding  of 
this  form  of  hernia  depends  upon  a  knowledge  of  the  anatomy  of  the  lower 
abdominal  wall: — 

Cord-like  Structures  upon  Inner  Aspect  of  Lower  Abdominal  Wall. — 
Seven  cord-like  structures  are  seen  upon  the  inner  aspect  of  the  lower  abdom- 
inal wall — ranging  from  near  the  median  line  upward: — (a)  Plica  Urachi — 
remains  of  fetal  urachus  in  median  line; — (b)  Two  Plica?  Hypogastrics — 
obliterated  hypogastric  arteries  on  each  side  of  median  line,  running  upward 
toward  the  median  line; — (c)  Two  Plicae  Epigastrica? — deep  epigastric  arteries 
running  upward  and  toward  median  line; — (d)  Two  Poupart's  Ligaments — 
running  upward  and  outward. 

Fossae  upon  Inner  Aspect  of  Lower  Abdominal  Wall. — Eight  fossa?  are 
formed  by  the  peritoneum  stretched  over  these  prominent  cord-like  structures 
— by  the  depressions  between  them: — (a)  Two  Internal  Inguinal  Fossa? — be- 
tween plica?  urachi  and  plicae  hypogastrics; — (b)  Two  Middle  Inguinal 
Fossa? — between  plica?  hypogastrica?  and  plica?  epigastricae; — (c)  Two  Ex- 
ternal Inguinal  Fossa? — between  plicae  hypogastrica?  and  Poupart's  ligaments; 
(d)  Two  femoral  fossa? — below  Poupart's  ligaments,  to  inner  side  of  femoral 
vein. 

Relations  of  Herniee  to  Fossae  upon  Inner  Aspect  of  Lower  Abdom- 
inal Wall. — (i)  Through  the  External  inguinal  fossa,  an  oblique  inguinal 
hernia  occurs; — (2)  Through  either  the  Internal  or  Middle  inguinal  fossa,  a 
direct  inguinal  hernia  comes; — (3)  Through  the  Femoral  fossa,  a  femoral 
hernia  occurs. 

Fossae  within  Hesselbach's  Triangle  through  which  direct  Inguinal 
Hernia  may  come. — Hesselbach's  Triangle  is  bounded — Externally;  by  deep 
epigastric  artery; — Internally;  by  outer  border  of  rectus  muscle; — Interiorly; 
by  Poupart's  ligament.  The  conjoint  tendon  of  the  internal  oblique  and  trans- 
versalis is  stretched  across  the  inner  two-thirds  of  Hesselbach's  triangle.  The 
remaining  outer  one-third  has  only  the  subperitoneal  areolar  tissue  and  trans- 
versalis fascia  between  the  peritoneum  and  the  external  oblique  aponeurosis. 
The  plica  hypogastrica  divides  Hesselbach's  triangle  into  an  internal  inguinal 
fossa  (which  is  the  region  of  the  conjoint  tendon)  and  a  middle  inguinal  fossa. 
Two  forms,  therefore,  of  direct  inguinal  hernia  may  occur — dependent  upon 
whether  the  hernia  escapes  through  the  inner  two-thirds  or  the  outer  one- 
third  of  Hesselbach's  triangle. 

Commoner  Form  of  Direct  Inguinal  Hernia. — In  which  the  hernia  en- 
ters the  internal  inguinal  fossa,  and  either  forces  its  way  through  the  conjoint 
tendon,  in  the  inner  two-thirds  of  Hesselbach's  triangle — or  carries  the  con- 
joint tendon  before  it — and  escapes  into  the  lower  part  of  the  inguinal  canal. 
This  form  of  direct  inguinal  hernia  has  the  following  coverings,  in  order: — (1) 
Within  Abdomen: — peritoneum;  subserous  areolar  tissue;  general  layer  of 
fascia  transversalis; — (2)  On  its  way  to  lower  part  of  Inguinal  Canal; — con- 
joint tendon  of  internal  oblique  and  transversalis  (instead  of  cremaster  muscle) ; 
and  then  enters  lower  part  of  inguinal  canal,  which  it  traverses  to  emerge  at 
external  abdominal  ring;— (3)  At  External  Ring: — intercolumnar  fascia; — (4) 
In  Scrotum: — superficial  fascia;  skin. 

Rarer  Form  of  Direct  Inguinal  Hernia. — In  which  the  hernia  enters  the 
middle  inguinal  fossa,  and  escapes  through  the  outer  third  of  Hesselbach's  tri- 
angle— external  to  the  conjoint  tendon — and  enters  the  upper  part  of  the  in- 


n66  OPERATIONS  FOR  HERNLE. 

guinal  canal.  This  form  of  direct  inguinal  hernia  has  the  following  coverings, 
in  order: — (i)  Within  abdomen: — peritoneum;  subserous  areolar  tissue;  gen- 
eral layer  of  fascia  transversalis  (instead  of  infundibuliform  process  of  trans- 
versalis  fascia,  as  in  the  oblique  form); — (2)  In  Inguinal  Canal: — (which  it 
now  enters  at  its  upper  part,  instead  of  entering  at  the  internal  abdominal  ring, 
and  travels  through  the  rest  of  the  way);  cremaster  muscle; — (3)  At  External 
Ring: — (from  which  it  exits  as  does  oblique  hernia) ;  intercolumnar  fascia; — (4) 
In  Scrotum: — superficial  fascia;  skin. 

Position  of  Direct  Inguinal  Herniae. — Both  of  the  varieties  of  direct  in- 
guinal hernia;  lie  upon  the  inner  side  of  the  deep  epigastric  artery.  They  do 
not  enter  the  upper  opening  of  the  inguinal  canal,  but  pass  through  the  tissues 
over  the  os  pubis  and  then  enter  the  canal  lower  down — but  make  their  exit 
at  the  external  abdominal  ring.  Both  these  direct  hernia1  generally  descend 
along  the  inner  and  anterior  aspect  of  the  spermatic  cord. 

Seat  of  Stricture  in  Both  Forms  of  Direct  Inguinal  Herniae. — Most 
frequently  at  the  neck  of  the  sac, — may  occur  at  the  external  ring.  Where  the 
hernia  pierces  the  conjoint  tendon,  the  stricture  may  be  at  the  margin  of  the 
fissure. 

Direction  of  Incision  for  Relief  of  Stricture. — Whether  in  operating 
for  the  relief  of  constriction  in  oblique  inguinal  hernia,  or  in  either  form  of 
direct  inguinal  hernia — divide  directly  upward — which  would  be  external  to  the 
deep  epigastric  artery  in  oblique  inguinal  hernia — and  interna]  to  it  in  direct 
inguinal  hernia:. 

INSTRUMENTS. 

Scalpels;  bistouries,  straight  and  curved,  sharp  and  blunt;  scissors,  straight 
and  curved,  sharp  and  blunt;  forceps,  dissecting  and  toothed;  artery-clamp 
forceps;  tenacula;  grooved  director;  special  hernia  knife;  special  hernia-director 
retractors;  probe;  needles,  straight  and  curved;  needle-holder;  ligatures  and 
sutures,  silk,  plain  gut,  chromic  gut,  kangaroo  tendon,  silkworm-gut. 


OPERATION  FOR  THE  RADICAL  CURE  OF  OBLIQUE  INGUINAL 

HERNIA. 

BASSINI'S  METHOD. 

Description. — Consists  in  the  transplantation  of  the  cord  from  its  old  to  a 
new  bed — between  the  internal  oblique  below,  and  the  external  oblique  above 
— formed  by  suturing  the  lower  borders  of  the  conjoint  tendon  and  the  trans- 
versalis and  internal  oblique  muscles  above,  to  the  shelving  portion  of  Pou- 
part's  ligament  below — and  covering  these  by  suturing  the  aponeurosis  of  the 
external  oblique,  fascia  and  skin  over  them.  The  hernial  sac  is  ligated  and 
removed  at  its  neck.     The  constituents  of  the  cord  are  not  disturbed. 

Preparation. — Bladder  and  bowels  are  emptied  and  pubic  region  shaved. 

Position. — Patient  supine  near  edge  of  that  side  of  table  upon  which 
hernia  is.  Surgeon  on  side  of  hernia,  cutting  from  above  downward  on  right, 
and  from  below  upward  on  left, — or  he  may  stand  upon  the  right  in  both  cases. 
Assistant  opposite. 

Landmarks. — Internal  and  external  rings;  inguinal  canal;  spermatic  cord; 
Poupart's  ligament;  anterior  superior  iliac  spine. 

Incision. — Begins  at  a  point  to  the  inner  side  of  the  anterior  superior  iliac 
spine,  and  about  1.3  cm.  (\  inch)  above  Poupart's  ligament — passes  obliquely 


BASSINI'S  OPERATION  FOR  OBLIQUE  INGUINAL  HERNIA.       1167' 

downward  parallel  with  and  about  1.3  cm.  (£  inch)  above  Poupart's  ligament — 
and  ends  over  the  middle  of  the  external  abdominal  ring — being  about  7.5  to 
9  cm.  (3  to  3^  inches)  long  (Fig.  838,  A). 

Operation.— (1)  Divide  skin  and  superficial  fascia,  clamping  bleeding 
vessels — and  retract  edges  of  wound,  exposing  aponeurosis  of  external  oblique. 
(2)  Demonstrate  the  external  abdominal  ring  and  pass  a  grooved  director 
through  its  opening  and  carry  it  obliquely  upward  in  the  line  of  the  fibers  of  the 
external  oblique  aponeurosis,  and  immediately  beneath  its  surface,  for  a  dis- 
tance of  about  6.3  cm.  (2^  inches) — the  instrument  showing  through  its  thin 
texture  (Fig.  839).  Slit  up  the  fibers  of  the  aponeurosis  of  the  external  oblique 
upon  the  grooved  director  with  a  scalpel,  traveling  in  the  cleavage  line  of  the 
fibers.     Dissect,  by  blunt  separation,  the  upper  edge  of  the  cut  aponeurosis  in- 


Fig.  83S.— Incisions  for  Radical  Cure  of  Oblique  Inguinal  Hernia:— A,  Incision  for  Bassini'j 
Operation;  B,  Incision  for  Halsted's  Operation. 


ward  and  upward  nearly  to  the  outer  edge  of  the  rectus  sheath.  Similarly  dis- 
sect, by  blunt  separation,  the  lower  edge  of  the  cut  aponeurosis  of  the  external 
oblique  downward  and  outward  to  the  shelving  portion  of  Poupart's  ligament. 
The  inguinal  canal,  except  that  part  covered  by  the  internal  oblique,  is  thus 
exposed.  (3)  Grasp,  with  forceps,  aided  by  the  fingers,  the  mass  of  soft 
tissues  just  within,  or  emerging  from  the  external  abdominal  ring,  composed 
of  cord  and  hernial  sac — and,  pushing  aside  the  muscle-fibers  with  a  blunt 
dissector,  or  closed  ends  of  blunt,  curved  scissors,  lift  upward  and  out- 
ward the  hernial  sac  and  cord — drawing  them  partly  from  the  direction 
of  the  inguinal  canal,  and  partly  from  the  direction  of  the  scrotum — the 
hernia  lying  anteriorly,  surrounded  by  the  infundibuliform  fascia,  and  the 
cord  posteriorly — the  sac  and  cord  being  more  or  less  intimately  adherent. 


1 68 


OPERATIONS  FOR  IIERNLF. 


(4)  Isolate  the  sac  from  the  cord  by  blunt  dissection — and  carry  on  the  free- 
ing of  the  sac  upward,  retracting  the  internal  oblique  muscle  outward  to 
expose  the  outer  aspect  of  the  inguinal  canal,  until  the  sac  begins  to  open 
out  into  the  general  peritoneum.  If  it  be  certain  that  the  sac  contains  no 
adherent  intestines  or  omentum,  it  need  not  be  opened.  If  there  be  any  ques- 
tion— and  it  is  probably  better  in  all  cases  to  do  so,  whether  question  or  not 
— the  sac  should  be  opened  at  some  distance  below  the  point  of  intended  closure 
and  examined.  The  contents  of  the  sac,  if  any,  are  returned  to  the  abdom- 
inal cavity.  The  sac  is  then  to  be  treated  in  one  of  two  ways: — If  it  be  small, 
a  double  chromic  gut  ligature  is  carried  through  the  center  of  that  portion 
which  is  to  form  the  line  of  occlusion — these  two  ligatures  are  crossed  and  are 


Fig. 830  —  Bassim's  Operation  for  Oblique  Inguinal  Hernia:— I.  Splitting  aponeurosis  of 
external  oblique;  A,  Aponeurosis  of  external  oblique;  E,  External  abdominal  ring;  C,  Cord;  D, 
Grooved  director  passed  beneath  aponeurosis  of  external  oblique.     (Modified  from  Bull  and  Coley.) 


firmly  tied  on  each  side — and  the  sac  cut  off  a  safe  distance  from  the  ligatures. 
If  the  sac  be  large  (so  that  ligating  would  cause  too  much  puckering  and  prob- 
ably slip  off),  its  surfaces  are  to  be  sutured  with  chromic  gut  on  a  level  with 
the  site  of  division — and  then -cut  off  with  scissors  at  a  safe  distance  distal  to  the 
suture  line.  The  sac  is  thus  disposed  of  and  returned  to  the  abdominal  cavity 
(Fig.  840).  (5)  The  cord  is  now  taken  up  in  the  left  thumb  and  index  and 
isolated  from  external  to  internal  ring,  en  masse,  without  disturbing  its  com- 
ponent structures,  and  a  strip  of  gauze  is  passed  beneath  it — whereby  it  is  held 
up  by  an  assistant  well  out  of  the  way,  until  its  new  bed  is  made  for  it.  (6)  The 
lower  borders  of  the  internal  oblique  and  transversalis  muscles  are  now  sutured 
to  the  shelving  portion,  or  border  of  Poupart's  ligament,  with  interrupted  su- 


BASSINI'S  OPERATION  FOR  OBLIQUE  INGUINAL  HERNIA.       1169 


Fig.  840.  —  BassinTs  Operation  for  Oblique  Inguinal  Hernia: — II.  Isolation  of  sac ;  A, 
External  oblique  muscle;  B,  B,  Aponeurosis  of  external  oblique;  C,  Internal  oblique  muscle;  D, 
Conjoint  tendon  of  internal  oblique  and  transversalis  ;  E,  Cord  ;  F,  Sac,  incised  and  drawn  outward  ; 
G,  Neck  of  sac  surrounded  by  ligature;  H,  Ilio-inguinal  nerve ;  I,  Genitocrural  nerve.  (Modified 
from  Bull,  Coley  and  Kelly.) 


Fig.841—  Bassini's  Operation  for  Oblique  Inguinal  Hernia:— III.  Forming  new  floor  for 
cord,  A,  A,  Aponeurosis  of  external  oblique;  B,  Shelving  portion  of  Poupart's  ligament;  C,  Cord, 
drawn  out  of  canal  by  hook  ;  1>.  Internal  oblique  and  transversalis  retracted  strongly  outward  ;  E, 
Needle  carrying  sutures  approximating  internal  oblique  and  transversalis,  above,  with  shelving  por- 
tion of  Poupart's  ligament,  below.     (Modified  from  Bull  and  Coley.) 

74 


OPERATIONS  FOR  HERN  I.E. 


tures  of  kangaroo  tendon  or  chromic  gut,  taking  a  good  hold  of  both  structures, 
using  a  curved  needle,  preferably  of  the  Hagedorn  type.     Prior  to  the  insertion 


Fig.  842.— Bassini's  Operation  for  Oblique  Inguinal  Hernia  : — IV.  New  floor  for  cord  com- 
pleted ;  A,  A,  Aponeurosis  of  external  oblique;  E,  Shelving  portion  of  Poupart's  ligament;  C,  In- 
ternal oblique  and  transversalis;  D,  Sutures  forming  new  bed  for  cord,  by  approximating  internal 
oblique  and  transversalis,  above,  to  shelving  portion  of  Poupart's  ligament,  below  ;  E,  Cord  drawn 
outward  by  hook.     (Modified  from  Bull  and  Coley.) 


A, 


Fig.  843.  —  Bassini's  Operation  for  Oblique  Inguinal  Hernia:  — V.  New  roof  of  canal 
formed  ;  A,  Sutures  uniting  split  fibers  of  external  oblique  aponeurosis  over  cord  ;  B,  Cord  emerg- 
ing from  new  external  ring.     (Modified  from  Bull  and  Coley.) 


of  the  sutures  uniting  internal  oblique  and  transversalis  above,  to  Poupart's  liga- 
ment below,  the  lower  borders  of  the  internal  oblique  and  transversalis  should 


HALSTED'S  OPERATION  FOR  OBLIQUE  INGUINAL  HERNIA.       1171 

be  isolated  by  the  surgeon's  fingers  from  the  transversalis  fascia,  beginning  at 
the  conjoint  tendon  and  extending  outward  to  the  internal  abdominal  ring. 
While  passing  the  sutures,  the  surgeon's  left  index  should  be  carried  behind  the 
conjoint  tendon  and  also  behind  the  lower  borders  of  the  internal  oblique  and 
transversalis  muscles,  so  as  to  guide  the  needle-point.  The  first  suture,  near 
the  upper  end  of  the  wound,  pierces  the  internal  oblique  almost  as  far  outward 
as  the  external  border  of  the  rectus  muscle.  It  should  just  come  in  contact 
with  the  inner  aspect  of  the  cord  when  the  latter  is  held  at  a  right  angle  to  the 
plane  of  the  internal  oblique  muscle  as  it  emerges  from  opposite  the  internal 
ring.  A  second  suture  is  placed  just  above  the  cord,  to  strengthen  the  internal 
ring,  the  cord  thus  emerging  between  two  sutures.  As  many  similar  sutures  as 
are  indicated  (generally  six  or  seven  altogether)  are  thus  placed.  The  last, 
lowest,  suture  passes  through  the  conjoint  tendon  of  the  internal  oblique  and 
transversalis  above,  and  the  shelving  portion  of  Poupart's  ligament  below. 
(Fig.  841.)  (7)  The  cord  is  now  dropped  down  upon  its  new  bed  made  by  su- 
turing the  conjoint  tendon  and  the  internal  oblique  and  transversalis  muscle  to 
the  shelving  border  of  Poupart's  ligament  (Fig.  842) .  (8)  The  separated  edges 
of  the  aponeurosis  of  the  external  oblique  are  now  sutured  directly  over  the 
cord  with  continuous  kangaroo  or  chromic  gut  sutures — carefully  avoiding  too 
tightly  suturing  the  edges  over  the  cord  at  the  lower  end,  the  new  external  ring, 
where  the  cord  escapes  into  the  scrotum  (Fig.  843).  (9)  The  skin  is  closed 
throughout  with  interrupted  sutures  of  fine  catgut.  No  drainage  is  used. 
The  first  dressing  usually  comes  off  at  the  end  of  a  week. 

Comment. — No  muscle  tissue,  except  aponeurosis  of  external  oblique,  is 
cut. 


OPERATION  FOR   THE  RADICAL  CURE  OF  OBLIQUE  INGUINAL 

HERNIA. 

halsted's  method. 

Description. — Like  Bassini's  operation,  which  it  resembles  in  many 
respects,  Halsted's  original  method  consisted  not  only  in  a  transplantation  of 
the  cord  from  its  natural  to  a  new  canal,  but  also  in  the  making  of  a  new, 
closely  fitting  internal  ring.  It  differed  from  Bassini's  technic  in  the  following 
respects: — (a)  a  new  internal  ring  was  made; — (b)  most  of  the  veins  of  the 
cord  were  excised; — (c)  the  internal  oblique  and  transversalis  muscles  and 
transversalis  fascia  were  incised; — (d)  the  cord  was  finally  made  to  lie  between 
the  aponeurosis  of  the  external  oblique  and  the  skin; — and  (e)  silver  wire 
mattress  sutures  were  extensively  used.  The  original  technic  has  been  con- 
siderably modified — as  described  under  Operation. 

Preparation — Position — Landmarks. — As  for  the  Bassini  operation. 

Incision. — Begins  about  3  cm.  (i|  inches)  to  the  outer  side  and  above  the 
internal  abdominal  ring — and  extends  thence  in  a  straight  line  to  the  spine  of 
the  pubis. 

Operation. — Incise  skin  and  fascia  and  split  the  fibers  of  the  muscular 
and  aponeurotic  portions  of  the  external  oblique  along  this  line,  to  and  through 
the  external  ring.  Retract  the  borders  of  the  incision,  thus  exposing  the  cord, 
cremaster  muscle  and  fascia,  vessels,  and  hernial  sac.  The  fibers  of  the 
cremaster  muscle  (which  constitutes  the  lower  part  of  the  internal  oblique 
muscle)  are  split  somewhat  above  the  cord.  The  vessels,  especially  the  redun- 
dant veins,  are  isolated,  grasped  with  forceps  at  either  end,  and  ligated  and 
divided  at  the  internal  and  external  rings — and  are  carefully  dissected  away 


1172 


OPERATIONS    FOR    HERNLE. 


between  the  sites  of  ligation,  retracting  and  guarding  the  vas  deferens  (Fig. 
844).     Having  freed  the  hernial  sac,  incise  it  and  return  its  contents  to  the 


Fig.  844. — Halsted's  Operation  for  Oblique  Inguinal  Hernia: — I. — The  aponeurosis 
and  fibers  of  the  external  oblique  have  been  split  and  retracted.  The  fibers  of  the  cremaster 
(internal  lower  part  of  internal  oblique)  have  been  retracted  and  split  somewhat  above  the  cord. 
The  hernial  sac,  spermatic  cord,  and  veins  are  seen  in  the  mass  of  connective  tissue,  being  retracted 
upward  by  catch-forceps. 

abdominal  cavity.     Having  especially  freed  the  neck  of  the  sac,  transfix  and 
ligate  it  with  chromic  gut,  leaving  both  ends  of  the  ligature  long.     Each  end 


Fig.  845. — Halsted's  Operation  for  Oblique  Inguinal  Hernia: — II. — The  median 
aspect  of  the  internal  oblique  sutured  (interrupted  mattress  sutures)  to  the  outer  aspect  of  the 
split  internal  oblique — causing  the  former  to  overlap  the  latter. 

of  this  ligature  is  threaded  with  a  curved  needle — both  of  which  are  carried 
upward  and  inward  under  the  internal  oblique,  1.3  cm.  (\  inch)  apart,  and 


HALSTED'S    METHOD    FOR    OBLIQUE    INGUINAL    HERNIA.  1 1 73 

passed  through  the  muscle  and  tied  so  as  to  draw  the  neck  of  the  sac  up  and 
anchor  it.      Mobilize  the  median  aspect  of  the  split  internal  oblique  sufficiently 


Fig.  846. — Halsted  s  Operation'  for  Op.lique  Inguinal  Herxia: — III. — The  free  edge 
of  the  internal  oblique  and  conjoint  tendon  sutured  (plain  interrupted  sutures)  to  the  shelving 
portion  of  Poupart's  ligament. 

to  subsequently  enable  its  edge  to  reach  to  Poupart's  ligament — and  suture 
it  to  the  outer  aspect  of  the  split  internal  oblique  by  several  mattress  sutures 


Fig.  S47.— Halsted 's  Operation  for  Oblique  Inguinal  Hernia: — IV. — The  inner 
aspect  of  the  external  oblique  is  sutured  (mattress  sutures)  to  the  outer  aspect  of  the  external 
oblique — causing  the  former  to  overlap  the  latter. 

of  fine  silk  (or  chromic  gut) — in  such  a  way  as  to  cause  an  overlapping  of  the 
median  upon  the  outer  aspect  of  the  internal  oblique  (Fig.  845).     Suture 


H74  OPERATIONS    FOR    HERNLF. 

the  free  edge  of  the  internal  oblique,  the  conjoint  tendon  (and  a  part  of  the 
sheath  of  the  rectus,  if  necessary)  to  the  shelving  portion  of  Poupart's  liga- 
ment by  interrupted  chromic  gut  sutures  (Fig.  846).  Suture,  with  chromic 
gut  mattress  sutures,  the  inner  aspect  of  the  aponeurosis  of  the  external  oblique 
to  the  outer  aspect  of  the  external  oblique  aponeurosis — causing  the  former 
to  overlap  the  latter  (Fig.  847).     And  then  suture,  with  plain,  interrupted 


Fig.  848. — Halsted's  Operation  for  Oblique  Inguinal  Hernia: — V. — The  free  border 
of  the  inner  aspect  of  the  external  oblique  is  sutured  to  the  outer  surface  of  the  outer  aspect  of 
the  external  oblique. 

chromic  gut  stitches,  the  free  border  of  the  inner  aspect  of  the  external  oblique 
aponeurosis  down  to  the  outer  surface  of  the  outer  aspect  of  the  external 
oblique  (Fig.  848) .  The  skin-wound  is  closed  with  a  subcuticular  silver-wire 
suture.  The  suture  line  is  covered  with  silver  foil — which  is  removed  in  two 
weeks,  at  which  time  the  subcuticular  suture  of  wire  is  withdrawn. 


II.  FEMORAL  HERNIA. 

SURGICAL  ANATOMY. 

The  structures  encountered  in  the  operations  for  Femoral  Hernia,  and  those 
in  the  immediate  neighborhood  of  the  site  of  operation,  will  be  here  briefly  de- 
scribed, chiefly  as  encountered,  from  without  inward. 

Superficial  Fascia. — Between  whose  layers  are  superficial  arteries,  veins, 
lymphatics,  and  nerves. 

Superficial  Layer  of  Superficial  Fascia. — 

Superficial  Arteries. — Superficial  external  pudic;  superficial  epigastric; 
superficial  circumflex  iliac — all  from  the  femoral. 

Superficial  Veins. — Internal  or  long  saphenous — receiving  superficial  ex- 
ternal pudic,  superficial  epigastric,  and  superficial  circumflex  iliac. 

Superficial  Inguinal  Glands. — Superior  set — along  Poupart's  ligament. 
Inferior  set — around  saphenous  opening. 

Superficial  Nerves. — Uio-inguinal;  crural  branch  of  genito-crural. 


SURGICAL    ANATOMY    OF    FEMORAL    HERXIA.  1175 

Deep  Layer  of  Superficial  Fascia. — Cribriform  fascia — that  portion 
attached  to  borders  of  saphenous  opening,  in  fascia  lata. 

Fascia  Lata. — Iliac  portion — outer  portion  of  fascia  lata.  Pubic  portion — 
inner  portion  of  fascia  lata. 

Saphenous  Opening. — Opening  in  fascia  lata  formed  by  iliac  and  pubic 
portions  uniting — through  which  opening  a  femoral  hernia  escapes  after  tra- 
versing the  crural  canal. 

Poupart's  Ligament  or  Crural  Arch. — See  Inguinal  Hernia. 

Gimbernat's  Ligament. — See  Inguinal  Hernia. 

Crural  or  Femoral  Sheath. — Formed  by  continuation  downward  of  trans- 
versalis  fascia  in  front  and  iliac  fascia  behind  the  femoral  vessels — the  two 
layers  being  united  and  continuous  directly  to  the  outer  side  of  the  vessels;  but 
at  a  short  distance  from  these  vessels,  upon  the  inner  side,  a  space  intervenes, 
usually  occupied  by  a  lymphatic  gland,  between  the  femoral  vein  and  the  inner 
limit  of  the  sheath,  constituting  the  crural  or  femoral  canal.  The  femorai 
sheath  is  redundant  and  funnel-shaped  opposite  Poupart's  ligament,  but  is  ad- 
herent to  the  areolar  sheath  of  the  femoral  vessels  about  2.5  cm.  (1  inch)  below 
the  saphenous  opening. 

Relations  of  Crural  or  Femoral  Sheath. — Anteriorly: — iliac  portion  of 
fascia  lata.     Posteriorly: — pubic  portion  of  fascia  lata.     Externallv: — genito 
crural  nerve  pierces.     Internally: — internal  saphenous  vein  and  lymphatics 
pierce. 

Septa  of  Crural  or  Femoral  Sheath. — Outer  antero-posterior  septum — 
between  femoral  artery  and  femoral  vein.  Inner  antero-posterior  septum — 
between  femoral  vein  and  femoral  canal. 

Compartments  within  Crural  or  Femoral  Sheath. — Three  compart- 
ments are  formed  by  the  two  above  septa.  Outer  compartment  is  occupied  by 
femoral  artery.  Middle  compartment — by  femoral  vein.  Inner  compart- 
ment— constitutes  femoral  canal — which  is  generally  filled  up  by  lymphatic 
glandular  and  areolar  tissue  in  the  normal  state. 

Deep  Crural  Arch. — A  thickened  portion  of  fascia  transversalis,  passing 
from  center  of  Poupart's  ligament,  across  the  anterior  aspect  of  the  crural 
sheath,  to  be  attached  to  the  pectineal  line  posterior  to  the  conjoint  tendon. 

Crural  or  Femoral  Canal. — Space  between  femoral  vein  and  inner  wall  of 
femoral  sheath — that  is,  the  inner  compartment  of  the  sheath  of  the  femoral 
vessels.  Anterior  wall—  formed  by  transversalis  fascia  covered  by  falciform 
process  of  iliac  portion  of  fascia  lata.  Posterior  wall — formed  by  iliac  fascia, 
resting  upon  pubic  portion  of  fascia  lata.  External  wall — formed  by  internal 
septum  between  it  and  femoral  vein.  Internal  wall — formed  by  union  of 
transversalis  and  iliac  fascia?  bounding  the  femoral  canal  and  resting  against 
the  base  or  outer  border  of  Gimbernat's  ligament.  Upper  opening  of  femoral 
canal — is  the  femoral  or  crural  ring,  and  is  closed  by  the  septum  crurale  (con- 
densed areolar  tissue).  Lower  opening  of  femoral  canal — is  the  saphenous 
opening,  and  is  closed  by  the  cribriform  fascia. 

Crural  or  Femoral  Ring. — Superior  opening  of  the  femoral  canal  into  the 
peritoneal  cavity — oval,  transverse  in  direction,  about  1.3  cm.  (i  inch)  in  ex- 
tent— and  having  following  boundaries: — Anteriorly: — Poupart's  ligament; 
deep  crural  arch.  Posteriorly: — os  pubis;  pectineus;  pubic  portion  of  fascia 
lata.  Internally: — external  border  of  Gimbernat's  ligament;  conjoint  tendon; 
transversalis  fascia;  deep  crural  arch.  Externally:- — inner  antero-posterior 
fibrous  septum  on  inner  aspect  of  femoral  vein. 

Relations  of  Structures  in  the  Near  Neighborhood  of  the  Ring. — Supe- 
riorlv: — spermatic  cord   in   male  (round   ligament  in  female);  deep  epigastric 


\l]6  OPERATIONS    FOR    HERXEE. 

vessels.  Externally: — femoral  vein;  deep  epigastric-  vessels.  Anteriorly: — com- 
municating branch  between  deep  epigastric  and  obturator  arteries.  Inter- 
nally:— no  important  structure.     Posteriorly : — no  important  structure. 

Obturator  Artery.-- Arises  in  common  with  deep  epigastric  once  in  every 
three  and  one-half  subjects — and  in  such  cases  it  follows  one  of  two  courses: 
— (i)  Runs  down  upon  inner  aspect  of  external  iliac  vein,  along  the  outer  side  of 
crural  ring — and  is,  therefore,  in  safety.  (2)  Runs  along  free  border  of  Gim- 
bernat's  ligament,  along  the  inner  side  of  crural  ring — and,  therefore,  is  apt  to 
be  cut  in  an  outward  incision  for  relief  of  stricture. 

Septum  Crurale. — Condensed  areolar  tissue  closing  upper  opening  of 
femoral  ring. 

Subperitoneal  Areolar  Tissue. — 

Peritoneum. — 


GENERAL  SURGICAL  CONSIDERATIONS. 

Course  of  Femoral  Hernia. — Coming  from  within  the  abdominal  cavity 
outward,  the  hernia  passes  at  first  vertically  through  the  femoral  canal,"  from 
the  femoral  ring  to  the  saphenous  opening — thence  (because  the  femoral  sheath 
here  narrows  and  is  more  closely  connected  to  the  vessels,  and  because  of  the 
closer  connection  of  superficial  fascia  and  crural  sheath  to  the  saphenous  open- 
ing) forward  through  the  cribriform  fascia — thence  upward  upon  the  falci- 
form process  of  the  fascia  lata  and  Poupart's  ligament.  In  manipulation  for 
the  reduction  of  such  a  hernia,  pressure  should  be  applied  in  the  reverse  direc- 
tions. 

Coverings  of  Femoral  Hernia. — Passing  from  within  outward,  the  hernia 
carries  with  it  the  following  structures,  in  order: — (1)  Within  the  abdomen: — 
peritoneum;  subserous  areolar  tissue.  (2)  At  femoral  ring: — septum  crurale. 
(3)  In  Femoral  canal: — femoral  sheath.  (4)  At  saphenous  opening : — cribri- 
form fascia.     (5)   Upon  thigh : — superficial  fascia ;  skin. 

Seats  of  Stricture. — (1)  At  the  border  of  the  saphenous  opening; — (2)  At 
the  union  of  the  falciform  process  of  the  fascia  lata  and  the  curved  edge  of 
Gimbernat's  ligament; — (3)  At  the  femoral  ring. 

Direction  of  Division  of  Stricture. — Upward  and  inward — for  4  to  6  mm. 
(2  to  3  lines). 


OPERATION  FOR  THE  RADICAL  CURE  OF  FEMORAL  HERNIA. 

BASSINI'S  METHOD. 

Description. — The  hernial  sac  is  exposed,  emptied  of  contents,  ligated, 
excised,  and  the  neck  returned  to  the  abdominal  cavity.  The  femoral  canal 
is  then  closed  by  suturing  Poupart's  ligament  and  the  falciform  process  of  the 
fascia  lata,  above  and  externally — to  the  pectineal  fascia  (pubic  portion  of 
fascia  lata)  below  and  internally. 

Preparation. — Pubic  region  and  region  of  the  saphenous  opening  shaved. 

Position. — Patient  supine  at  edge  of  table.  Surgeon  on  side  of  hernia. 
Assistant  opposite. 

Landmarks. — Poupart's  ligament;  femoral  vessels;  saphenous  opening. 

Incision. — Parallel  with  and  just  below  Poupart's  ligament,  with  its  center 
over  the  saphenous  opening. 

Operation. — (1)  Incise  skin  and  superficial  fascia — clamp  and  tie  vessels 
— retract  edges  of  wound — and  expose  the  saphenous  opening.     (2)  Dissect 


BASSIXFS    OPERATION    FOR    FEMORAL    HERNIA. 


1177 


out  the  hernial  sac  from  its  canal,  as  high  up  as  possible.  Open  its  lower  part 
and  return  its  contents  to  the  abdominal  cavity.  Draw  the  sac  well  down  and 
transfix  its  neck  with  double  chromic  ligature.  Cross  the  ends  of  the  ligatures 
and  ligate  and  cut  off  the  neck  safely  below  the  ligature — the  stump  receding 
into  the  abdomen.  (3)  Pass  kangaroo  tendon,  or  chromic  gut  sutures,  in  a 
curved  needle,  in  the  following  manner: — (a)  Pass  three  sutures  to  approxi- 
mate Poupart's  ligament  to  the  pectineal  fascia — the  first,  near  the  pubic 
spine — the  second,  about  5  mm.  (nearly  %  inch)  to  the  outer  side  of  the  first — 
and  the  third,  about  1  cm.  (f  inch)  to  the  inner  side  of  the  femoral  vein — each 
passing  through  the  pectineal  fascia  below.  These  sutures  are  left  tempora- 
rily untied,  (b)  Pass  three  or  four  other  sutures  through  the  falciform  process 
of  the  iliac  portion  of  the  fascia  lata,  externally — and  the  pectineal  fascia  (which 
is  the  same  as  the  pubic  portion  of  the  fascia  lata)  internally — the  lowest  su- 


Fig.  849. —  Eassini's  Opkration  for  Femoral  Hernia:  —  A,  Poupart's  ligament;  B,  Falci- 
form process  of  fascia  lata  ;  C,  Pectineal  fascia  (pubic  portion  of  fascia  lata;;  D,  Internal  saphenous 
vein.  Three  sutures  to  right  approximate  Poupart's  ligament  to  pectineal  fascia.  Remaining  sutures 
pass  through  falciform  process  of  fascia  lata  externally,  and  the  pectineal  fascia  internally.  (^N'ote — 
the  femoral  opening  is  represented  somewhat  too  far  outward .) 


ture  passing  just  above  the  saphenous  vein.  (4)  The  upper  sutures  are  then 
tightened  and  tied,  bringing  Poupart's  ligament  backward  to  the  linea  pectinea. 
The  lower  sutures  are  next  tightened  and  tied,  approximating  the  anterior  and 
posterior  walls  of  the  femoral  canal.  (5)  The  skin  incision  is  closed  with  silk. 
No  drainage  is  used.     (Fig.  849.) 

Comment. — The  closure  of  the  femoral  opening  may  also  be  made  by  a 
purse-string  suture.  Kangaroo  tendon,  upon  a  curved  needle,  is  passed 
through  the  inner  aspect  of  Poupart's  ligament,  or  through  the  roof  of  the 
femoral  canal — thence  passes  downward,  taking  a  firm  hold  upon  the  pec- 
tineal fascia  and  underlying  muscle — thence  outward  and  upward  through 
the  fascia  lata,  covering  the  femoral  vein — thence  upward,  coming  out  through 


1178 


OPERATIONS    FOR    HERNEE. 


the  roof  of  the  femoral  canal  6  cm.  (|  inch)  from  its  place  of  entrance.  When 
this  suture  is  tied,  the  floor  of  the  femoral  canal  is  brought  up  into  contact  with 
its  roof,  thus  obliterating  the  femoral  opening.     (Fig.  850.) 


Fig.  CS50. — Closure  of  the  Femoral  Caxal  by  a  Purse-string  Suture. 


III.  UMBILICAL  HERNIA. 

SURGICAL  ANATOMY. 

Parts  Passing  through  the  Umbilicus  Early  in  Fetal  Life.— Urachus; 
umbilical  arteries;  umbilical  vein;  some  of  the  fetal  membranes  and  part  of  the 
digestive  tract. 

Congenital  Umbilical  Hernia. — A  form  of  hernia  existing  at  birth — 
owing  to  an  error  of  development — the  above  conditions  persisting. 

Infantile  Umbilical  Hernia. — A  form  of  hernia  occurring  in  the  early 
years  of  life  (generally  prior  to  ten  years  of  age).  It  is  that  form  of  hernia 
where,  after  birth,  the  intestines  protrude  through  the  umbilicus,  which,  in  the 
latter  part  of  fetal  life,  transmits  only  the  umbilical  vessels. 

Method  of  Normal  Closure  of  the  Umbilicus. — (a)  Several  changes  in 
the  component  structures  take  place: — (1)  Contraction  and  shrinkage  of  the 
umbilical  ring  after  birth — dividing,  by  its  closure,  the  umbilical  vessels  run- 
ning through  the  ring.  (2)  Clotting  of  the  vessel  contents — proliferation  of 
connective  tissue — and  contraction  of  the  muscle-fibers  of  the  vessels,  (b)  As 
a  result,  a  firm,  fibrous  scar  is  thus  formed  at  the  site  of  the  umbilicus,  with  two 
sets  of  fibers  decussating  about  it; — (1)  One  set  of  fibers  decussating  in  the 
median  line; — (2)  Two  sets  of  circular  fibers  interlacing  upon  the  lateral 
aspects  of  the  umbilicus. 

Site  of  Umbilical  Hernia. — Thus  it  is  seen  that  the  umbilical  vessels  and 
ring  unite  to  form  scar-tissue — which,  remaining  weak  for  a  time — or  subse- 


OPERATION    FOR    RADICAL    CURE    OF    UMBILICAL    HERXIA.       1 179 

quently  submitted  to  strain — may  yield  to  hernia.  Hernia  occurring  after 
birth,  therefore,  may  make  its  appearance  by  two  routes: — (1)  Exceptionally, 
hernia  comes  through  the  abdominal  wall  near  to,  but  not  through,  the  um- 
bilicus. (2)  Ordinarily,  hernia  comes  through  the  umbilical  ring — and  usually 
through  its  upper  third  (where  is  the  weaker  scar-tissue  about  the  umbilical 
vein) — and  but  seldom  through  the  lower  two-thirds  (where  is  the  stronger  scar- 
tissue  of  the  umbilical  arteries  and  urachus). 

Coverings  of  Umbilical  Hernia. — (From  within  outward) — peritoneum; 
subserous  areolar  tissue;  transversalis  fascia;  stretched  and  distended  umbilical 
scar-tissue;  superficial  fascia,  deprived  of  fat;  integument. 


A- 


-■ 


Fig.  851. 


-Mayo's  Operation  for  the  Radical  Cure  of  Umbilical  Herxia: — I. — Clearing 
the  neck  of  the  hernial  sac. 


OPERATION  FOR  THE  RADICAL  CURE  OF  UMBILICAL  HERNIA 

P,V  EXCISION  OF  SAC  AND  SUTURING  OF   FRESHENED  EDGES  OF  RING. 

Description. — The  hernial  sac,  together  with  the  redundant  tissues  cover- 
ing it,  is  excised  by  an  elliptical  incision — followed  by  the  suturing  together  of 
the  freshened  margins  of  the  abdominal  ring. 


n8o 


OPERATIONS    FOR    HERNLE. 


Preparation. — Site  of  hernia  thoroughly  scrubbed  and  shaved.  Bowels 
emptied. 

Position. — Patient  supine  at  edge  of  table.  Surgeon  to  patient's  right. 
Assistant  opposite. 

Landmarks. — Site  and  form  of  hernia;  umbilicus;  median  line. 

Incision. — Elliptical  in  outline,  with  upper  and  lower  ends  in  median 
line — and  maximum  separation  of  limbs  of  ellipse  opposite  the  greatest  width 
of  the  hernia,  and  determined  by  the  size  of  the  tumor.  Laterally  the  lines  of 
incision  generally  come  near  the  base  of  the  tumor,  so  as  to  remove  the  excess 
of  skin. 


Fig.  852. — Mayo's  Operation  for  the  Radical  Cure  of  Umbilical  Hernia: — II. — ■ 
Suturing  of  the  margins  of  abdominal  aponeuroses  and  muscles,  mattress  sutures  of  Pagen- 
stecher  thread  in  the  center  and  of  chromic  catgut  laterally. 

Operation. — (1)  Incise,  at  first,  through  skin  and  fascia  only.  (2)  Care- 
fully deepen  the  wound  on  one  side  until  the  abdominal  aponeurosis  (sheath 
of  the  recti)  is  reached — aiming  to  come  down  upon  it  a  short  distance  to  the 
outer  side  of  the  hernial  neck.  (3)  Having  once  reached  the  rectal  aponeuro- 
sis, similarly  expose  this  aponeurosis  and  the  neck  of  the  hernial  sac  all  around 
the  outline  of  the  ellipse.  All  bleeding  is  controlled  by  clamp  and  ligature. 
(4)  The  hernial  sac  is  now  incised  and  its  contents  dealt  with  as  indicated. 


OPERATION    FOR    RADICAL    CURE    OF    UMBILICAL    HERNIA.       Il8l 

Adhesions  are  separated.  Excess  of  omentum  is  ligated  and  excised.  x\ll 
remaining  contents  of  the  sac  are  returned  to  the  abdomen — and  kept  in  place 
by  a  large,  anchored  gauze  pad — which  is  removed  just  before  closure  of  the 
abdomen.  (5)  The  entire  sac,  with  the  umbilicus  and  the  coverings  included 
in  the  ellipse,  is  now  excised—dividing  the  peritoneum  in  an  elliptical  manner 
about  the  neck  of  the  sac.  (6)  The  peritoneum — or  the  peritoneum  and  trans- 
versalis  fascia  together — is  sutured  with  interrupted  or  continuous  gut  sutures. 

(7)  The  borders  of  the  abdominal  ring — formed  by  the  sheaths  and  margins 
of  the  recti  muscles — are  freshened  with  curved  scissors.  The  edges  of  the 
ring  are  then  brought  together  with  interrupted  sutures  of  kangaroo  tendon  or 
chromic  gut — using  either  the  plain  interrupted  suture,  or  the  mattress  type. 

(8)  The  skin  and  fascia  (unless  the  fascia  be  thick  enough  to  require  separate 
gut  suturing)  are  sutured  with  interrupted  silkworm-gut  sutures.  (9)  The 
part  is  then  well  supported  by  an  abdominal  dressing. 

Comment. — Various  forms  of  operation   have  been  devised — including 
die  transposition  of  portions  of  the  recti  muscles  over  the  site  of  hernia. 


Fig.  853. — Mayo's  Operation  for  the  Radical  Cure  of  Umbilical  Hernia: — III. — 
Overlapping  of  the  aponeuroses,  accomplished  by  the  preceding  tier  of  sutures,  after  which  the 
free  edge  of  the  upper  margin  of  aponeuroses  is  stitched  to  the  surface  of  aponeuroses  of  the 
lower  aspect  of  the  wound. 

OPERATION  FOR   THE  RADICAL  CURE  OF  UMBILICAL    HERNIA. 

MAYO'S    "  OVERLAPPING  "    METHOD. 

Description. — Following  the  excision  of  the  hernial  mass,  the  abdominal 
aponeuroses  are  overlapped  transversely  and  sutured. 


Il82  OPERATIONS    FOR    HERNL-E. 

Preparation — Position — Landmarks. — As   for   abdominal   section. 

Incision. — Two  elliptical  incisions  are  made  transversely,  surrounding 
the  neck  of  the  sac  and  meeting  on  either  side. 

Operation. — Having  carried  the  incision  through  skin  and  fascia  down  to 
the  abdominal  aponeuroses,  the  neck  of  the  hernial  sac  is  cleared  in  its  entire 
circumference  (Fig.  851).  The  sac  is  incised  and  its  contents  returned  to  the 
abdomen — carefully  separating  adhesions  from  the  sac-wall,  and  seeing  that 
no  dangerous  interintestinal  adhesions  are  left.  All  protruding  omentum  is 
tied  off  in  segments,  severed,  and  the  stumps  returned  to  the  abdominal  cavity. 
The  sac,  including  fascia  and  skin,  are  now  excised — leaving  a  clean-cut 
opening  bounded  by  aponeuroses.     A  central  mattress  suture  of  stout  Pagen- 


K 


Fig.  854. — Blake's  Operation  for  the  Radical  Cure  of  Umbilical  Hernia  :- 
vertical  division  of  the  parts  and  overlapping  of  the  aponeuroses. 


-Showing  a 


stecher  thread  is  carried  through  the  margins  of  the  sac-opening — in  such  a 
way  as  to  cause  the  upper  edge  of  the  wound  to  overlap  the  lower — passing 
through  the  entire  thickness  of  aponeuroses,  muscles,  and  peritoneum  (Fig.  852) . 
On  each  side  of  the  central  stitch  a  chromic  gut  mattress  suture  is  similarly 
placed.  Upon  drawing  upon  these  three  sutures,  the  lower  flap  is  brought 
upward  and  behind  the  upper  flap — the  two  flaps  being  brought  into  close 
approximation  upon  tightening  the  sutures.  On  retracting  the  upper  flap 
upward  for  examination,  if  any  lack  of  approximation  is  found,  the  mattress 
sutures  are  reinforced  by  interrupted  chromic  gut  sutures.  The  free  margin 
of  the  upper  flap  is  now  sutured  to  the  surface  of  the  lower  flap  by  interrupted 


OPERATION    FOR    RADICAL    CURE    OF    UMBILICAL    HERNIA.       1 183 

or  continuous  chromic  gut  suturing  (Fig.  853).  The  skin  and  fascia  are 
closed  in  the  ordinary  manner.  The  patient  is  kept  in  bed  from  twelve  to 
twenty  davs. 

Comment.— The  same  principle  is  carried  out  by  Blake's  operation— in 
which  a  median  incision  is  made  and  retracted  and  the  margins  of  the  apo- 
neuroses made  to  overlap  from  side  to  side— instead  of  from  above  downward. 
(Fig.  854.) 


NDEX 


Abbe's  operation  for  esophageal  stricture, 

716    _ 
Abdominal  aorta,  anatomy  of,  78 
ligation  of,  79 
hysterectomy,    partial,    1151 

total,  1 153  _ 
section,  anterior,  through  rectal  sheath, 
811 
anterolateral,      Harrington-Weir     pro- 
longation   of    anterolateral    intra- 
muscular  incision   through   rectal 
sheath,  Sio 
inferior.    Fowler's    angular    incision, 
818 
Meyer's  hockey-stick  incision,  817 
McBurney's  intramuscular  incision, 

807 
superior,  oblique  subcostal  incision, 
818 
lateral,  Yischer's  lumbo-iliac  incision, 

819 
median,  801 

complications  during,  806 
inferior,  Pfannenstiel's  incisions,  815 
Abdominopelvic    region,    operations    upon, 

793 
general  considerations,   799 
wall,  anatomy  of,  793 
operations  upon,  793 
instruments  for,  801 
Abscess,  cerebellar,  operation  for,  596 
cerebral,  operation  for,  595 
intra-abdominal,  operative  treatment  of, 
829 
Acupressure  for  radical  cure  of  aneurism, 

139 
of  veins,  145 
Albert's  method  of  gastrostomy,  959 
Alexander's  method  of  prostatectomv,  1144 
Allingham's  operation  for  hemorrhoids,  944 
Amputation,  271 

about  hands,  general  considerations,  339 
adjustment    and    suturing    of    musculo 

periosteal    or    periosteocapsular    cover- 
ing, 297 
anesthesia  in,  272 
circular,  303 

cuff  method,  305 

division  of  muscles  in,  281 

modified,  306 

ordinary,  303 
complications  of,  immediate,  320 
drainage  in,  300 
dressing  of  wound,  301 
elliptical,  315 

75 


Amputation,  flap,  309 

division  of  muscles  in,  284 
equal,  of  skin,  312 

and  muscle,  311 
single,  of  skin,  311 

muscles,  309 
unequal,  of  skin,  314 
muscles,  313 
rectangular,  of  skin  and  muscles,  314 
freeing  and  retracting  muscles  in,  288 

skin  and  fascia  in,  279 
general  considerations  in,  271 
hemorrhage  in,  control  of,  272 
incision  of  skin  and  fascia  in,  276 
instruments  for,  271 
interilio-abdominal,  460 
intermediate,  319 
irregular  methods  of,  317 
ligating  arteries  and  veins  in,  295 
location  of  limits  of  skin  incisions  in,  275 

of  line  of  bone-section  in,  274 
making    musculoperiosteal   or   periosteo- 
capsular covering,  289 
methods  of,  301 

selection  of,  317 
of  arm  at  surgical  neck,  370 
general  considerations,  367 
in  general,  368 
lower  third,  368 
together    with    scapula    and    part    of 

clavicle,  383 
upper  two-thirds,  370 
of  fingers,  at  first  phalanx,  331 
by  palmar  flap,  331 
by  short  dorsal  and  palmar  flaps, 

332 
at  last  phalanx,  by  palmar  flap,  327 

in  general,  327 
at  second  phalanx,  by  palmar  flap,  330 
by  short  dorsal  and  long  palmar 

flaps,  330 
in  general,  330 
excluding  thumb,  with  parts  of  meta- 
carpals,  343 
general  considerations,  325 
little,  with  part  of  metacarpal,  342 
three   innermost,    with   parts  of   meta- 
carpals, 343 
inside,  with  parts  of  metacarpals,  342 
two    contiguous    inside,    with   parts   of 

metacarpals,  342 
with  parts  of  metacarpals,  341 
of  foot,  general  considerations,  401 
of  forearm,  general  considerations,  355 
in  general,  356 

118.; 


u86 


INDEX 


Amputation    of   forearm,    lower   third,   cir- 
cular method,  cuff  variety,  357 
modified  circular  method,   356 

upper  two-thirds,  358 
of  leg,  at  lower  third,  420 

femorotibial  osteoplastic,  443 

general  considerations,  418 

middle  third,  424 

osteoplastic,  422 
at  upper  third,  429 

supramalleolar  region,  419 

upper  third,  425 

bilateral  hooded  flaps,  427 
of  lower  extremity,  385 
of  penis,  partial,  11 14 

total,  n  16 
of  thigh,  440 

at  condyles  of  femur,  440 

general  considerations,  438 

just  above  condyles  of  femur,  441 

just  below  trochanters,  449 

lower,  middle,  or  upper  third,  440,  44S 

lower  third,  444 
of  thumb,  with  part  of  metacarpal,  342 
of  toes,  at  first  phalanx,  391 
circular  method,  392 
oval  method,  392 

at  last  phalanx,  388 

by  plantar  flap,  388 

at  metatarsus,  402 

at  second  phalanx,  390 
by  plantar  flap,  390 

general  considerations,  386 

with  part  of  metatarsals,  401 
of  upper  extremity,  323 
osteoplastic,  317 
oval,  307 
position  of  assistants  in,  271 

of  patient  in,  271 

of  surgeon  in,  271 
preparation  of  patient  in,  271 
primary,  319 
quilting  of  muscles,  298 
racket,  308 

removal  of  dressings,  301 
removing  splintered  bone,  294 
retraction  of  skin  and  fascia  in,  280 

of    soft    parts    preparatory    to    sawing 
bone,  292 
sawing  bone,  292 
secondary,  319 
site    of,    in    connection    with    resulting 

stump  and  its  adaptability  to  artificial 

limb,  322 
stump,  319 

adaptability  of,   to  artificial  limb,  322 

bad,  characteristics  of,  320 

cicatrices  of,  position,  321 

function  of,  321 

good,  qualities  of,  319 

suturing,  300 

tissues  of,  contractilitv,  321 

vitality  of,  conditions  influencing,  320 
technic  in,  general,  274 
treatment   of   nerves,    tendons,    and    tags 

of  muscle,  fascia,  and  skin  in,  297 


Amputation,  trimming  of  flaps,  297 
Anastomosis,  facio-accessorv,  for  peripheral 
facial  paralysis,  196 
faciohypoglossal,     for     peripheral     facial 

paralysis,  196 
intestinal,  854.     See  also  Entero-enteros- 

tomy. 
nerve-,   165 
uretero-ureteral,  10S0 
Anesthesia  in  amputations,  272 

massive  infiltration,  with  weak  analgesic 
solutions,      Mata's      modification      of 
Schleich's  method,  172 
regional,  intraneural  infiltration  for,   169 
Matas  and  Crile's  operation,   169 
paraneural      infiltration      for      Mata's 
method,  171 
spinal,  subarachnoid  puncture  for,  666 
Aneurism,    arteriovenous,    radical    cure    of 
Matas-Bickham  operation  for,  133 
radical  cure  of,  acupuncture  for,  124 
introduction  of  wire  for,  139 
ligation  for,  139 
Macewen's  operation  for,   139 
Mata's  operation  for,  125 
needling  for,  140 
Aneurismorrhaphy,  125 
Ankle-joint,  anatomy  of,  412 

disarticulations  at,  general  considerations, 

4_i3 
excision  of,  510 
Annandale's  osteoplastic  resection  of  supe- 
rior maxilla,  474 
Anus,  artificial,  closure  of,  operation  for,  927 
permanent,  left  inguinal  colostomy  for, 

_  919 
right  inguinal  enterostomy  for,  914 
fistula  in,  operation  for,  947 
Aorta,  abdominal,  anatomy  of,  78 

ligation  of,  79 
Aponeurotomy,  269 
Appendicectomy,  900 
Halsted's  method,  910 
McBurney's  method,  900 
non-intramuscular  method,  911 
through  rectal  sheath,  911 
Appendicostomv,  912 
Weir's  method,  912 
Arm,  amputation  about,  general  considera- 
tions, 367 
amputation  of,  368 
anatomy  of,  365 
Arterial  forcipressure,  140 
Arteriorrhaphy,  118 

Bougie's  method  of,  123 
Gluck's  method  of,  123 
Murphy's  method,  1 19 
Salomoni  and  Tomaselli's  method  of,  123 
Arteriostrepsis,  140 
Arteriovenous    aneurism,    radical    cure    of, 

Matas-Bickham  operation  for,  133 
Artery,  abdominal  aorta,  anatomy  of,  78 
ligation  of,  79 
axillary,  anatomy  of,  59 
first  part,  ligation  of,  60 
third  part,  ligation  of,  62 


INDEX 


1187 


Artery,  brachial,  anatomy  of,  63 
ligation  of,  64 
carotid,  common,  'anatomy  of,  32 
left,  anatomy  of,  32 
ligation  of,  34 
right,  anatomy  of,  32 
external,  anatomy  of,  36 

ligation  of,  37 
internal,  anatomy  of,  40 
ligation  of,  50 
clearing  of,  for  ligation,  22 
dorsalis  pedis,  anatomy  of,  107 

ligation  of,  107 
exposure  of,  for  ligation,  20 
facial,  anatomy  of,  40 

ligation  of,  41 
femoral,  anatomy  of,  91 
common,  ligation  of,  93 
superficial,  ligation  of,  96 
gluteal,  anatomy  of,  87 

ligation  of,  87 
iliac,  common,  anatomy  of,  81 
ligation  of,  81 
external,  anatomy  of,  88 

ligation  of,  89 
internal,  anatomy  of,  83 
ligation  of,  84 
innominate,  anatomy  of,  27 

ligation  of,  27 
intercostal,  anatomy  of,  76 

ligation  of,  76 
ligation    of,    17.     See    also    Ligation    0} 

artery. 
line  of,  18 
lingual,  anatomy  of,  38 

ligation  of,  39 
mammary,  internal,  anatomy  of,  57 

ligation  of,  58 
maxillary,  internal,  anatomy  of,  44 
meningeal,  middle,  anatomy  of,  44,  535 
anterior  branch,  ligation  of,  48 
posterior  branch,  ligation  of,  49 
topography  of,  542 
trunk  of,  ligation,  47 
occipital,  anatomy  of,  42 

ligation  of,  42 
of  cerebral  hemorrhage,  535 
opening  sheath  of,  for  ligation,  21 
peroneal,  anatomy  of,  114 

ligation  of,  1 1 4 
plantar,  external,  anatomy  of,  115 
ligation  of,   116 
internal,  anatomy  of,   1 1 7 
ligation  of,  1  17 
popliteal,  anatomy  of,  99 

ligation  of,  100 
pressure  of,  140 
profunda  femoris,  anatomy  of,  94 

ligation  of,  95 
pudic,  internal,  anatomy  of,  85 

ligation  of,  85 
radial,  anatomy  of,  66 

ligation  of,  69 
sciatic,  anatomy  of,  84 

ligation  of,  84 
subclavian,  anatomy  of,  50 


Artery,  subclavian,  left,  first  portion,  liga- 
tion of,  52 
right,  first  portion,  ligation  of,  52 
second  portion,  ligation  of,  53 
third  portion,  ligation  of,  53 
suture  of,  118 
temporal,  anatomy  of,  43 

ligation  of,  43 
thyroid,  inferior,  anatomy  of,  56 

ligation  of,  57 
tibia,  anterior,  anatomy  of,  103 
ligation  of,  104 
posterior,  anatomy  of,  108 
ligation  of,   109 
torsion  of,  140 
ulnar,  ligation  of,  73 
vertebral,  anatomy  of,  35 

ligation  of,   55 
wounds   of,    closure,    Brewer's   operation 
for,  124 
by  special  rubber  plaster,  124 
Arthrectomy,  242 
Arthrodesis,  242 
Arthroplasty,  241 
Arthrotomy,  241 

Artificial  anus,  closure  of,  operation  for,  927 
permanent,     left     inguinal     colostomy 
for,  919 

right  inguinal  enterostomy  for,   914 
larynx,  introduction  of,  702 
Astragalus,  excision  of,  507 
Auditory  word  area,  localization  of,  545 
Auricle,  right,  of  heart,  paracentesis  of,  787 
Axillary  artery,  anatomy  of,  59 
first  part,  ligation  of,  60 
third  part,  ligation  of,  62 
lvmphatic  glands,  anatomy  of,   154 
removal  of,   155 
trunk,  anatomy  of,  154 
region,  anatomy  of,  154 


Bardexheuer's  method  of  ligating  innomi- 
nate artery,  31 
Barker's  excision  of  hip-joint,  529 
Bartholin's  duct,  anatomy  of,  726 

operations  upon,  726 
Basal  ganglia,  topography  of,  541 
Bassini's  operation  for  femoral  hernia,  1 1 76 

for  oblique  inguinal  hernia,  1166 
Battle-Galaguier-Kammerer      method       of 

anterior  abdominal  section,  811 
Baum's  method  of  exposing  facial  nerve,  195 
Bell's     cyrtometer     in     Chipault's     cranio- 
cerebral localization,   550 
Bennett's  modification  of  Howse's  operation 

for  varicocele,   1 137 
Berger's  method  of  amputation  of  arm,  383 
Bier's  method  of  amputating  leg  at  upper 

third,  429 
Billroth's  method  of  pylorectomy,  997 
Birth  palsy,  brachial,  o] a-ration  for,  199 
Bladder,  anatomy  of,  1091 
drainage  of,  1108 
perineal,  1108 
suprapubic,  110S 


Ill 


INDEX 


Bladder,  drainage  of,  urethral,   1 108 

female,  introduction  of  sound  or  catheter 

into,  1095 
implantation  of  ureter  into,  10S5 
male,  introduction  of  sound  or  catheter 

into,  [094 
operations  upon,    1091 

general  considerations,  1093 
instruments  for,  1094 
puncture  of,  1095 

stone  in,   lateral   perineal   cystotomy  for, 
1099 
median  perineal  cystotomy  for,    1102 
suture  of,    1 103 
Blake's   method   of  treating   diffuse   septic 

peritonitis,  826 
Bobroff's  operation  for  spina  bifida,  683 
Boeckel-Langenbeck's    excision    of    wrist- 
joint,  491 
Bone-grafting,  227 
Bone-implantation,  227 
Bones,  operations  upon,  210 
osteoplastic  resections  of,  468 
uniting  of  tendons  to,  operation  for,  264 
Bose's    bloodless    method   of   tracheotomy, 

706 
Bougie,  esophageal,  introduction  of,  715 
Bougie's  method  of  arteriorrhaphy,   123 
Bovee's    method    of    uretero-ureterostomy, 

1081 
Brachial  artery,  anatomy  of,  63 
ligation  of,  64 
birth  palsy,  operation  for,  199 
plexus  of  nerves,  anatomy  of,  198 
exposure  of,  in  neck,  198 
Brain,  anatomy  of,  533 
areas,  localization  of,  543 
bullet  wound  of,  operation  for,  591 
parts  of,  533 

puncture  of,  exploratory,  584 
ventricles  of,  lateral,  puncture  and  drain- 
age of,  594 
topograph}-  of,  542 
Braun-Loessen  method  of  exposing  superior 
maxillary  nerve  and  Meckel's  ganglion, 
186 
Breast,  female,  anatomy  of,   736 
excision  of,  ordinary,  745 
partial,  737 

radical,  Halsted's  operation,  741 
Warren's  operation,  744 
Meyer's  operation,  738 
subcutaneous,  746 
incision  of,  737 
operations  upon,  736 

general  considerations,   736 
Brewer's    method    of    closing    wounds    of 

arteries,    124 
Broad  ligament  of  uterus,  anatomy  of,  1148 
Bronchi,  anatomy  of,  791 

operations  upon,  791 
Bronchotomy,  791 
Bryant's  method  of  colopexy,  932 
of  posterior  thoracotomv,  752 
operation  for  esophageal  stricture,  716 
Bullet  wound  of  brain,  operation  for,  591 


Bursa:,  excision  of,  270 
incision  of,  270 
operations  upon,   276 
puncture  of,  270 


Calculus,  vesical,  lateral  perineal  cystot- 
omy for,  1099 
median  perineal  cystotomy  for,  1102 
Carden's  amputation  of  thigh,  440 
( lardiac  orifice  of  stomach,  dilatation  of,  987 
Cardiorrhaphy,  790 
Carnochan's  method  of  exposing  superior 

maxillary  nerve,  185 
Carotid  artery,  common,  anatomy  of,  32 
left,  anatomy  of,  ^ 
ligation  of,  34 
right,  anatomy  of,  32 
external,  anatomy  of,  36 

ligation  of,  37 
internal,  anatomy  of,  49 
ligation  of,  50 
Cartilages,   nasal,   chondroplastic  resection 

of,  473 
semilunar,  dislocation  of,  operation  for, 

244 
Castration,  1134 

Catheter,  Eustachian,  introduction  of,  619 
introduction  of,  into  female  bladder,  1095 
into  male  bladder,  1094 
Celiotomy  veins,  800 
Cerebellar  abscess,  operation  for,  596 

subarachnoid     space,     incision     of,     for 

drainage,  595 
tumor,  operation  for,  599 
Cerebellum,  anatomy  of,  535 
extent  of,  539 
function  of,    545 
Cerebral  abscess,  operation  for,  595 
hemispheres,  extent  of,  538 
hemorrhage,  artery  of,  535 
tumor,  operation  for,  597 
Cerebrum,  fissures  of,  533 
lobes  of,  534 

mesial  fissures  and  lobes  of,  534 
Cervical  esophagectomy,  partial,   714 
esophagostomy,  714 
esophagotomy,  external,  712 
nerves,     first,     second,     third,     posterior 

divisions,  exposure  of,   107 
sympathetic  ganglia  and  cord,  anatomy 
of,  208 
•total  exi  ision  of,  209 
Cheever's  method  of  tonsillectomy,  719 
Chiene's  method  of  determining  Rolandic 
fissure,  554 
of  exposing  retropharyngeal  space,  710 
Chipault's  method  of  craniocerebral  locali- 
zation, 546 
Bell's  cyrtometer  in,  551 
operation  for  spina  bifida,  683 
Cholecystectomy,  1029 

Cholecystenterostomy    by   Murphy  button, 
1026 
by  simple  suturing,  1028 
Cholecystolithotrity,  1028 


INDEX 


1189 


Cholecystectomy,   oblique  or  vertical   sub- 
costal  incision,    1024 

Cholecystotomy,  vertical  subcostal  incision, 
1022* 

Choledochostomy,    transduodenal,   1034 

Choledochotomy,   retroduodenal,  1034 
supraduodenal,  1031 

Chondroplastic  resection  of  chest-wall,  734 

Chopart's  disarticulation  of  foot,  409 

Circumcision,  n  12 

Cirrhosis  of  liver,  operation  for,  102 1 

Clamp  and  cautery  for  hemorrhoids,  946 

Clavicle,  excision  of,  4S0,  481 

Coccyx,  excision  of,  468 

Cock's  method  of  external   perineal  ureth- 
rotomy, 1 1 26 

Coffey's  method  of  entero-enterostomv,  §§ 3 

Colopexy,  Bryant's  method,  932 

Colostomy,  916 
inguinal,  left,  917 

for  permanent  artificial  anus,  919 
for  temporarv  fecal  fistula,  918 
intramuscular,  anterior,  921 
lumbar,  left,  924 
Mixter's  method  of,  921 

Compression  of  nerve,  operation  for,  169 

Connell's    method    of    entero-enterostomv, 
864 

Convolution,  frontal,  ascending,  topography 
of,  541 
inferior,  topography  of,  541 
middle,  topography  of,  541 
superior,  topography  of,  541 
parietal,  .ascending,  topography  of,  541 

Cooper's    metallic    amputation     retractors, 

293 
Cranial   contents,    relations   of,    to   cranial 
bones,  554 
landmarks,  537 
Craniectomy,  partial,  581 
Craniocerebral     localization,     Chipault's 
method,  546 
Bell's  cyrtometer  in,  550 
Kroenlein's  method,  553 
Reid's  method,  551 
operations,  instruments  for,  557 

surgical  considerations,  554 
region,  operations  upon,  533 
topography,  538 
Craniotomy,  557 
circular,  558 

for  fracture  of  skull,  590 
linear,  580 
varieties  of,  558 
Crile    and    Matas'    operation    for    regional 

anesthesia,  169 
Crura  cerebri,  function  of,  545 
Crural  nerve,  anterior,  anatomy  of,  205 

exposure    of,    below    Poupart's   liga- 
ment, 205 
( 'unciform  osteotomy,  214 
Cushing's  exposure  of  Gasserian  ganglion, 

175 

method   of   uretero-ureterostomy,    1080 
right-angled   continuous  suture  of  intes- 
tine, 846 


Cyrtometer,    Bell's,    in    Chipault's    cranio- 
cerebral localization,  550 

Cystectomy,  partial,  1109 
total,  1 1 10 

Cysticotomy,  1035 

Cystorrhaphy,  1103 

Cystotomy,  1096 

lateral  perineal,  for  vesical  calculus,  1099 
median  perinal,  for  vesical  calculus,  1 102 
suprapubic,  1096 

Czerny-Lembert       entero-enterostomy      by 
interrupted  suture,  867 
interrupted  suture  of  intestine,  844 

Czerny's  method  of  exposing  tonsil,  720 


D'Urso  and  Fabii's  modification  of  Mon- 
ari's     method     of     uretero-ureterostomv, 

1083  ; 

Dawbarn's    method    of    closing    appendix 

in  appendicectomy,  907 
Dental  nerve,  inferior,  anatomy  of,  191 

exposure  of,  at  mental  foramen,  193 
in  mouth,  191 

through      ascending      ramus      of 
inferior  maxilla,  192 
De  Yilbiss'  forceps,  563 
Diaphragm,  anatomy  of,  755 
exposure  of,  transthoracic,   756 
operations  upon,  755 
Dilatation   of   cardiac    orifice   of   stomach, 
987 
of  esophagus,  direct,  for  stricture,  716 
retrograde,  for  stricture,  716 
Disarticulation  at  ankle-joint,  general  con- 
siderations, 413 
at  elbow-joint,  anterior  ellipse,  362 
in  general,  362 

long  antero-internal  and  short  postero- 
external flaps,  364 
posterior  ellipse,  363 
at  hip-joint,  anterior  racket  method,  459 
external  racket  method,  458 
general  considerations,  452 
Wyeth's  method,  456 
at  knee-joint,  433 

bilateral  hooded  flaps,  434 
by  oblique  curved  incision,  435 
general  considerations,  432 
at  shoulder-joint,  377 

anterior  racket  method,  378 
external  or  deltoid  flap,  382 

racket  method,  381 
general  considerations,  374 
at  wrist-joint,  anterior  ellipse,  351 
external  lateral,  or  radial  flap,  353 
general  considerations,  350 
in  general,  350 
palmar  flap,  352 
of  fingers  and  thumb  at  carpometacarpal 
articulation,  348 
at  first  interphalangeal  joint,  by  palmar 
Hap,  331 
by  short  dorsal  and  long  palmar 

flaps,  331 
in  general,  331 


1 190 


INDEX 


Disarticulation    of    fingers   at    metacarpo- 
phalangeal   joints,    in    general, 

332 
oval  method,  332 
at    second    interphalangeal    joint,    by 
palmar  flap,  329 

by  short  dorsal  and  long  palmar 

flaps,  329 
in  general,  329 
excluding    thumb,    with    metacarpals, 

348 
index,    at    metacarpophalangeal   joint, 

335 
with  metacarpal,  344 
inner,  with  metacarpal,  344 
little,  at  metacarpophalangeal  joint,  336 

with  metacarpal,  344 
three  innermost,  with  metacarpals,  346 

inside,  with  metacarpals,  346 
two  contiguous  inside,  with  metacar- 
pals, 346 
with  metacarpals,  343 
of    foot,    anterior    part,    at    mediotarsal 
joint,  409 
at  ankle-joint,  heel  flap,  414,  415 

in  general,  414,  415 
at  subastragaloid  joint,  410 
heel  flap,  4 1 2 

large  internoplantar  flap,  410 
of  lower  extremity,  385 
of  thumb  at  metacarpophalangeal  joint, 
oblique  palmar  flap,  335 
oval  method,  334 
with  metacarpal,  345 
of  toes,  at  first  interphalangeal  joints,  390 
oval  method,  390 
at  metatarsophalangeal  joints,   392 
at  second  interphalangeal  joint,  389 

plantar  flap,  389 
at     tarsometatarsal     joints,     by     short 
dorsal  and  long  plantar  flaps,   407, 
408 
en      masse,      at      metatarsophalangeal 

joint,  395  _ 
general  considerations,  386 
great,    at    metatarsophalangeal    joint, 

393 

with  metatarsal,  404 
little,  at  metatarsophalangeal  joint,  394 

with  metatarsal,  406 
second,  third,  or  fourth,  at  metatarso- 
phalangeal joint,  392 
two  adjoining,  at  metatarsophalangeal 

joint,  395 
two  or   three   contiguous,   with  meta- 
tarsals, 407 
with  metatarsals,  403,  404 
of  upper  extremity,  323 
Discission  of  pleura  in   chronic  empyema, 

Ransohoff's  operation,  771 
Dislocations  complicating  fractures,  opera- 
tive treatment  of,  232 
of  semilunar  cartilages,  operation  for,  244 
of  spine,  operative  treatment,  672 
Divulsion    of    pvloric    orifice    of    stomach, 
Loreta's  operation,  986 


Dollinger's  operation  for  spina  bifida,  683 
Dorsahs  pedis  artery,  anatomy  of,  107 

ligation  of,   107 
Doyen's  brace,  566 

c  nisei,  563 

electric-motor  drill  and  saw,  572 

saw,  555 
Drainage  in  amputations,  300 

of  pancreatic  cavities,  1046 

of  subarachnoid  space,   spinal   puni  ture 
for,  670 

vesical,  it 08 
Dubrueil's    method    of    disarticulation    at 

wrist-joint,  353 
Dura  mater,  venous  sinuses  of,  536 


Ear,  operations  upon,  618 

speculum,    introduction    of,    for    exami- 
nation of  membrana  tympani,  618 
Edebohl's  method  of  nephropexy,  1064 
Ejaculatory  ducts,  anatomy  of,  1138 
Elbow-joint,  anatomy  of,  359 
disarticulation  at,  362 

general  considerations,  361 
excision  of,  494 
Empyema,  chronic,  discission  of  pleura  in, 

Ransohoff's  operation,  771 
End-to-end      entero-enterostomy    by     per- 
forating    mattress    sutures     knotted    in 
lumen,  864 
Enterectomy,  partial,  849 
Entero-enterostomy,  854 
by  absorbable  bobbins,  879 

mechanical  devices  left  within  intestine, 
878 
by  Coffey's  method,  883 
by  Connell's  method,  S64 
by   Czerny-Lembert   interrupted    suture, 

867 
by     Halsted's     method     of     interrupted 

mattress  sutures,  868 
by  Harrington's  segmented  rings,  893 
by  Lee's  intestinal  holder,  895 
by  Maunsell's  invagination  method,  870 
by  mechanical  means,  895 
by  Murphy  button,  885 
by    non-absorbable    mechanical    devices 

left  within  intestinal  canal,  884 
by  simple  continuous  suture  of  all  coats, 
followed  by  interrupted  or  continuous 
Lembert    sutures    of     outer    coats, 
856 
suturing,  855 
by  Ullmann's  modification  of  Maunsell's 

operation,  881 
end-to-end,   by  perforating   mattress   su- 
tures knotted  in  lumen,  864 
lateral,  by  Jaboulay  button,  892 
Enteroplasty,  930 
Enterorrhaphy,  841 

by  continuous  suture  of  all  coats,  followed 
bv    interrupted    Lembert    suturing    of 
outer  coats,  848 
bv     Cushing's    right-angled     continuous 
suture,  846 


INDEX 


1191 


Enterorrhaphy   by    Czerny-Lembert    inter- 
rupted  suture,  S44 
by  Halsted's  interrupted  quilt  or  mattress- 
suture,  845 
bv  Lembert's  continuous  suture,  846 

interrupted  suture,  843 
for  wounds  of  intestine,  848 
Enterostomy,  913 

inguinal,    right,    for   permanent   artificial 
anus,  914 
for  temporary  fecal  fistula,  914 
Enterotomy,  841 
Enucleation  of  eyeball,  615 
Epididymes,  anatomy  of,  1136 
Epiphyses,   separated,   operative  treatment 

of,  232 
Epiplopexy  for  cirrhosis  of  liver,  102 1 
Epiplorrhaphv  for  cirrhosis  of  liver,  102 1 
Erasion  of  joint,  242 
Esophageal  bougie,  introduction  of,  715 
Esophagectomy,  cervical,  partial,  714 
Esophagoscopy,  715 
Esophagostomy,  cervical,  714 
Esophagotomy,  cervical,  external,  712 
internal,  715 

thoracic,   by  posterior  mediastinal  osteo- 
plastic flap  operation,  792 
Esophagus,  anatomy  of,  -  1 1 

dilatation  of,  direct,  for  stricture,  716 
foreign  bodies  in,  operation  for,  715 
operations  upon,  711 

general  considerations,  712 
instruments  for,   7  1  2 
stricture  of,   division,    by  string  friction, 
Abbe's  operation,  716 
direct  dilatation  for,  716 

divulsion  of,  716 
division,    by    string    friction,    Bryant's 

operation,  716 
permanent  tubage,  716 
retrograde  dilatation  for,  716 
divulsion  of,  716 
Estlander's  thoracoplastic  operation,  765 
Eustachian   catheter,   introduction   of,    619 

tube,  operations  upon,  61 S 
Evisceration  of  eyeball,  616 
Excision,  463 

of  ankle-joint,  510 

external  curved  and  internal   angular 

incisions,  5  1 1 
transversely    curved    external    incision, 

511 
of  astragalus,  external  angular  and  inter- 
nal curved  incision,  508 
curved  incision,  507 
of  bones  and  joints  about  foot,  507 

about  toes,  505 
of  breast,  female,  ordinary,  745 
partial,  737 

radical,   Halsted's  operation,   741 
Mever's  operation,  738 
Warren's  operation,  744 
subcutaneous,   746 
of  bursae,  270 

of  cervical  sympathetic  ganglia  and  cord, 
total,  209 


Excision  of  clavicle,  480,  481 
of  coccyx,  468 
of  elbow-joint,  494 

by  posterior   bayonet-shaped  incision, 

median  incision,  495 

by     vertically     curved     dorso-external 
incision,  498 
of  femur,  526 

diaphysis,  parts  of,  526 
of  fibula,  519 

by  posterior  vertical  incision,  520 
of  fingers,  483 

first  interphalangeal  joints,  487 

first  phalanges,  487 

metacarpals,  488 

metacarpophalangeal  joints,  487 

second  interphalangeal  joints,  484 

terminal  phalanges,  484 
general  considerations,  463 
of  hand,  487 
of  hemorrhoids,   Whitehead's  operation, 

945  .  . 
of  hip-joint,  526 
.by  anterior  straight  incision,  529 
by  external  straight  incision,  528 
bv  posterior  angular  or  curved  incision, 

53° 
of  humerus,  500 

long  external  incision,  501 
of  ileocecum,  899 

of    index-finger,    second    interphalangeal 
joint,  486 

second  phalanx,  486 
of  innominate  bone,  531 
of  knee-joint,  521 

by  curved  transverse  anterior  incision, 

522 
by  vertically  curved  external  incision, 

'523 
of  little  finger,  metacarpal,  489 

second  phalanx,  48 7 
of  maxilla,  inferior,  477 

anatomy  involved  in,  475 

superior,  anatomv  involved  in,  469 
median  incision,  471 
of  nerve,  158 
of  os  calcis,  510 
of  parotid  gland,  722 
of  patella,  520 

of  radio-ulnar  articulation,  superior,  500 
of  radius,  494 

total,  494 
of  rectum,  935.     See  also  Rectrectomy. 
of  ribs,  479 

and  costal  cartilage,  480 
of  scapula,  48] 

total,  482 
of  scrotum,  partial,  11 29 
of  seminal  vesicles  and  part  of  ejaculatory 

ducts.  Young's  operation,  1139 
of  shoulder-joint,  501 

anterior  oblique  incision,  502 
of    sublingual     gland    through    floor    of 

mouth,  726 
of  submaxillary  gland,  725 


1192 


INDEX 


Excision  of  tarsus,  5  1 8 

of  temporomaxillary  articulation,  476 

of  tendon-sheaths,  267 

of  thumb,  metacarpal,  489 

of  tibia,  518 

by  internal  vertical  incision,  519 
of  toes,  first  interphalangeal  joints,  506 
first  phalanges,  507 
metatarsal  bones,  507 
metatarsophalangeal  joints,  507 
second  interphalangeal  joints,   506 
second  phalanges,  506 
terminal  phalanges,  506 
of  tongue,  619 

general  considerations,  620 
instruments  for,  621 
limited  portions,  621 
through      mouth     after       preliminary 
ligation  of  lingual  arteries,  624 

without    preliminary    ligation     of 
lingual  arteries,  622 
together  with   cervical   and   submaxil- 
lary glands,  627 
with   osteoplastic    division    of    inferior 
maxilla,  624 
of  ulna,  493 
total,  493 
of  veins,  145 
of  wrist-joint,  489 

by    radial   and   ulnar   dorsal    incision, 

490 
by  single  dorsoradial  incision,  491 
dorso-ulnar  incision,  492 
open  method,  467 
subperiosteal,  464 
Exenteration  of  orbit,  616 
Eyeball,  enucleation  of,  615 
evisceration  of,  616 
operations  upon,  614 


Facial  artery,  anatomy  of,  40 
ligation  of,  41 
nerve,  anatomy  of,  194 

exposure  of,  in  front  of  mastoid  pro- 
cess, 195 
topography  of,  542 
paralysis,       peripheral,       facio-accessory 
anastomosis  for,  196 
Fallopian  tubes,  anatomy  of,  1159 
Farabeuf's    disarticulation    at    elbow-joint, 
362 
of  foot,  410 
of  great  toe,  393 

of    index-finger    at    metacarpophalan- 
geal joint,  335 
of  little  finger  at  metacarpophalangeal 
joint,  336 
toe,  394 
of     thumb     at     metacarpophalangeal 
joint,  335 
method    of    amputating    leg    at    lower 
third,  420 
at  upper  third,  425 
Facio-accessory  anastomosis  for  peripheral 
facial  paralysis,  196 


Facio-hypoglossal  anastomosis  for  periph- 
eral facial  paralysis,  196 
Fascia  in  amputation,  treatment  of,  297 

operations  upon,  269 
Easciotomy,  269 

by  open  method,  269 
by  subcutaneous  method,  269 
Fecal  fistula,  closure  of,  operation  for,  927 
temporary,  left  inguinal  colostomy  for, 
918 
right  inguinal  enterostomy  for,  914 
Femoral  artery,  anatomy  of,  91 
common,  ligation  of,  93 
superficial,  ligation  of,  96 
hernia,  1174.     See  also  Hernia,  femoral. 
Femur,  excision  of,  526 
Fergusson's  excision  of  superior  maxilla,  471 
Fibula,  excision  of,  519 

Finger,  index-,  disarticulation  of,  at  meta- 
carpophalangeal joint,  335 
with  metacarpal,  344 
second  interphalangeal  joint,   excision 

of,  486 
second  phalanx,  excision  of,  486 
inner,  disarticulation  of,  with  metacarpal, 

344 
little,  amputation  of,  with  part  of  meta- 
carpal, 342 
disarticulation  of,  at  metacarpophalan- 
geal joint,  336 
with  metacarpal,  344 
metacarpal  of,  excision,  489 
second  phalanx,  excision  of,  487 
Fingers,  amputation  of,  at  first  phalanx,  331 
at  last  phalanx,  327 
at  second  phalanx,  330 
excluding  thumb,  with  parts  of  meta- 
carpals, 343 
general  surgical  considerations,  325 
with  parts  of  metacarpals,  341 
anatomy  of,  323 

and  thumb,  disarticulation  of,  at  carpo- 
metacarpal articulation,  348 
disarticulation  of,  at  first  interphalangeal 
joint,  331 
at  metacarpophalangeal  joints,  332 
at  second  interphalangeal  joint,  329 
excluding    thumb,    with    metacarpals, 

348 
with  metacarpals,  343 
excision  of,  483 

of  first  interphalangeal  joints,  487 
of  first  phalanges,  487 
of  metacarpals,  488 
of  metacarpophalangeal  joints,  487 
of  second  interphalangeal  joint,  484 
of  second  phalanges,  486 
of  terminal  phalanges,  484 
three    innermost,    amputation    of,    with 
parts  of  metacarpals,  343 
disarticulation  of,  with  metacarpals, 

34° 
inside,    amputation    of,    with    parts    of 
metacarpals,  342 
disarticulation  of,  with  metacarpals, 
346 


INDEX 


"93 


Fingers,  two  contiguous  inside,  amputation 
of,   with  parts  of    metacarpals, 

disarticulation   of,    with   metacar- 
pals, 346 
Finnev's    method    of    gastroduodenostomv, 

.9S7' 
Fissure,  frontal,  inferior,  topogarphy  of,  540 
superior,  topography  of,  540 
intraparietal,  topography  of,  540 
longitudinal,  great,  anatomy  of,  533 

topography  of,  539 
mesial,  and  lobes  of  cerebrum,  534 
of  cerebrum,  533 
parietooccipital,  anatomy  of,  534 

topography  of,  540 
postcentral,  topography  of,  540 
precentral,  topography  of,  540 
Rolandic,  anatomy  of,  534 

Chiene's  method  of  determining,  554 
topography  of,  539 
Sylvian,  anatomy  of,  533 

topography  of,  539 
temporosphenoidal,  superior,  topography 

of,  541 
transverse,  great,  topography  of,  539 
Fistula,  fecal,  closure  of,  operation  for,  927 
temporary,  left  inguinal  colostomy  for, 
918  ' 
right  inguinal   enterostomy  for,   914 
Fistula-in-ano,  operation  for,  947 
Foot,  amputations  about,  general  considera- 
tions, 401 
anatomy  of,  397 
anterior  part,  disarticulation  of,  at  medio- 

tarsal  joint,  409 
disarticulation  of,  at  ankle-joint,  414,  415 

at  subastragaloid  joint,  410 
excision  of  bones  and  joints  about,  507 
osteoplastic    resection    of,    externolateral 
curved  incision,  518 
transversa     upper     and     lower     and 
oblique  lateral  incisions,  516 
Foramen  of  Winslow,  anatomy  of,  820 
Forcipressure,  arterial,    140 

venous,  145 
Forearm,  amputation  of,  356 
general  considerations,  355 
anatomy  of,  353 
Foreign    bodies    in    esophagus,     operation 
for.  715 
in  larynx,  operation  for  removal  of,  702 
in  trachea,  operation  for  removal,  707 
Fowler's    method    of    inferior    anterolateral 
abdominal  section,  818 
of  ureterorectostomy,  1086 
thoracoplastic  operation,  770 
Fracture-dislocations    of    spine,     operative 

treatment,  673 
Fractures,  comminuted,  operative  treatment 
of,  230 
complicated,  operative  treatment  of,  231 
compound,    operative   treatment   of,    230 
delayed  union  of,  operations  for,  228 
dislocations  complicating,  operative  treat- 
ment of,  232 


Fractures  involving  joints,  operative  treat- 
ment of,  231 
mal-union  of,  operations  for,  229 
non-union  of,  operations  for,  229 
of  skull,  trephining  for,  590 
of  spine,  operative  treatment,  670 
operative  treatment,  in  general,  214 
simple,  operative  treatment  of,  225 
ununited,    of    olecranon,    operation    for, 
by  wiring  or  suturing  of  bone  and 
soft  parts,  238 
of  patella,  operation  for,  by  encircling 
suture  of  soft  parts,  236 
by  suturing  of  soft  parts,  233 
by  wiring  or  suturing  of  bone  and 

soft  parts,  234 
Stimson's  operation  for,  233 
operation    for,    by    combined    ligature 
and  suture,  224 
by  frame  ligature  of  bone,  224 
by  intramedullary  pegging,  224 
by  ligation  of  bone,  223 
by  metallic  nails  or  ivory  pegs,  221 
or  bone  ferrules,  222 
plates  and  screws  or  screws,  222 
Parkhill's  clamp,  227, 
by  resection  of  ends  of  bones,  215 
by  suturing  of  ends  of  bones,  217 
Frontal    convolution,    ascending,    topogra- 
phy  of,    541 
inferior,  topography  of,  541 
middle,  topography  of,  541 
superior,  topography  of,  541 
fissure,  inferior,  topography  of,  540 

superior,  topography  of,  540 
sinuses.     See  Sinuses,  frontal. 


Gall-bladder,  anatomy  of,  102 1 
operations  upon,   102 1 

general  considerations,  1022 
instruments  for,  1008 
Gall-ducts,  anatomy  of,  1030 
operations  upon,  1030 

general  considerations,  103 1 
instruments  for,  103 1 
Ganglion,  basal,  topography  of,  541 

cervical  sympathetic,  and  cord,  anatomv 
of,  208 
total  excision  of,  209 
Gasserian,  anatomy  of,  175 

exposure    of,    by    direct    infra-arterial 
route,  175 
by  orbital  route,  1S6 
by      trephining      through      pterygo- 

maxillarv  fossa,  181 
through  temporal  fossa,  177 
maxillary,  anatomy  of,  188 
Meckel's,  anatomy  of,  182 

exposure  of,  by  antral  route,  185 
by  pterygomaxillary  route,    186 
operations  upon,   157 
otic,  anatomy  of,  188 
Gasserian  ganglion,  anatomy  of,  175 

exposure    of,    by    direct    infra-arterial 
route,  175 


ir94 


INI  MX 


Gasserian    ganglion,    exposure  of,   by  tre- 
phining through  pterygomaxillary 

fossa,   i  Si 
through  temporal  fossa,   177 
Gastrectomy,    partial,    of    median    portion, 

999 
total,  1001 
Gastric  ulcer,  operation  for,  1002 

perforated,  operation  for,   1003 
Gastroduodenostomy,    Finney's   operation, 

987 
Gastroenterostomy,  967 

anterior,  by  Murphy  button,  followed  by 
Jaboulay-Braun  method  of  intes- 
tinal anastomosis,  971 
Wolfler's  operation,  968 
posterior,   by  Murphy  button,   978 
by  von  Hacker's  method,  974 
Gastrogastrostomy,   Wolfler's   method,   979 
Gastrolysis,  983 
Gastropexy,  983 
Gastroplasty,  984 
Gastroplication,  981 

Moynihan's     modification     of     Bircher's 

operation  for,  983 
Weir's  modification  of  Bircher's  operation 
for,  981 
Gastrorrhaphy,  955 
Gastrostomy,  956 
Albert's  method,  959 
Hahn's  method,  959 
Kader's  method,  964 
Marwedel's  method,  962 
Ssabanajew-Franck's  method,   957 
Witzel's  method,  959 
Gastrotomy  by  median  incision,  952 
by  oblique  subcostal  incision,  954 
Genital   organs,    female,    operations   upon, 
1147 
male,  operations  upon,  1 1 1 1 
Gimbernat's  ligament,  anatomy  of,   1163 
Gliick's  method  of  arteriorrhaphy,  123 
Gluteal  artery,  anatomy  of,  87 
ligation  of,  87 
nerve,  superior,  exposure  of,  205 
Gouley's  method  of  external  perineal  ure- 
throtomy, 1 1 24 
Grafting,  bone-,  227 
nerve-,  165 
omental,  832 
tendon-,  261 
Gritti-Stokes'  method  of  amputating  thigh, 

441 
Gunshot  wounds  of  spinal  cord,  operative 

treatment  of,  675 
Gustatory  nerve,  anatomy  of,  193 

exposure  of,  in  mouth,  104 
Guvon's  supramalleolar  method  of  ampu- 
tating leg,  419 
Gyrus,  angular,  topography  of,  541 


Haasler's  method  of  retroduodenal  chole- 
dochotomy,  1034 

Hacker's  method  of  posterior  gastroenter- 
ostomy, 974 


Hahn's  method  of  gastrostomy,  959 
Halsted's     interrupted     mattress-suture     of 
intestine,  845 
method  of  appendicectomy,  910 

of   entero-enterostomy    by    interrupted 
mattress-sutures,  868 
operation    for    oblique    inguinal    hernia, 

1171 
radical  excision  of  breast,  741 
Hand,  amputation  about,  general  consider- 
ations, 339 
anatomy  of,  336 
excision  of,  487 
Harrington's  segmented  rings,  entero-enter- 
ostomy by,  893 
Harrington-Weir    method    of    anterolateral 

abdominal  section,  810 
Hartley-Krause  exposure  of  Gasserian  gan- 
glion, 177 
Hartley's  double  osteoplastic  flaps,  583 
electric  motor,  575 

method  of  ligating  intercostal  artery,   78 
preliminary   excision   of   spinous   process 
in  osteoplastic  resection  of  spine,  647 
sterilizable  compressed-air  motor,  576 
Head  and  face,  bony  air  sinuses  of,  opera- 
tions upon,  600 
operations  upon,  533 
Heart,  anatomy  of,  785 

and  pericardium,  exposure  of,  by  excision 
of  left  fifth  costal  cartilage,  784 
by  thoracoplastic  flap,  788 
operations   upon,    785 
puncture  of,  787 

right  auricle  of,  paracentesis  of,  787 
ventricle  of,  paracentesis  of,  787 
suture  of,  790 
Heineke-Mikulicz  method  of  pvloroplastv, 

984 
Hemorrhage,  cerebral,  artery  of,  535 
control  of,  in  amputations,  272 
intracranial,  operation  for,  585 
Hemorrhoids,  clamp  and  cautery  for,  946 
excision  of,  Whitehead's  operation,  945 
ligation    and    excision    of,     Allingham's 
method,  944 
Henle's  internal  cremaster,  anatomy  of,  1136 
Hepatectomy,  partial,  1019 
Hepaticotomy,  1036 
Hepatopexy,  10 19 
Hepatorrhaphy,  1019 
Hepatotomy,  1009 

anterior  subcostal  transperitoneal,   1010 
Hernia,  femoral,  anatomy  of,  1 1 74 
Bassini's  operation  for,  n  76 
operations  for,  1174 

for  radical  cure  of,  1176 
upon,  general  considerations,  11 76 
inguinal,  anatomy  of,  1163 

oblique,   Bassini's  operation   for,    1166 
Halsted's  operation  for,  1171 
operation  for  radical  cure  of,    1166, 
1171 
operations  for,   1163 

general  considerations,   1164 
instruments  in,    1166 


INDEX 


11 95 


Hernia,  operations  for,  1163 
umbilical,  anatomy  of,  1 1  78 
Mayo's  operation  for,  1181 
operations  for,   11 78 

for  radical  cure  of,  excision  of  sac, 
1179 
Hey's  disarticulation  of  toes,  408 

method    of    amputating    leg    at    middle 
third,  424 
Hip-joint,  anatomy  of,  450 

disarticulation  at,  general  considerations, 

45? 

excision  of,  526 
Humerus,  excision  of,  500 
Hydrocele,  Jaboulay's  operation  for,  1132 
Yolkmann's  operation  for,   1131 
Von  Bergmann's  operation  for,  1133 
Hypochondriac    regions,    exposure    of,    by 
chondroplastic  resection  of  chest-wall,  819 
Hysterectomy,  abdominal,  partial,   1151 
total,  1 153 
vaginal,  total,  1153 
Hysterosalpingo-obphorectomy,  abdominal, 
partial,  1151 
total,   1 153 


Ileocecum,  excision  of,  899 

Ileostomy   for    permanent    artificial    anus, 

for  temporary  fecal  fistula,  914 
Iliac  artery,  common,  anatomy  of,  Si 
ligation  of,  81 
external,  anatomy  of,  88 

ligation  of,  89 
internal,  anatomy  of,  83 
ligation  of,  84 
Implantation,  bone-,  227 

intestinal,    854.     See    also    Entero-enter- 

ostomy. 
nerve-,  165 
of  ureter,  1084 
into  bladder,  1085 
into  large  intestine,  1086 
upon  skin,  1089 
tendon-,  261 
Infiltrator,  Matas',  172 
Infra-orbital  nerve,  exposure  of,  188 
Inguinal   hernia,    1163.     See   also   Hernia, 
inguinal. 
lymphatic  glands,  anatomy  of,  155 
removal  of,  156 
Innominate  artery,  anatomy  of,  27 
ligation  of,  27 
bone,  excision  of,  531 
Intercostal  artery,  anatomy  of,  76 
ligation  of,  76 
nerve,  anatomy  of,  204 

exposure  of,  between  angle  and  middle 
of  rib,  204 
thoracotomy,  761 
Interilio-abdominal  amputation,  460 
Intestinal      anastomosis,      854.     See      also 
Entero-enter  ostomy. 
approximation,    854.     See    also    Entero- 
enterostomy. 


Intestinal    implantation,     854.      See     also 

Enter  o-enteroslomy . 
Intestines,  adhesions  to,  operations  for,  824 
large,  anatomy  of,  836 

implantation  of  ureters  into,  1086 
operations  upon,  833 

general  considerations,  840 
instruments  for,  840 
small,  anatomy  of,  833 
suture  of,  S41.     See  also  Enter orrhaphy. 
wounds  of,  enterorrhaphy  for,  848 
Intraneural   infiltration   for   regional   anes- 
thesia, 169 
Matas  and  Crile's  operation,  169 
Intra-orbital  structures,  exposure  of,  617 
Intraparietal  fissure,  topography  of,  540 
Intravenous  infusion  of  salt  solution,  146 
Intubation  of  larynx,  701 
Intussusception,    Jessett-Barker    operation 
for,  930 
operation  for,  930 
Island  of  Reil,  anatomy  of,  534 
topography  of,  541 


Jaboulay-Braun's     method    of    multiple 
lateral  intestinal  anastomosis,  891 

Jaboulay's       button,       lateral       intestinal 
anastomosis  by,  892 
operation  for  hydrocele,  1132 

Jessett-Barker    operation    for    intussuscep- 
tion, 930 

Jobert's    operation    for    ligating    popliteal 
artery,  100 

Joints,  erasion  of,  242 

fractures  involving,   operative  treatmeat 

of,  231 
operations  upon,  241 
osteoplastic  resection  of,  468 
puncture  of,  exploratory,  241 

Jonnesco's  operation  for  excision  of  cervical 
sympathetic  ganglia  and  cord,  209 


Kader's  method  of  gastrostomy,  964 
Keen's  interilio-abdominal  amputation,  460 
operation     for     exposure     of     posterior 
divisions    of    first,    second,    and    third 
cervical  nerves,  197 
Kidneys,  anatomy  of,  1048 

exposure  of,  by  abdominolumbar  opera- 
tion, 1059 
extraperitoneal,  and  entire  ureter,  1076 
retroperitoneal,    by    Koenig's    angular 
lumbo-abdominal  incision,  1056 
by    lumbar    intramuscular    method, 

1057 
by  oblique  lumbar  incision,  1053 
transperitoneal,  by  median  abdominal 
section,  1059 
by    vertical    incision    in    linea    semi- 
lunaris,  Langenbuch's   operation, 
1057 
operations  upon,  1048 

general  considerations,  1052 
instruments  for,  1053 


1196 


INDEX 


Kidneys,  puncture  of,  exploratory,  1060 

suture  of,  1063 
King's  scrotal  (lamp,  1130 
Knee-joint,  anatomy  of,  430 
disarticulation  at,  433 

general  considerations,  432 
excision  of,  521 
Kocher's  excision  of  elbow-joint,  498 
of  hip-joint,  530 
of  knee-joint,  523 
of  tongue,  together  with  cervical  and 

submaxillary  glands,  627 
of  wrist-joint,  492 
incision  of  innominate  bone,  531 
median  excision  of  tongue,  624 
method  of  complete  thyroidectomy,  729 
of   exposing   inferior   maxillary    nerve, 
188 
superior  maxillary  nerve,  183 
of  partial  thyroidectomy,  727 
of  pharyngotomy,  708 
of  pylorectomv,  994 
of     transduodenal      choledochostomy, 

resection  of  shoulder-joint,  503 
Koenig's  method  of  exposing  kidney,  10^6 
Kraske's  method  of  rectectomy,  935 
Kroenlein's  method  of  craniocerebral  local- 
ization, 553 
of     exposure      of     intra-orbital      and 
retrobulbar  structures,  617 


Lambotti's  operation  for  Pott's  disease,  691 
Laminectomy,  661 

general  considerations,  642 
Langenbeck's  excision  of  elbow-joint,  495 
of  hip-joint,  528 
osteoplastic  resection  of  superior  maxilla, 
474 
Langenbuch's  method  of  exposing  kidnev, 

io57 
Lange's   operation    for   uniting   tendon    to 

periosteum,  263 
Larry's    disarticulation    at    shoulder-joint, 

38i 
Laryngectomy,  complete,  699 

partial,  700 
Laryngoscopy,  702 
Laryngotomy,  697 

suprathyroid,  702 
Laryngotracheotomv,  702 
Larynx,  anatomy  of,  695 

artificial,  introduction  of,  702 

foreign  bodies  in,  operation  for,  removal 
of,  702 

intubation  of,  701 

operations  upon,  695 

tamponing  of,  702 
Lauenstein's  excision  of  ankle-joint,  5 1 1 
Lee's  intestinal  holder,  entero-enterostomy 

by,  895 
Leg,  amputation  of,  at  lower  third,  420 
femorotibial  osteoplastic,  443 
general  considerations,  418 
middle  third,  424 


Leg,  amputation  of,  osteoplastic,  422 
at  upper  third,  429 
supramalleolar  region,  419 
upper  third,  425 

bilateral  hooded  flaps,  427 
anatomy  of,  416 
Lembert's   continuous   suture   of  intestine, 
846 
interrupted  suture  of  intestine,  843 
Ligaments,   broad,  of  uterus,  anatomy  of, 
1 148 
lengthening  of,  268 
operations  upon,  268 
round,  of  uterus,  anatomy  of,  1149 
shortening  of,  268 
suturing  of,  268 
Ligation  of  abdominal  aorta  by  retroperi- 
toneal operation,  80 
by  transperitoneal  method,  79 
of  artery,  1 7 

after-treatment,  26 

closure  of  wound,  26 

comment,  26 

control   of  circulation   preliminary   to, 

18 
dangers,  26 
en  masse,  118 

for  radical  cure  of  aneurism,  139 
general  considerations,  17 
in  amputation,  295 
incision,  19 
indications,  18 
instruments  for,  17 
intermediate,  118 
materials  for,  18 
passing  ligature,  22 
position  of  patient,  17 
preparation,  17 
provisional,  118 
results,  26 
temporary,  118 
tying  ligature,  24 
varieties,  17 
of  axillary  artery,  first  part,  60 

third  part,  60 
of  brachial  artery,  at  bend  of  elbow,  65 

in  middle  of  arm,  64 
of  carotid  artery,  common,  34 

above  omohyoid  muscle,  34 
below  omohyoid  muscle,  35 
external,  above  digastric  muscle,  38 

below  digastric  muscle,  37 
internal,  near  origin,  50 
of  dorsalis  pedis,  just  below  ankle-joint, 

107 
of  facial  artery,  near  origin,  41 
over  inferior  maxilla,  41 
of  femoral  artery,   common,   at  base  of 
Scarpa's  triangle,  93 
superficial,     at     apex     of     Scarpa's 
triangle,  96 
in  Hunter's  canal,  98 
of  gluteal  artery,  on  buttock,  87 
of    iliac    artery,    common,    by    retroperi- 
toneal operation,  81 
by  transperitoneal  operation,  83 


INDEX 


1197 


Ligation  of  iliac  artery,  external,  by  retro- 
peritoneal route,  89 
by  transperitoneal  method,  91 
internal,    by    retroperitoneal    opera- 
tion, 84 
by  transperitoneal  operation,  84 
of  innominate  artery,  27 

Bardenheuer's  method,  31 
by  angular  incision,  27 
by  oblique  incision,  30 
by    partial    bony    resection    through 
transverse   and    vertical    incisions, 

31        . 

by  splitting  of  manubrium  sterni,  31 

Mutt's  method,  27 
of  intercostal   artery   by  intercostal  inci- 
sion, 76 
by  subperiosteal  excision  of  rib,  78 
of  lingual  artery,  beneath  hypoglossus,  39 

near  origin,  39 
of  mammary  arterv,  internal,  in  second 

intercostal  space,  58 
of    meningeal    artery,     middle,    anterior 
branch,  48 
posterior  branch,  49 
trunk  of,  47 
of     occipital     artery,      behind      mastoid 
process,  42 
near  origin,  42 
of  omentum,  831 

of  peroneal  artery,  in  middle  of  leg,  114 
of  plantar  arterv,  external,  in  sole  of  foot, 

I  if) 

internal,  at  origin,  1 1 7 
in  sole  of  foot,  117 
of  popliteal  artery,  in  lower  part,  101 

in  upper  part,  100 
of  profunda  femoris,  near  origin,  95 
of  pudic  artery,  internal,  in  perineum,  85 

upon  buttock,  S5 
of  radial  artery,  deep  palmar  arch,  72 
in  lower  third  of  forearm,  70 
in  upper  third  of  forearm,  69 
of  sciatic  artery,  upon  buttock,  84 
of  sinus,  lateral,  586 

of  subclavian  artery,  left,  first  portion,  52 
right,  first  portion,  52 
second  portion,  53 
third  portion,  53 
of  temporal  artery,  just  above  zygoma,  43 
of  thoracic  duct,  149 
of  thyroid  artery,  inferior,  57 
of  tibial  atery,   anterior,   in    lower   third 
106 
in  middle  third,  105 
in  upper  third,  104 
posterior,  behind  internal  malleolus, 
112 
in  lower  third,  112 
in  middle  third,  no 
in  upper  third,  109 
of  ulnar  arterv,  in  lower  third  of  forearm, 

.76. 

in  middle  third  of  forearm,  73 
of  veins,  en  masse,   145 
in  amputation,  295 


Ligation  of  veins,  lateral,  143 
temporary,  144 
transverse,   144 
of  vertebral  artery,  near  origin,  55 
Ligature,  passing,  in  ligation  of  artery,  22 

tying,  in  ligation  of  artery,  24 
Linea  alba,  anatomy  of,  796 
Linear  craniotomy,  580 

osteotomy  by  open  method,  213 
by  subcutaneous  method,  211 
Lingual  artery,  anatomy  of,  38 
ligation  of,  39 
nerve,  anatomy  of,  193 

exposure  of,  in  mouth,  194 
Lisfranc's  disarticulation  of  toes,  407 
Lister's  modification  of  Carden's  amputa- 
tion of  thigh,  440 
Litholapaxy,  1104 
Lithotrity,  1104 
Liver,  anatomy  of,  1004 

cirrhosis  of,  operation  for,  102 1 
exposure  of,  by  anterior  subcostal  trans- 
peritoneal route,  10 1 2 
by   chrondroplastic    resection    of   right 

costal  arch,  1017 
by    lateral     subcostal    transperitoneal 

route,  1013 
by  subpleural  route,  1014 
by  transpleural  route,  1016 
operations  upon,  1004 

general  considerations,  1006 
instruments  for,  1008 
puncture  of,  exploratory,  1008 
suture  of,  1019 
Lobe,  occipital,  topography  of ,  541 
parietal,  topography  of,  541 
temporal,  topography  of,  541 
Lobuli  testis,  anatomy  of,  n  29 
j    Loreta's    method    of    divulsion    of    pyloric 
orifice  of  stomach,  986 
Lumbar  puncture  for  diagnosis  and  thera- 

peusis,  669 
Lungs,  anatomy  of,  772 
operations  upon,  772 
Lymphatic  glands,  axillary,  anatomy  of,  154 
removal  of,  155 
inguinal,  anatomy  of,  155 

removal  of,  156 
of  neck,  isolated,  removal  of,  153 

removal  of,  751 
operations  upon,  148 
trunk,  axillary,  anatomy  of,  154 
vessels,  operations  upon,  148 


Macewen's  operation  for  radical  cure  of 
aneurism,  139 
trephining-brace,  556 
Mammary  arterv,  internal,  anatomy  of,  57 
ligation  of,  58 
gland,  female,  operations  upon,  736.     See 
also  Breast,  female. 
Marion's  gigli-saw  conductor,  569 
Markoe's  method  of  uretero-ureterostomv, 

to8i 
Marwedel's  method  of  gastrostomy,  962 


1198 


INDEX 


Mastoid  antrum,  anatomy  of,  600 

exposure     of,     antrum     operation     of 
Schwartze,  604 
Schwartze-Stacke  operation,  606 
operations  upon,  600 

general  considerations,  603 
instruments  for,  604 
cells,  anatomy  of,  600 
operations  upon,  600 

exposure    of,   antrum    operation    of 

Schwartze,  604 
Schwartze-Stacke  operation,  606 
general  considerations,  603 
instruments  for,  606 
Matas  and   Crile's  operation   for  regional 

anesthesia,  169 
Matas'  infiltrator,  172 

method    of    paraneural    infiltration    for 

regional  anesthesia,  171 
modification    of     Schleich's    method    of 

massive  infiltration  anesthesia,  172 
operation  for  radical   cure  of  aneurism, 

Matas-Bickham  operation  for  radical  cure 

of  arteriovenous  aneurism,  133 
Maunsell's  invagination  method  of  entero- 

enterostomy,  S70 
Maxilla,  inferior,  excision  of,  477 
anatomy  involved  in,  475 
osteoplastic  resection  of,  479 
osteoplastic    resection    of,     Annandale's 
method,  474 
Langenbeck's  method,  474 
superior,   excision  of,  anatomy  involved 
in,  469 
median  incision,  471 
osteoplastic  resection  of,  473 
Maxillary  ganglion,  anatomy  of,  188 
artery,  internal,  anatomy  of,  44 
nerve,  inferior,  anatomy  of,  188 

exposure  of,  at  foramen  ovale,  188, 
190 
superior,  anatomy  of,  182 

exposure  of,  at  foramen  rotundum, 
183,  190 
by  antral  route,  185 
by  orbital  route,  186 
by  ptervgomaxillarv  route,  186 
sinuses.     See  Sinuses,  maxillary. 
Mayo's  method  of  pylorectomy,  991 

operation  for  umbilical  hernia,  1181 
McBurney's       method      of      anterolateral 
abdominal  section,  807 
of  appendicectomy,  900 
point,  808 
Meatotomy,  11 20 

Meckel's  ganglion,  anatomy  of,  182 
exposure  of,  by  antral  route,  185 
by  orbital  route,  186 
by  ptervgomaxillarv  route,  186 
Median  nerve,  anatomy  of,  201 

exposure  of,  at  bend  of  elbow,  202 
in  middle  of  arm,  201 
Mediastinotomy,  Milton's  method  of,  748 
Mediastinum,  anterior,  anatomy  of,  748 
operations  upon,  748 


Mediastinum,  middle,  anatomy  of,  752 
operations  upon,  752 
posterior,  anatomy  of,  752 

operations  upon,  752 
superior,  anatomy  of,  747 
operations  upon,  747 
Medulla,  function  of,  545 
Membrana  tympani,  anatomy  of,  618 

introduction     of     ear     speculum     for 
examination  of,  618 
Meningeal  artery,  middle,  anatomy  of,  44, 

535 
anterior  branch,  ligation  of,  48 
posterior  branch,  ligation  of,  49 
trunk  of,  ligation  of,  47 
topography  of,  542 
Mesentery,  anatomy  of,  S33 
operations  upon,  833 

general  considerations,  833 
Meyer's  radical  excision  of  breast,  738 
Mid-tarsus,  osteoplastic  resection  of,  514 
Mikulicz's  method  of  exposing  tonsil,  720 
Milton's      osteoplastic      anterior      medias- 
tinotomy, 748 
Mixter's  method  of  colostomy,  921 

of   exposing   inferior   maxillary   nerve, 
190 
Motor  areas,  localization  of,  544 

center,  exposure  of,  operation  for,  593 
Mott's  method  of  ligating  innominate  artery, 

27 
Moynihan's      modification      of      Bircher's 

operation  for  gastroplication,  983 

Murphy  button,  anterior  gastro-enterostomy 

by,    followed     by     Jaboulay-Braun 

method    of    intestinal    anastomosis, 

971 

cholecystenterostomy  by,  1026 

entero-enterostomy  by,  885 

posterior  gastro-enterostomy  by,  978 

Murphy's  method  of  suturing  arteries,  119 

of  treating  diffuse  septic  peritonitis,  825 

Muscle  in  amputation,  treatment  of,  297 

Muscle-lengthening,  246 

Muscles,  operations  upon,  245 

suture  of,  24O 

Musculospiral  nerve,  anatomy  of,  203 

exposure  of,  below  middle  of  arm,  203 

Myer's    method    of    inferior    anterolateral 

abdominal  section,  817 

Myorrhaphy,  245 

Myotomy,  245 

Nasal  cartilages,   chondroplastic  resection 

of,  473 
cavities,  operations  upon,  619 

Nasolambdoidal  line,  topography  of,  542 

Neck,  anatomy  of,  695 

anterolateral  aspect,  anatomy  of,  149 
lymphatic    glands   of,    isolated,    removal 

of>  153 

removal  of,  151 
operations  upon,  695 

instruments  for,  696 
Needling  for  radical  cure  of  aneurism,  139 


INDEX 


1199 


Neoplasms,  vascular,  injection  of  water  at 

high  temperature  in,  141 
Nephrectomy,    partial,    by   oblique  lumbar 
incision,  1072 
subcapsular,  1072 

total,  by  anterior  transperitoneal  opera- 
tion, 1072 
by  oblique  lumbar  incision,  1070 
Nephrolithotomy,  1062 
Nephropexy  by  simple  suturing,  1069 
Edebohl's  method,  1064 
Turner's  method,  106S 
Nephrorrhaphy,  1063 
Nephrotomy,   1061 
Nerve,  crural,  anterior,  anatomy  of,  205 

exposure   of,    below   Poupart's   liga- 
ment, 205 
dental,  inferior,  anatomy  of,  191 

exposure  of,  at  mental  foramen,  193 
in  mouth,  191 

through  ascending  ramus  of  infe- 
rior maxilla,  192 
excision  of,  158 
facial,  anatomy  of,  194 

exposure     of,     in     front     of     mastoid 

process,  195 
topography  of,  542 
gluteal,  superior,  exposure  of,  205 
gustatory,  anatomy  of,  193 

exposure  of,  in  mouth,  194 
in  amputation,  treatment  of,  297 
infra-orbital,  exposure  of,  188 
intercostal,  anatomy  of,  204 

exposure  of,  between  angle  and  middle 
of  rib,  204 
lingual,  anatomy  of,  193 

exposure  of,  in  mouth,  194 
maxillarv,  inferior,  exposure  of,  188 
at  foramen  ovale,  188,  190 
superior,  anatomy  of,  182 

exposure  of,  at  foramen  rotundum, 
183,  190 
by  antral  route,  185 
by  orbital  route,  186 
by  pterygomaxillary  route,  186 
median,  anatomy  of,  201 

exposure  of,  at  bend  of  elbow,  202 
in  middle  of  arm,  201 
musculospiral,  anatomy  of,  203 

exposure  of,  below  middle  of  arm,  203 
obturator,  exposure  of,  205 
popliteal,  external,  anatomy  of,  207 

exposure  of,  behind  tendon  of  biceps, 
207 
internal,  anatomy  of,  206 

exposure  of,  at  lower  part  of  popliteal 
space,  206 
pudic,  exposure  of,  205 
sciatic,  great,  anatomy  of,  205 

exposure    of,    at    lower    border    of 
gluteus  maximus,  206 
spinal  accessory,  anatomy  of,  195 

exposure   of,    at   anterior   border  of 
sternomastoid  muscle,  195 
supra-orbital,  anatomy  of,  182 
exposure  of,  182 


Nerve,  suture  of,  160 

tibial,  anterior,  anatomy  of,  208 
exposure  of,  near  origin,  20S 
posterior,  anatomy  of,  207 

exposure  of,  behind  internal  malleo- 
lus, 207 
between  origin  and  ankle,  207 
trifacial,    exposure    of,    by    direct    infra- 
arterial  route,  175 
by      trephining      through      pterygo- 
maxillary fossa,  1S1 
through  temporal  fossa,  177 
ulnar,  anatomy  of,  202 

exposure    of,    above    internal    condyle 
of  humerus,  203 
above  middle  of  arm,  202 
Nerve-anastomosis,  165 
Nerve-avulsion,  159 
Nerve-grafting,  165 
Nerve-implantation,  165 
Nerve-stretching,  158 

Nerves,  brachial  plexus  of,  anatomy  of,  19S 
exposure  of,  in  neck,  198 
cervical,    first,    second,    third,    posterior 

divisions,  exposure  of,  197 
compression  of,  operation  for,  169 
operations  upon,  157 
Neurectasy,  158 
Neurectomy,  158 

intraspinal,    partial,   of   posterior   nerve- 
roots,  679 
Neurolysis,  169 
Neuroplasty,  163 
Neurorrhaphy,  160 
Neurotomy,  157 
Nose,  operations  upon,  619 


Obturator  nerve,  exposure  of,  205 
Occipital  artery,  anatomy  of,  42 
ligation  of,  42 
lobe,  topography  of,  541 
O'Dwyer's  method  of  intubation  of  larynx, 

'OI 
Olecranon,  fracture  of,  ununited,  operation 

for,   by  wiring  or  suturing  of  bone  and 

soft  parts,  238 

Ollier's  excision  of  elbow-joint,  497 

of  wrist-joint,  490 

Omentum,  adhesions  to,  operations  for,  S24 

anatomy  of,  830 

grafting  with,  832 

ligation  of,  831 

operations  upon,  830 

general  considerations,  831 

Oophorectomy,  1160 

Orbit,  anatomy  of,  614 

exenteration  of,  616 

Orchidectomy,  11 34 

Os  calcis,  excision  of,  510 

Osteitis,     vertebral     tubercular,     anterior, 

operative  treatment  of,  685 

posterior,  operative  treatment  of,  685 

Osteoplastic  amputations,  317 

resection  of   foot,    externolateral    curved 

incision,  518 


INDEX 


Osteoplastic   resection   of    foot,    transverse 
upper  and  lower  and  oblique  lateral 
incisions,  516 
of  mid-tarsus,  514 
of  skull,  505 
of  spine,  648 

formation  and  turning  hack  of  flap 

in,  65  1 
general  considerations,  642 
Hartley's    preliminary    excision    of 
spinous  process  in,  647,  649 
of  tarsus  and  tarsometatarsus,  513 
posterior,  515 
Osteoplasty,  240 
Osteotomy,  210 
cuneiform,  214 
indications  for,  210 
instruments  for,  210 
linear,  by  open  method,  213 

by  subcutaneous  method,  211 
position  in,  2  1  1 

preparation  of  patient  for,  211 
varieties  of,  210 
Otic  ganglion,  anatomy  of,  188 
Ovariectomy,  1100 
Ovaries,  anatomy  of,  1159 
operations  upon,  1159 


Pancreas,  anatomy  of,  1043 
operations  upon,  1043 

general  considerations,  1044 
instruments  for,   1040 
Pancreatectomy,  partial,  3047 
Pancreatic  cavities,  drainage  of,  1046 
Pancreatotomy  by  gastrocolic  route,  1046 
Paracentesis  abdominis,  824 
thoracis,  761 
of  right  auricle  of  heart,  787 

ventricle  of  heart,  7S7 
pericardii,  781 
tunica?  vaginalis,  11 29 
tympani,  619 
vesicae,  1095 
Paralysis,  brachial  birth,  operation  for,  199 
facial,  peripheral,  facio-accessory  anasto- 
mosis for,  196 
Paraneural    infiltration   for   regional    anes- 
thesia, Matas'  method,  171 
Paravicini's  intrabuccal  method  of  exposing 

inferior  dental  nerve,  191 
Parietal     convolution,     ascending,     topog- 
raphy of,  541 
lobe,  topograph}-  of,  541 
Parieto-occipital  fissure,  anatomy  of,  534 

topography  of,  540 
Parkhill's  bone-clamp,  223 
Parkin's  incision  of  cerebellar  subarachnoid 

space  for  drainage,  595 
Parotid  gland,  anatomy  of,  721 
excision  of,  722 
operations  upon,  721 
Patella,  excision  of,  520 

fracture  of,  ununited,  operation  for,  by 
encircling  suture  of  soft  parts, 
236 


Patella,  fracture  of,  ununited,  operation  for, 
by  suturing  of  soft  parts,  233 
by  wiring  or  suturing  of  bone  and 
soft  parts,  234 
Pelviotomy,  1062 

Penis,  amputation  of,  partial,  n  14 
total,  1  1  id 
operations  upon,  1 1 1 1 

instruments  for,  11  n 
Pericardiocentesis,  781 
Pericardiorrhaphy,  785 
Pericardiotomy  through  intercostal  incision, 

782 
Pericardium,  anatomy  of,  780 

and  heart,  exposure  of,  by  excision  of  left 
fifth  costal  cartilage,  784 
by  thoracoplastic  flap,  788 
operations  upon,  780 
puncture  of,  781 
suture  of,  785 
Perineal     cystotomy,     lateral,     for    vesical 
calculus,  1099 
median,  for  vesical  calculus,  1 102 
prostatectomy,  1143 

urethrotomy,  external,  Cock's  operation, 
1 1 26 
Gouley's  method,  n  24 
Syme's  method,  1123 
Wheelhouse's  method,  11 25 
Periosteum,  uniting  of  tendon  to,  operation 

for,  263 
Peritoneum,   adhesions  of,   operations  for, 
822 
anatomy  of,  820 
operations  upon,  820 

general  considerations,  822 
septic,  diffuse,  Blake's  method  of  treating, 
826 
Murphy's  method  of  treating,  825 
operative  treatment  of,  825 
Peroneal  artery,  anatomy  of,  114 

ligation  of,  1 14 
Pfannenstiel's   method   of   median   inferior 

abdominal  section,  815 
Pharyngotomy,  lateral,  708 
median,  708 
subhyoid,  709 
Pharynx,  anatomy  of,  707 
operations  upon,  707 

instruments  for,  707 
Phlebectomy,  145 
Phleborrhapl.v,  142 
Phlebostrepsis,  145 
Phlebotomy,   141 

Pirogoff's  disarticulation  of  foot  at  ankle- 
joint,  415 
Plantar  artery,  external,  anatomy  of,  115 
ligation  of,  116 
internal,  anatomy  of,  117 
ligation  of,  117 
Pleuracentesis,  761 
Pleura,  anatomy  of,  759 

discission      of,     in      chronic     empyema, 

Ransohoff's  operation,  771 
operations  upon,  759 
puncture  of,  761 


INDEX 


Pleurectomy,    partial,    Estlander's   method 
of,  765 
Schede's  method  of,  768 
total,  Fowler's  method  of,  770 
Pleurotomy,  761 
Plexus,  brachial,  of  nerves,  anatomy  of,  198 

exposure  of,  in  neck,  198 
Plexuses,  operations  upon,  157 
Pneumectomy,     partial,    through    cutaneo- 
musculo-osseous  thoracoplastic  flap,  776 
Pneumotomy       through      cutaneomuscular 

thoracoplastic  flap,  774 
Poggi's    method    of    uretero-ureterostomy, 

1081 
Pons,  function  of,  545 
Popliteal  artery,  anatomy  of,  99 
ligation  of,  100 
nerve,  external,  anatomy  of,  207 

exposure  of,  behind  tendon  of  biceps, 
207 
internal,  anatomy  of,  206 

exposure  of,   at  lower  part  of  pop- 
liteal space,  206 
Postcentral  fissure,  topography  of,  540 
Pott's  disease,  Lambotti's  operation  for,  691 
operative  treatment  of,  685 
Treves'  operation  for,  687 
Poupart's  ligament,  anatomy  of,  1163 
Precentral  fissure,  topography  of,  540 
Pressure  of  artery,   140 
Proctectomy,  935.     See  also  Rectectomy. 
Proctopexy,  933 
Proctotomy,  934 
Profunda  femoris,  anatomy  of,  94 

ligation  of,  95 
Prostate  gland,  anatomy  of,  1140 
operations  upon,  1140 

instruments  for,  1141 
Prostatectomy,   1  r4 1 

Alexander's  operation,  1144 
perineal,  11 43 
suprapubic,   1142 
Prostatotomy,  1141 
Psychical  area,  localization  of,  545 
Pudic  artery,  internal,  anatomy  of,  85 
ligation  of,  85 
nerve,  superior,  exposure  of,  205 
Puncture  and  drainage  of  lateral  ventricles 
of  brain,  594 
exploratory,  of  joints,  241 
of  kidney,   1060 
of  liver,  1008 
of  spleen,  1038 
lumbar,    for    diagnosis    and    therapeusis, 

669 
of  bladder,  1095 
of  brain,  exploratory,  584 
of  bursie,  270 
of  heart,  787 
of  pericardium,   781 
of  pleura,   761 
of  tunica  vaginalis,  n  29 
spinal,     for    drainage    of    subarachnoid 

space,  670 
subarachnoid,  for  spinal  analgesia,  666 
Pyelotomy,  1062 

76 


Pylorectomy,  991 

followed    by    end-to-end    gastroenteros- 
tomy, Billroth's  method,  997 
followed        by        independent        gastro- 
jejunostomy, Mayo's  method,  991 
followed    by    posterior    gastroduodenos- 
tomy,  Kocher's  method,  994 
Pyloric    orifice    of    stomach,    divulsion    of, 

Loreta's  operation,  986 
Pyloroplasty,     Heineke-Mikulicz     method, 
984 


Radial  artery,  anatomy,  66 

ligation  of,  69 
Radius,  excision  of,  494 

total,  494 
Radio-ulnar  articulation,  superior,  excision 

of,  500 
Ransohoff's  method  of  discission  of  pleura 

in  chronic  empyema,  771 
Re-amputation  for  improperly  made  flaps, 

297 
Rectectomy,  935 

by  perineal  route,  942 
by  sacral  route,  935 
Kraske's  method,  935 
Rehn-Rydygier  osteoplastic  flap  method, 
940 
Rectopexy,  Verneuil's  method,  933 
Rectotomy,  external,  934 
internal,  934 
posterior,  934 
Rectum,  anatomy  of,  838 

excision  of,  935.     See  also  Rectectomy. 
Rehn-Rydygier  osteoplastic  flap  method  of 

rectectomy,  940 
Reid's  method   of  craniocerebral   localiza- 
tion, 551 
Reil,  island  of,  anatomy  of,  534 

topography,  541 
Resection,  chondroplastic,  of  chest -wall,  734 
of  nasal  cartilages,  473 
osteoplastic,  of  bones  and  joints,  468 
of  foot,  externolateral  curved  incision, 

transverse    upper    and    lower    and 
oblique  lateral  incisions.  516 
of  lower  jaw,  479 
of  mid-tarsus,  514 
of  shoulder-joint,  503 
of  skull,  565 
of  spine,  648 

formation  and  turning  back  of  flap 

in,  648 
general  considerations,  642 
Hartley's    preliminary    excision    of 
spinous  process  in,  647,  649 
of  superior  maxilla,  473 

Annandale's  operation,  474 
Langenbeck's  operation,  474 
of  tarsus  and  tarsometatarsus,  513 
posterior,  515 
Retrobulbar  structures,  exposure  of,  617 
Retroduodenal  choledochotomy,  1034 
Retropharyngeal  space,  exposure  of,  710 


1202 


INDEX 


Retzius'  space,  anatomy  of,  1092 

Rib  and  costal  cartilage,  excision  of,  480 

excision  of,  471) 
Rivinus,  ducts  of,  anatomy  of,  726 
Robson's  method  of  uretero-ureterostomy, 

1082 
Rolandic  fissure,  anatomy  of,  534 

Chiene's  method  of  determining,  554 
topography  of,  539 
Rose's  exposure  of  Gasserian  ganglion,  1S1 
Rotter's    method    of    exposing    heart    and 

pericardium,  788 
Rouge's   chondroplastic   resection   of   nasal 

cartilages,  473 
Round  ligaments  of    uterus,    anatomy    of, 

1 149 
Ruptured  tendon-sheaths,  repair  of,  265 


Salomoni     and     Tomaselli's     method     of 

arteriorrhaphy,  123 
Salpingo-obphorectomy,  1160 
Salpingo-ovariectomy,  1160 
Salt  solution,  intravenous  infusion  of,  146 
Scalp,  anatomy  of,  533 
Scapula,  excision  of,  481 

total,  482 
Scarpa's  fascia,  anatomy  of,  1163 

triangle,  anatomy  of,  155 
Schede's  thoracoplasty  operation,  768 
Schopf's   method    of   uretero-ureterostomy, 

1080 
Schwartze's  antrum  operation,  604 
Schwartze-Stacke    operation    for    exposing 

mastoid  antrum  and  cells,  606 
Sciatic  artery,  anatomy  of,  84 
ligation  of,  84 
nerve,  great,  anatomy  of,  205 

exposure    of,    at    lower    border    of 
gluteus  maximus,  206 
Scrotum,  anatomy  of,  11 28 
excision  of,  partial,  11 29 
operations  upon,  n  28 
Section,  abdominal.     See  .4  bdominal  section. 
Semilunar  cartilages,  dislocation  of,  opera- 
tion for,  244 
Seminal  vesicles,  anatomy  of,  n  38 

and    part    of    ejaculatory    ducts,    total 
excision  of,  Young's  operation,  1139 
operations  upon,  1138 

instruments  for,  1139 
Sensory  areas,  localization  of,  544 
Sequestrotomy,  239 
Shoulder-joint,  anatomy  of,  372 
disarticulation  at,  377 

general  considerations,  374 
excision  of,  501 
osteoplastic  resection  of,  503 
Sight  area,  localization  of,  545 
Sinus,  lateral,  anatomv  of,  536 
ligation  of,  586 

thrombosis  of,  operation  for,  588 
longitudinal,  inferior,  anatomy  of,  536 
ligation  of,  586 
superior,  anatomy  of,  536 
topography  of,  542 


Sinus,  straight,  anatomy  of,  536 
Sinuses  at  base  of  skull,  536 

bony,  air,  of  head  and  face,  operations 

upon,  600 
frontal,  anatomy  of,  608 

exposure  and  drainage  of,  610 
operations  upon,  608 

general  considerations,  609 
instruments  for,  610 
lateral,  topography  of,  542 
maxillary,  anatomy  of,  611 

exposure    of,     through    facial    aspei!, 
above  alveolar  margin,  613 
second  molar  tooth,  614 
operations  upon,  611 

general  considerations,  612 
instruments  for,  613 
venous,  of  dura  mater,  536 
Skin,  implantation  of  ureter  upon,  1089 

in  amputation,  treatment  of,  297 
Skull,  anatomy  of,  533 

fracture  of,  trephining  for,  590 
osteoplastic  resection  of,  565 
Smell  area,  localization  of,  545 
Smith's  disarticulation  at  knee-joint,  434 
method    of    amputating    leg    at     upper 
third,  427 
Snuff-box,  anatomy  of,  67 
Sound  areas,  localization  of,  545 

introduction  of,  into  female  bladder,  1095 

into  male  bladder,  1094 

Speech  aeas,  localization  of,  545 

Speculum,       ear,       introduction      of,       for 

examination  of  membrana  tympani,  618 

Spence's   disarticulation   at   shoulder-joint, 

378 
Spermatic  cord,  anatomy  of,  1135 
operations  upon,  1135 

instruments  for,  1136 
Spina  bifida,  679 

Bobroff's  operation  for,  683 
Chipault's  operation  for,  683 
Dollinger's  operation  for,  683 
varieties  of,  680 
Zenenko's  operation  for,  683 
Spinal  accessory  nerve,  anatomy  of,  195 

exposure    of,    at    anterior    border   of 
sternomastoid  muscle,  195 
analgesia,  subarachnoid  puncture  for,  666 
cord,  anatomy  of,  630 

gunshot  wounds  of,  operative  treatment, 

675 
incised    and    penetrating    wounds    of, 

operative  treatment,  674 
operations  upon,  630 

general  considerations,  642 
tumors  of,  operations  for,  677 
puncture   for   drainage   of  subarachnoid 
space,  670 
Spine,  anatomy  of,  630 

dislocations  of,  operative  treatment,  672 
fracture-dislocations   of,    operative   treat- 
ment, 673 
fractures  of,  operative  treatment,  670 
localization  of,  632 
operations  upon,  630 


INDEX 


1203 


Spine,  operations  upon,  general  considera- 
tions, 642 
osteitis  of,  tubercular,  anterior,  operative 
treatment  of,  685 
posterior,  operative  treatment  of,  685 
osteoplastic  resection  of,  648 

formation  and  turning  back  of  flap 

in,  651 
general  considerations,  642 
Hartley's    preliminary    excision    of 
spinous  process  in,  647,  649 
Spleen,  anatomy  of,  1036 

exposure  of,  by  subpleural  route,  1039 
operations  upon,  1036 

general  considerations,  1037 
instruments  for,  1038 
puncture  of,  exploratory,  1038 
suture  of,  1039 
Splenectomy,  partial,  1040 

total,   1 04 1 
Splenopexy,  1039 
Splenorrhaphy,  1039 

Splenotomv,  oblique  subcostal  incision,  1038 
Ssabanajeff's       femorotibial       osteoplastic 

amputation  of  leg,  443 
Ssabanajew-Franck's    method    of    gastros- 
tomy, 957 
Stenson's  duct,  anatomy  of,  721 

operations  upon,  721 
Stimson's  operation  for   ununited  fracture 

of  patella,  233 
Stomach,  anatomy  of,  950 

cardiac  orifice,  dilatation  of,  987 
operations  upon,  950 

general  considerations,  951 
instruments  for,  952 
pyloric     orifice,     divulsion     of     Loreta's 

operation,  986 
wall,  suture  of,  955 
Stomach-tube,  introduction  of,  952 
Stone  in  bladder,  lateral  perineal  cystotomy 
for,  1099 
median  perineal  cystotomy  for,  1102 
Stricture    of    esophagus,    direct    dilatation 
for,  716 
divulsion  of,  716 
division,     by    string    friction,     Abbe's 
operation,  716 
Bryant's  operation,  716 
permanent  tubage,  716 
retrograde  dilatation  for,   716 
divulsion  of,  716 
Subarachnoid  puncture  for  spinal  analgesia, 
666 
space,  cerebellar,  incision  of,  for  drainage, 

595 
drainage  of,  spinal  puncture  for,  670 
Subcapsular  nephrectomy,  1072 
Subclavian  artery,  anatomy  of,  50 
left,  first  portion,  ligation  of,  52 
right,  first  portion,  ligation  of,  52 
second  portion,  ligation  of,  53 
third  portion,  ligation  of,  53 
Subhyoid  pharyngotomy,  709 
Sublingual  gland,  anatomy  of,  726 

excision  of,  through  floor  of  mouth,  726 


Sublingual  gland,  operations  upon,  726 
Submaxillary  gland,  anatomy  of,  724 
excision  of,  725 
operations  upon,  724 
Sudeck's  fraise,  576 
Supraduodenal  choledochotomy,  1031 
Supra-orbital  nerve,  anatomy  of,  182 

exposure  of,  182 
Suprapubic  cystotomy,  1096 

prostatectomy,  1142 
Suprathvroid  laryngotomy,  702 
Suture  of  artery,  118 

of  bladder,  1103 

of  heart,  790 

of     intestines,     841.     See     also     Enter- 
orrkaphy. 

of  kidney,  1063 

of  ligaments,  268 

of  liver,  10 19 

of  muscle,  245 

of  nerve,  160 

of  pericardium,  785 

of  spleen,  1039 

of  stomach-wall,  955 

of  tendon,  251 

of  thoracic  duct,  148 

of  ureters,  1079 

of  urethra,  1 127 

of  veins,  142 
Sylvian  fissure,  anatomy  of,  533 

topography  of,  539 
Syme's    disarticulation    of    foot    at    ankle- 
joint,  414 

method  of  external  perineal  urethrotomy, 
1123 
Syndesmotomy,  268 


Tabatiere,  anatomy  of,  67 
Talma-Drummond  operation  for  cirrhosis 

of  liver,   102 1 
Tamponing  of  larynx,  702 

of  trachea,  707 
Tarsus    and    tarsometatarsus,    osteoplastic 
resection  of,  513 

excision  of,  5 1 8 

mid-,  osteoplastic  resection  of,  514 

posterior,  osteoplastic  resection  of,  5 1 5 
Taste  area,  localization  of,  545 
Teale's  method  of  amputation  bv  unequal 

rectangular  flaps,  314 
Temporal  artery,  anatomy  of,  43 
ligation  of,  43 

lobe,  topography  of,  541 
Temporomaxillary  articulation,  excision  of, 

476 
Temporosphenoidal  fissure,  superior,  anat- 
omy of,  541 
Tendon-grafting,  261 
Tendon-implantation,  261 
Tendon-lengthening,  254 
Tendon-sheaths,  excision  of,  267 

operations  upon,  249 

ruptured,  repair  of,  265 
Tendon-shortening,  259 
Tendon-transplantation,  261 


1204 


INDEX 


Tendons  in  amputation,  treatment  of,  297 
operations  upon,  249 

suture  of,  251 

transplantation    of,    with    their    osseous 

insertions,  265 
uniting  of,  to  bone,  operation  for,  264 
to  periosteum,  operation  for,  263 
Tendoplasty,  254 
Tenorrhaphy,  251 
Tenotomy,  249 
open,  250 
subcutaneous,  250 
Testes,    anatomy    of,    1128 

operations  upon,  11 28 
Thigh,  amputation  of,  440 
at  condyles  of  femur,  440 
general  considerations,  43S 
just  above  condyles  of  femur,  441 
just  below  trochanters,  449 
lower,  middle,  or  upper  third,  446,  448 
third,  444 
anatomy  of,  436 
Thomas'  forceps  tourniquet  for  controlling 

hemorrhage,  455 
Thoracentesis,  761 
Thoracic  duct,  anatomy  of,  148 
ligation  of,  149 
suture  of,  148 
esophagotomy,    by  posterior   mediastinal 

osteoplastic  flap  operation,  792 
tracheotomy,  707 

by  posterior  mediastinal  thoracoplastic 
flap  operation,  791 
wall  and  contents,  anatomy  of,  731 
operations  upon,  736 
chondroplastic  resection  of,  734 
Thoracotomy  by  partial  excision  of  one  or 
more  ribs,  763 
intercostal,  761 

mediastinal,    anterior,    by    long    median 
incision,  748 
by  osteoplastic  resection  of  part  of 
sternum,  750 
posterior,  752 
Thorax,  anatomy  of,  731 
operations  upon,  731 

instruments  for,  734 
Thrombosis  of  lateral  sinus,  operation  for, 

588 
Thumb,     amputation     of,     with     part     of 
metacarpal,  342 
disarticulation   of,    at   metacarpophalan- 
geal-joint,  334 
with  metacarpal,  345 
metacarpal  of,  excision  of,  489 
Thyroid  artery,  inferior,  anatomy  of,  56 
ligation  of,  57 
gland,  anatomy  of,  727 
operations  upon,  727 
Thyroidectomy,  complete,  729 

partial,  727 
Thyrotomy,  698 
Tibia,  excision  of,  518 
Tibial  artery,  anterior,  anatomy  of,  103 
ligation  of,  104 
posterior,  anatomy  of,  108 


Tibial  artery,  posterior,  ligation  of,  109 
nerve,  anterior,  anatomy  of,  208 
exposure  of,  near  origin,  208 
posterior,  anatomy  of,  207 

exposure  of,  behind  internal  malleo- 
lus, 207 
between  origin  and  ankle,  207 
Toes,     amputations    about,     general    con- 
siderations, 386 
amputation  of,  at  first  phalanx,  391 
at  last  phalanx,  388 
at  metatarsus,  402 
at  second  phalanx,  390 
with  part  of  metatarsals,  401 
disarticulation  of,  at  first  interphalangeal 
joints,  390 
at  metatarsophalangeal  joints,  392 
at  second  interphalangeal  joint,  389 
at  tarsometatarsal  joints,  407,  408 
en     masse,     at     metatarsophalangeal 

joints,  395 
general  considerations,  386 
with  metatarsals,  403,  404 
excision  of  bones  and  joints  about,  505 
of  first  interphalangeal  joints,  506 

phalanges,  507 
of  metatarsal  bones,  507 
of  metatarsophalangeal  joints,  507 
of  second  interphalangeal  joints,  506 

phalanges,  506 
of  terminal  phalanges,  506 
great,    disarticulation    of,    at    metatarso- 
phalangeal joints,  393 
with  metatarsals,  404 
little,    disarticulation    of,    at    metatarso- 
phalangeal joints,  394 
with  metatarsals,  406 
second,    third,   or  fourth,   disarticulation 

of,  at  metatarsophalangeal  joints,  392 
two     adjoining,     disarticulation     of,     at 

metatarsophalangeal  joint,  395 
two  or  three   contiguous,   disarticulation 
of,  with  metatarsals,  407 
Tongue,  anatomy  of,  619 
excision  of,  619 

general  considerations,  620 
instruments  for,  621 
limited  portions,  621 
through      mouth,      after     preliminary 
ligation  of  lingual  arteries,  624 
without    preliminary    ligation    of 
lingual  arteries,  622 
together    with    cervical    and    submax- 
illary glands,  627 
with   osteoplastic    division    of   inferior 
maxilla,  624 
operations  upon,  619 
Tonsillectomy,    complete,    through    mouth, 
718 
through  neck,  719 
partial,  through  mouth,  71S 
Tonsillotomy,  717 
Tonsils,  anatomy  of,  717 
operations  upon,  717 

general  considerations,  717 
instruments  for,  717 


INDEX 


1205 


Torsion  of  artery,  140 
Trachea,  anatomy  of,  702 

foreign  bodies  in,  operation  for  removal 

of,  707 
operations  upon,  702 

general  considerations,  703 
instruments  for,  703 
tamponing  of,  707 
Tracheolaryngotomy,  706 
Tracheoscopy,  707 

Tracheotomy,  Bose's  bloodless  method  of, 
706 
high,  704 
low,  706 
thoracic,  707 

by  posterior  mediastinal  thoracoplastic 
flap  operation,  791 
Transduodenal  choledochostomy,  1034 
Transplantation,  tendon-,  261 

with  its  osseous  insertion,  265 
Trendelenburg's   rod  for   controlling   hem- 
orrhage in  amputations    near  hip-joint, 

455 
Trephining,  558 

for  fracture  of  skull,  590 
linear,  580 
varieties  of,  558 
Treve's  operation  for  Pott's  disease,  687 
Trifacial  nerve,  exposure  of,  by  direct  infra- 
arterial  route,  175 
by      trephining      through      pterygo- 

maxillary  fossa,  181 
through  temporal  fossa,  177 
Trigonum  vesicae,  anatomy  of,  1092 
Tubercular     osteitis     of     spine,     anterior, 
operative  treatment  of,  685 
posterior,  operative  treatment  of,  685 
Tuffier's  method  of  nephropexy,  1068 

of  uretero-ureterostomy,  1081 
Tumor,  cerebellar,  operation  for,  599 
cerebral,  operation  for,  597 
of  spinal  cord,  operations  for,  677 
Tunica  albuginea,  anatomy  of,  n  29 
vaginalis,  anatomy  of,  n  28 

puncture  of,  n  29 
vasculosa,  anatomy  of,  n  29 


Ulcer,  gastric,  operation  for,  1002 
perforated,  operation  for,  1003 
Ullmann's      modification      of      Maunsell's 

method  of  entero-enterostomy,  881 
Ulna,  excision  of,  493 

excision  of,  total,  493 
Ulnar  artery,  ligation  of,  73 
nerve,  anatomy  of,  202 

exposure  of,  above  internal  condyle  of 
humerus,  203 
above  middle  of  arm,  202 
Umbilical  hernia,   11 78.     See  also  Hernia, 

umbilical. 
Ureterei  tomv,   10S9 

partial,  by  oblique  lumbar  incision,  1090 
total,  with  removal  of  kidney,  1090 
Ureterocystostomy,  1085 
Ureteroplasty,  1080 


Ureterorectostomy,  10S6 
Ureterorrhaphy,  1079 
Ureterotomy,  1078 
Uretero-ureteral  anastomosis,  1080 
Uretero-ureterostomy,  1080 
Ureters,  anatomy  of,  1073 

and  kidneys,  extraperitoneal  exposure  of, 

1076 
exposure  of,  1076 
implantation  of,  1084 
into  bladder,  1085 
into  large  intestine,  1086 
upon  skin,  1089 
operations  upon,  1073 

general  considerations,  1075 
instruments  for,  1076 
suture  of,  1079 
Urethra,  anatomy  of,  111S 
female,  anatomy  of,  n  19 
male,  anatomy  of,  111S 
operations  upon,  n  18 

general  considerations,  1 1 19 
instruments  for,  n  20 
suture  of,  1127 
Urethrorrhaphy,  n  27 
Urethrostomv,  1127 
Urethrotomy,  n  20 
external  perineal,  n  26 

Cock's  operation,  11 26 
Gouley's  method,  n 24 
Syme's  method,  1123 
YVheelhouse's  method,  n  25 
internal,  by  dilating  urethrotome,  n  21 
Uterus,  anatomy  of,  1147 

broad  ligament  of,  anatomv,  1148 
operations  upon,  n  47 

instruments  for,  11 50 
round  ligaments  of,  anatomy,  1149 


Vagina,  anatomy  of,  1149 
Vaginal  hysterectomy,  total,  1153 
Van    Hook's    method    of    uretero-ureteros- 
tomy, 1082 
Varicocele,      Bennett's      modification      of 
Howse's  operation  for,  1137 
operation  for  radical  cure  of,  1137 
Vas  deferens,  anatomv  of,  1136 
Vascular  neoplasms,  injection  of  water  at 

high  temperature  in,  141 
Vasectomy,  partial,  1136 
Veins,  acupressure  of,  145 
celiotomv,  800 
excision  of,  145 

infusion  of  salt  solution  into,  145 
ligation  of,  en  masse,  145 
in  amputation,  295 
lateral,  143 
temporary,  144 
transverse,  144 
operations  upon,  142 
suture  of,  142 
Venesection,  142 
Venous  forcipressure,  145 
Ventricles,  lateral,  of  brain,  puncture  and 
drainage  of,  594 


1206 


INDEX 


Ventricles,    lateral,    of    brain,    topography 
of,  542 
right,  of  heart,  paracentesis  of,.  787 
Verneuil's  method  of  rectopexy,  933 
Vertebral  artery,  anatomy,  55 
ligation  of,  55 
tubercular    osteitis,     anterior,     operative 
treatment  of,  685 
posterior,  operative  treatment  of,  685 
Vesical  calculus,  lateral  perineal  cystotomy 
for,  1099 
median  perineal  cystotomy  for,  1102 
drainage,  1108 
Vesicnlae  seminales.     See  Seminal  vesicles. 
Vischer's    method    of    lateral     abdominal 

section,  819 
Visual  word  area,  localization  of,  545 
Volkmann's  operation  for  hydrocele,  1131 
Yon   Bergmann's  operation  for  hydrocele, 

\  on  Hacker's  method  of  posterior  gastro- 
enterostomy, 974 


Warren's  radical  excision  of  breast,  744 
Weir-Harrington    method    of    anterolateral 

abdominal  section,  810 
Weir's  method  of  appendicostomy,  912 
modification   of    Bircher's   operation    for 
gastroplication,  981 
of  Murphy's  button,  lateral  anastomo- 
sis with,  890 
Wharton's  duct,  anatomy  of,  724 

operations  upon,  724 
Wheelhouse's  method  of  external  perineal 

urethrotomy,  n 25 
Whitehead's  excision  of  tongue,  622 


Whitehead's  operation  for  hemorrhoids,  945 
Winslow's  foramen,  anatomy  of,  820 

method  of  uretero-ureterostomy,    1082 
Wirsung's  canal,  anatomy  of,  1043 
Witzel's  method  of  gastrostomy,  959 
Wladimiroff-Mikulicz  resection  of  foot,  516 

modification  of,  518 
Wolff's    operation    for    uniting    tendon    to 

bone,  264 
Wblfler's  method  of  anterior  gastroenter- 
ostomy, 968 
of  gastrogastrostomy,  979 
Wounds,  bullet,  of  brain,  operation  for,  591 
gunshot,  of  spinal  cord,  operative  treat- 
ment of,  675 
incised  and  penetrating,  of  spinal  cord, 

operative  treatment  of,  674 
of  artery,  closure  of,  Brewer's  operation 
for,  124 
by  special  rubber  plaster,  124 
of  intestine,  enterorrhaphy  for,  848 
Wrist-joint,  anatomy  of,  348 
disarticulation  at,  350 
excision  of,  489 
Wyeth's  disarticulation  at  hip-joint,  456 
operation  for  vascular  neoplasms,  141 
pins  in  amputating  at  hip-joint,  453 
in     controlling     hemorrhage     in     dis- 
articulation at  shoulder-joint,  374 


Young's  method  of  total  excision  of  seminal 
vesicles  and  part  of  ejaculatory  ducts, 
"39 

Zenenko's  operation  for  spina  bifida,  683  ' 


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"  Dr.  Kerley's  book  is  one  of  the  best  on  the  subject  that  has  come  under  our  notice.  All 
through  it  shows  evidence  of  ripe  experience  and  sound  judgment," 


SAUNDERS'    BOOKS    ON 


Friihwald  and  WestcottV 
Diseases    of  Children 


Diseases  of  Children.  A  Practical  Reference  Book  for  Students 
and  Practitioners.  By  Professor  Dr.  Ferdinand  Fruhwald,  of 
Vienna.  Edited,  with  additions,  by  Thompson  S  Westcott,  M.  D., 
Associate  in  Diseases  of  Children,  University  of  Pennsylvania.  Octavo 
volume  of  533  pages,  containing  176  illustrations.         Cloth,  $4.50  net. 

RECENTLY  ISSUED 

This  work  represents  the  author's  twenty  years'  experience,  and  is  intended 
as  a  practical  reference  work  for  the  student  and  practitioner.  With  this  refer- 
ence feature  in  view,  the  individual  diseases  have  been  arranged  alphabetically. 
The  prophylactic,  therapeutic,  and  dietetic  treatments  are  elaborately  discussed. 
The  practical  value  of  the  book  has  been  considerably  enhanced  by  the  many 
excellent  illustrations. 
E.  H.  Bartley,   M.  D.. 

Professor  of  Pediatrics,  Chemistry,  and  Toxicology,  Long  Island  College  Hospital,  New  York, 
"It   is  a  new  idea,  which  ought  to  become  popular  because  of  the  alphabetic   arrangement. 
Its  title  expresses  just  what  it  is— a  ready  reference  hand-book." 


Ruhrah's 
Diseases  of  Children 

A  Manual  of    Diseases  of   Children.     By  John    Ruhrah,   M.  D., 

Clinical  Professor  of  Diseases  of  Children,  College  of  Physicians  and 
Surgeons,  Baltimore.  i2mo  of  425  pages,  fully  illustrated.  Flexible 
leather,  $2.00  net. 

RECENTLY    ISSUED— NEW      2d)     EDITION 

In  revising  this  work  for  the  second  edition  Dr.  Ruhrah  has  carefully 
incorporated  all  the  latest  knowledge  on  the  subject.  All  the  important  facts 
are  given  concisely  and  explicitly,  the  therapeutics  of  infancy  and  childhood 
being  outlined  very  carefully  and  clearly.  There  are  also  directions  for  dosage 
and  prescribing,  and  many  useful  prescriptions  are  included.  The  entire  work 
is  amply  illustrated  with  practical  illustrations.  A  valuable  aid  consists  in  the 
references  to  pediatric  literature. 

American  Journal  of  the  Medical  Sciences 

"  Treatment  has  been  satisfactorily  covered,  being  quite  in  accord  with  the  best  teaching, 
yet  withal  broadly  general  and  free  from  stock  prescriptions." 


NERVOUS  AND   MENTAL   DISEASES. 


Church  and  Peterson's 
Nervous  and  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases  and  Medical  Jurisprudence, 
Northwestern  University  Medical  School,  Chicago ;  and  Frederick 
Peterson,  M. D.,  President  New  York  State  Commission  on  Lunacy; 
Professor  of  Psychiatry  at  the  College  of  Physicians  and  Surgeons, 
N.  Y.  Handsome  octavo,  960  pages  ;  350  illustrations.  Cloth,  ,$5.00 
net ;  Sheep  or  Half  Morocco,  56.50  net. 

JUST     ISSUED— NEW     (6th)     EDITION 

This  work  has  met  with  a  most  favorable  reception  from  the  profession  at 
large.  It  fills  a  distinct  want  in  medical  literature,  and  is  unique  in  that  it 
furnishes  in  one  volume  practical  treatises  on  the  two  great  subjects  of  neurology 
and  psychiatry.  In  preparing  this  edition  Dr.  Church  has  carefully  revised  his 
entire  section,  placing  it  in  accord  with  the  most  recent  neurologic  advances. 
Among  the  additions  of  particular  interest  are  the  chapters  on  Psychosthenia  and 
the  Motor  Tics.  Dr.  Peterson,  for  his  section — Mental  Diseases — has  taken 
unusual  care  to  have  it  representative  of  the  present-day  knowledge  of  the  sub- 
ject. While  the  changes  throughout  have  been  many,  they  have  been  so  made 
as  but  slkditlv  to  increase  the  size  of  the  work. 


OPINIONS  OF  THE    MEDICAL  PRESS 


American  Journal  of  the  Medical  Sciences 

"  This  edition  has  been  revised,  new  illustrations  added,  and  some  new  matter,  and  really 
is  two  books.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
and  disputed  matters  and  theories  are  omitted.     Altogether  it  is  a  most  useful  text-book." 

Journal  of  Nervous  and  Mental  Diseases 

"The  best  text-book  exposition  of  this  subject  of  our  day  for  the  busy  practitioner.  .  .  . 
The  chapter  on  idiocy  and  imbecility  is  undoubtedly  the  best  that  has  been  given  us  in  any 
work  of  recent  date  upon  mental  diseases.  The  photographic  illustrations  of  this  part  of  Dr. 
Peterson's  work  leave  nothing  to  be  desired." 

New  York  Medical  Journal 

"To  be  clear,  brief,  and  thorough,  and  at  the  same  time  authoritative,  are  merits  that 
ensure  popularity.  The  medical  student  and  practitioner  will  find  in  this  volume  a  ready  and 
reliable  resource." 


SAUNDERS'    BOOKS    ON 


Peterson  arid  Haines' 
Legal  Medicine  &  Toxicology 


A  Text=Book  of  Legal  Medicine  and  Toxicology.  Edited  by 
Frederick  Peterson,  M.  D.,  Professor  of  Psychiatry  in  the  College 
of  Physicians  and  Surgeons,  New  York ;  and  Walter  S.  Haines, 
M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Two 
imperial  octavo  volumes  of  about  750  pages  each,  fully  illustrated. 
Per  volume:  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.50  net. 
Sold  by  Subscription. 

IN  TWO   VOLUMES— BOTH  VOLUMES  NOW   READY 

The  object  of  the  present  work  is  to  give  to  the  medical  and  legal  professions 
a  comprehensive  survey  of  forensic  medicine  and  toxicology  in  moderate  compass. 
This,  it  is  believed,  has  not  been  done  in  any  other  recent  work  in  English.  Under 
* '  Expert  Evidence  "  not  only  is  advice  given  to  medical  experts,  but  suggestions 
are  also  made  to  attorneys  as  to  the  best  methods  of  obtaining  the  desired  infor- 
mation from  the  witness.  An  interesting  and  important  chapter  is  that  on  "  The 
Destruction  and  Attempted  Destruction  of  the  Human  Body  by  Fire  and  Chemi- 
cals." A  chapter  not  usually  found  in  works  on  legal  medicine  is  that  on  "  The 
Medicolegal  Relations  of  the  X-Rays."  This  section  will  be  found  of  unusual  im- 
portance. The  responsibility  of  pharmacists  in  the  compounding  of  prescriptions, 
in  the  selling  of  poisons,  in  substituting  drugs  other  than  those  prescribed,  etc., 
furnishes  a  chapter  of  the  greatest  interest  to  every  one  concerned  with  questions 
of  medical  jurisprudence.  Also  included  in  the  work  is  the  enumeration  of  the 
laws  of  the  various  states  relating  to  the  commitment  and  retention  of  the  insane. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  News,  New  York 

"  It  not  only  fills  a  need  from  the  standpoint  of  timeliness,  but  it  also  sets  a  standard  of 
what  a  text-book  on  Legal  Medicine  and  Toxicology  should  be." 

Columbia  Law  Review 

"  For  practitioners  in  criminal  law  and  for  those  in  medicine  who  are  called  upon  to  give 
•court  testimony  in  all  its  various  forms  ...  it  is  extremely  valuable." 

Pennsylvania  Medical  Journal 

"  If  the  excellence  of  this  volume  is  equaled  by  the  second,  the  work  will  easily  take  rank 
as  the  standard  text-book  on  Legal  Medicine  and  Toxicology." 


INSANITY  AND   HYGIENE. 


Brower  and  Bannister 
on  Insanity 

A  Practical  Manual  of  Insanity.  For  the  Student  and  General 
Practitioner.  By  Daniel  R.  Brower,  A.M.,  M.D.,  LL.  D.,  Professor 
of  Nervous  and  Mental  Diseases  in  Rush  Medical  College,  in  affiliation 
with  the  University  of  Chicago  ;  and  Henry  M.  Bannister,  A.  M., 
M.  D.,  formerly  Senior  Assistant  Physician,  Illinois  Eastern  Hospital 
for  the  Insane.  Handsome  octavo  of  426  pages,  with  a  number  of 
full-page  inserts.     Cloth,  #3.00  net. 

FOR   STUDENT   AND    PRACTITIONER 

This  work,  intended  for  the  student  and  general  practitioner,  is  an  intelligible, 
up-to-date  exposition  of  the  leading  facts  of  psychiatry,  and  will  be  found  of  in- 
valuable service,  especially  to  the  busy  practitioner  unable  to  yield  the  time  for  a 
more  exhaustive  study.  The  work  has  been  rendered  more  practical  by  omitting 
elaborate  case  records  and  pathologic  details,  as  well  as  discussions  of  speculative 
and  controversial  questions. 

American  Medicine 

"  Commends  itself  for  lucid  expression  in  clear-cut  English,  so  essential  to  the  student  in 
any  department  of  medicine.  .  .  .  Treatment  is  one  of  the  best  features  of  the  book,  and  for 
this  aspect  is  especially  commended  to  general  practitioners." 

Bergey's  Hygiene 

The  Principles  of  Hygiene :  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  536  pages,  illustrated.     Cloth,  $3.00  net. 

RECENTLY  ISSUED— SECOND  REVISED  EDITION 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
This  new  second  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  Medical  Journal 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 


SAUNDERS'   BOOKS  ON 


Draper's  Legal  Medicine 

A  Text=Book  of  Legal  Medicine.  By  Frank  Winthrop  Draper, 
A.  M.,  M.  D.,  Professor  of  Legal  Medicine  in  Harvard  University,  Bos- 
ton; Medical  Examiner  of  the  County  of  Suffolk,  Massachusetts,  etc.  Octavo 
volume  of  573  pages,  fully  illustrated.  Cloth,  $4.00  net;  Half  Morocco, 
$5.50  net. 

Hon.  Olin  Bryan,  LL.  B. 

Professor  of  Medical  Jurisprudence,  Baltimore  Medical  College 

"  A  careful  reading  of  Draper's  Legal  Medicine  convinces  me  of  the  excellent  character 
of  the  work.  It  is  comprehensive,  thorough,  and  must,  of  a  necessity,  prove  a  splendid 
acquisition  to  the  libraries  of  those  who  are  interested  in  medical  jurisprudence." 

Chapman's   Medical   Jurisprudence       Third  Edition 

Medical  Jurisprudence,  Insanity,  and  Toxicology.  By  Henry  C. 
Chapman,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Juris- 
prudence in  Jefferson  Medical  College,  Philadelphia.  i2mo  of  329  pages, 
fully  illustrated.      Cloth,  $1.75  net. 

Medical  Record,   New  York 

"  The  manual  is  essentially  practical,  and  is  a  useful  guide  for  the  general  practitioner, 
besides  possessing  literary  merit." 

Hofmann  and   Peterson's   Legal   Medicine      Hand-Atiases 

Atlas  of  Legal  Medicine.  By  Dr.  E.  von  Hofmann,  of  Vienna. 
Edited  by  Frederick  Peterson,  M.  D.,  Professor  of  Psychiatry  in  the 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates  and  193  half-tone  illustrations.      Cloth,  $3.50  net. 

The  Practitioner,  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection 
with  this  department  of  medicine,  and  they  cannot  fail  to  be  useful  alike  to  the  medical 
jurist  and  to  the  student  of  forensic  medicine." 

Jakob   and   Fisher's  Nervous  System 

and     itS     Diseases  In  Saunders*  Hand-Atlases 

Atlas  and   Epitome  of  the  Nervous   System  and   its   Diseases.     By 

Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Revised- 
German  Edition.  Edited,  with  additions,  by  Edward  D.  Fisher,  M.  D., 
Professor  of  Diseases  of  the  Nervous  System,  University  and  Bellevue 
Hospital  Medical  College,  New  York.  With  83  plates  and  copious  text. 
Cloth,  $3.50  net. 

Philadelphia  Medical  Journal 

"  We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  scientific  fidelity  of  this  hand-atlas." 


xr/ts/NG. 


Golebiewski  and  Bailey's 
Accident  Diseases 


Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dr.  Ed. 

Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey, 
M.D.,  Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York. 
With  71  colored  illustrations  on  40  plates,  143  text-illustrations,  and 
549  pages  of  text.  Cloth,  $4.00  net.  In  Saunders'  Hand- Atlas 
Series. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  accident 
injury  ;  the  functional  disability  caused  thereby  ;  the  medicolegal  questions  in- 
volved, and  the  amount  of  indemnity  justified  in  given  cases.  The  work  is 
indispensable  to  every  physician  who  sees  cases  of  injury  due  to  accidents,  to 
advanced  students,  to  surgeons,  and,  on  account  of  its  illustrations  and  statistical 
data,  it  is  none  the  less  useful  to  accident-insurance  organizations. 

The  Medical  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  grow- 
ing in  extent  all  the  time.     The  pictorial  part  of  the  book  is  very  satisfactory." 

Stoney's 
Materia  Medica  for  Nurses 


Practical  Materia  Medica  for  Nurses,  with  an  Appendix  containing 
Poisons  and  their  Antidotes,  with  Poison-Emergencies  ;  Mineral  Waters  ; 
Weights  and  Measures  ;  Dose-List,  and  a  Glossary  of  the  Terms  used 
in  Materia  Medica  and  Therapeutics.  By  Emily  M.  A.  Stoney,  of  the 
Carney  Hospital,  South  Boston.      i2mo  of  300pages.     Cloth,  #1.50  net. 

RECENTLY  ISSUED— NEW  (3rd)  EDITION 

In  making  the  revision  for  this  new  third  edition,  all  the  newer  drugs  have 
been  introduced  and  fully  discussed.  The  consideration  of  the  drugs  includes* 
their  sources  and  composition,  their  various  preparations,  physiologic  actions, 
directions  for  administering,  and  the  symptoms  and  treatment  of  poisoning. 

Journal  of  the  American  Medical  Association 

"  So  far  as  we  can  see,  it  contains  everything  that  a  nurse  ought  to  know  in  regard  to  drugs. 
As  a  reference-book  for  nurses  it  will  without  question  be  very  useful." 


SAUNDERS'     BOOKS    ON 


Hoxie's  Medicine  for  Nurses  Recently  issued 

Practice  of  Medicine  for  Nurses.  A  Text-Book  for  Nurses  and  Students 
of  Domestic  Science,  and  a  Hand-Book  for  All  Those  Who  Care  for  the  Sick. 
By  GEORGE  HOWARD  Hoxie,  .M.  J).,  Professor  of  Internal  Medicine,  Uni- 
versity of  Kansas.  With  a  Chapter  on  Technic  of  Nursing  by  Pearl  L. 
Laptad,  Principal  of  the  Training  School  for  Nurses,  University  of  Kansas. 
I2mo  of  284  pages,  illustrated.  Cloth,  $1.50  net. 

I  his  work  is  truly  a  practice  of  medicine  for  the  nurse,  enabling  her  to  recognize  any 
signs  and  changes  that  may  occur  between  visits  of  the  physician,  and,  if  necessary,  to 
combat  them  until  the  physician's  arrival.  This  information  the  author  presents  in  a  way 
most  acceptable,  particularly  emphasizing  the  nurse's  part.  There  are  also  special  chapters 
on  the  diseases  of  infancy  and  childhood,  diseases  of  the  eye,  ear,  nose,  and  throat, 
venereal  diseases,  nervous  and  mental  diseases,  surgical  nursing,  nursing  in  skin  diseases, 
emergency  measures,  and  the  care  and  management  of  the  sick-room  and  the  patient. 

McCombs'  Diseases  of  Children  for  Nurses  e£ued 

Diseases  of  Children  for  Nurses.  By  Robert  S.  McCombs,  M.  D., 
Instructor  of  Nurses  at  the  Children's  Hospital  of  Philadelphia.  i:mo  of 
430  pages,  illustrated.      Cloth,  g2.oo  net. 

Dr.  McCombs'  experience  in  lecturing  to  nurses  has  enabled  him  to  emphasize  just  those 
points  that  nurses  most  need  to  know.  He  has  given  a  short  but  clear  description  of  each 
disease,  so  that  the  nurse  will  be  enabled  to  know  what  symptoms  to  expect  and  what 
complications  to  guard  against.  The  nursing  side  has  been  written  by  head  nurses, 
especially  praiseworthy  being  the  work  of  Miss  lennie  Manly. 

Wilson's  Obstetric  Nursing  Recently  issued 

A   Reference   Hand=Book  of  Obstetric   Nursing.       By   W.    Reynolds 

Wilson,    M.  U.,    Visiting   Physician   to   the    Philadelphia   Lying-in   Charity. 
321x10  of  258  pages,  illustrated.      Flexible  leather,  $1.25  net. 

Dr.  Wilson's  work  discusses  the  subject  of  obstetrics  entirely  from  the  nurse's  point  of 
view,  presenting  in  detail  everything  connected  with  pregnancy  and  labor  and  their  man- 
agement. The  entire  subject  is  covered,  from  the  beginning  of  pregnancy,  its  course, 
signs,  on  to  the  approach  of  labor,  its  actual  accomplishment,  the  puerperium,  and  care 
of  the  infant.     The  text  is  copiously  illustrated. 

Aikens'  Training-School   Methods  Recently  issued 

Hospital  Training=SchooI  Methods  and  the  Head  Nurse.  By  Char- 
lotte A.  Aikens,  Late  Director  of  Sibley  Memorial  Hospital,  Washington, 
D.  C.      i2mo  of  267  pages.      Cloth,  $1.50  net. 

This  new  work  is  indispensable  to  all  those  who  aspire  to  become  head  nurses.  It  sug- 
gests plans  that  have  been  tested  personally,  and  gives  definite  help  to  those  beginning 
the  work  of  teaching  and  supervising  in  hospitals.  It  tells  the  head  nurse  how  to  teach, 
it  tells  what  should  be  taught  the  nurse  and  how  much. 


NURSING. 


De  Lee's  Obstetrics  for  Nurses 

Obstetrics  for  Nurses.  By  Joseph  B.  De  Lee,  M.D.,  Professor 
of  Obstetrics  in  the  Northwestern  University  Medical  School;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  volume  of  512  pages, 
fully  illustrated.  Cloth,  $2.50  net. 

JUST     ISSUED— NEW     (3d)     EDITION 

The  illustrations  in  Dr.  De  Lee's  work  are  nearly  all  original,  and  represent 
photographs  taken  from  actual  scenes.  The  text  is  the  result  of  the  author's  many 
years'  experience  in  lecturing  to  the  nurses  of  five  different  training  schools. 

J.  Clifton  Edgar,  M.  D., 

Professor  of  Obstetrics  and  Clinical  Afidwi/ery,  Cornell  Medical  School,  N.  Y. 
"  It  is  far-and-away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Philadel- 
phia Polyclinic.      i2mo  of  436  pages,  illustrated.      Buckram,  $1.75  net. 

JUST    ISSUED— THIRD    REVISED    EDITION 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 

Reference   Handbook  for  Nurses 

A  Reference  Handbook  for  Nurses.  By  Amanda  K.  Beck,  of 
Chicago,  111.     321110  of  177  pages.      Flexible  leather,  S1.25  net. 

RECENTLY  ISSUED 

This  little  book  contains  information  upon  every  question  that  comes  to  a 
nurse  in  her  daily  work,  and  embraces  all  the  information  that  she  requires  to 
carry  out  any  directions  given  by  the  physician. 

Boston  Medical  and  Surgical  Journal 

"Must  be  regarded  as  an  extremely  useful  book,  not  only  for  nurses,  but  for  physicians  " 


SAUNDERS'    BOOKS    ON 


Stoney's  Nursing 


Practical  Points  in  Nursing:  for  Nurses  in  Private  Practice.  By 
Emily  M.  A.  Stoney,  Superintendent  of  the  Training  School  for  Nurses 
at  the  Carney  Hospital,  South  Boston,  Mass.  466  pages,  fully  illus- 
trated.    Cloth,  $175  net. 

THIRD  EDITION,  THOROUGHLY  REVISED— RECENTLY  ISSUED 

In  this  volume  the  author  explains  the  entire  range  of  private  nursing  as  dis- 
tinguished from  hospital  nursing,  and  the  nurse  is  instructed  how  best  to  meet  the 
various  emergencies  of  medical  and  surgical  cases  when  distant  from  medical  or 
surgical  aid  or  when  thrown  on  her  own  resources.  An  especially  valuable  feature 
will  be  found  in  the  directions  how  to  i?nprovise  everything  ordinarily  needed  in  the 
sick-room. 

The  Lancet,  London 

"A  very  complete  exposition  of  practical  nursing  in  its  various  branches,  including  obstetric 
and  gynecologic  nursing.     The  instructions  given  are  full  of  useful  detail." 


Stoney's  Technic  for  Nurses 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  M.  A. 
Stoney,  Superintendent  at  Carney  Hospital,  South  Boston.  Revised 
by  Frederic  R.  Griffith,  M.  D.,  Surgeon,  of  New  York.  i2mo, 
278  pages,  illustrated.     Cloth,  $1.50  net. 

RECENTLY  ISSUED— NEW  (2d)  EDITION 
Trained  Nurse  and  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value  both  during 
their  hospital  course  and  in  private  practice." 

Spratling  on  Epilepsy 

Epilepsy  and  Its  Treatment.  By  William  P.  Spratling,  M.  D., 
Medical  Superintendent  of  the  Craig  Colony  for  Epileptics,  Sonyea, 
New  York.     Octavo  of  522  pages,  fully  illustrated.     Cloth,  $4.00  net. 

The  Lancet,  London 

"  Dr.  Spratling's  work  is  written  throughout  in  a  clear  and  readable  style.  .  .  .  The  work 
is  a  mine  of  information  on  the  whole  subject  of  epilepsy  and  its  treatment." 


CHILDREN  AND   HYGIENE.  13 

Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Cro«er  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Penn. ;  Physician  to  the 
Children's  Hospital,  Phila.    121110,  455  pp.  Illustrated.    Cloth,  $1.50  net. 

RECENTLY    ISSUED— THE    NEW   (4th)    EDITION 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  in  the  hope  that  the  volume 
may  be  of  service  not  only  to  mothers  and  nurses,  but  also  to  students  and  practi- 
tioners whose  opportunities  for  observing  children  have  been  limited. 

New  York  Medical  Journal 

"We  are  confident  if  this  little  work  could  find  its  way  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lessened  by  at  least  fifty  per  cent." 

Crothers'  Morphinism 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs  ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  ByT.  D.  Crothers,  M.  D.,  Superintendent 
of  Walnut  Lodge  Hospital,  Hartford,  Conn.  Handsome  i2mo  of  351 
pages.     Cloth,  $2.00  net. 

The  Lancet,  London 

"An  excellent  account  of  the  various  causes,  symptoms,  and  stages  of  morphinism,  the 
discussion  being  throughout  illuminated  by  an  abundance  of  facts  of  clinical,  psychological,  and 
social  interest." 

Abbott's  Transmissible  Diseases 

The  Hygiene  of  Transmissible  Diseases :  Their  Causation,  Modes 
of  Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.     Cloth,  $2. 50  net. 

SECOND   REVISED    EDITION 

During  the  interval  that  has  elapsed  since  the  appearance  of  the  first  edition 
investigations  upon  the  modes  of  dissemination  of  certain  of  the  specific  infections 
have  been  very  active.  The  sections  on  Malaria,  Yellow  Fever,  Plague,  Filariasis, 
Dysentery,  and  Tuberculosis  have  been  both  revised  and  enlarged. 

The  Lancet,  London 

"  We  heartily  commend  the  book  as  a  concise  and  trustworthy  guide  in  the  subject  with 
which  it  deals,  and  we  sincerely  congratulate  Professor  Abbott." 


i4  SAUNDERS'    BOOKS   ON 

Register's   Fever  Nursing  Recently  issued 

A  Text-Book  on  Practical  Fever  Nursing.  By  Edward  C. 
Register,  M.  I).,  1'rofessor  of  the  Practice  of  Medicine  in  the  North 
Carolina  Medical  College.      121110  of  352  pages.     Cloth,  $2.50  net. 

The  work  completely  covers  the  field  of  practical  fever  nursing.  Just  sufficient  of 
pathology,  symptoms,  and  treatment  is  given  to  enable  the  nurse  to  care  for  the  patient 
intelligently.  The  work  is  thoroughly  practical  and  nurses  will  find  it  most  valuable. 
The  illustrations  show  the  nurse  how  to  perform  those  measures  that  come  within  her 
province,  such  as  bathing,  hypodermoclysis,  pulse  and  temperature  taking,  etc. 

Hecker,  Trumpp,  and  Abt  on  Children        Recently  issued 

Atlas  and  Epitome  of  Diseases  of  Children.     By  Dr.  R.  Hecker 

and  Dr.  J.  Trumpp,  of  Munich.  Edited,  with  additions,  by  Isaac  A. 
Abt,  M.D.,  Assistant  Professor  of  Diseases  of  Children,  Rush  Medical 
College,  Chicago.  With  48  colored  plates,  144  text-cuts,  and  453  pages 
of  text.     Cloth,  $5.00  net. 

The  many  excellent  lithographic  plates  represent  cases  seen  in  the  authors'  clinics,  and 
have  been  selected  with  great  care,  keeping  constantly  in  mind  the  practical  needs  of  the 
general  practitioner.  These  beautiful  pictures  are  so  true  to  nature  that  their  study  is 
equivalent  to  actual  clinical  observation.  The  editor,  Dr.  Isaac  A.  Abt,  has  added  all  new 
methods  of  treatment. 

Lewis'  Anatomy  and  Physiology  New  $?&££ 

Anatomy  and  Physiology  for  Nurses.  By  LeRoy  Lewis,  M.D., 
Surgeon  to  and  Lecturer  on  Anatomy  and  Physiology  for  Nurses  at  the 
Lewis  Hospital,  Bay  City,  Michigan.  121110  of  347  pages,  with  146 
illustrations.      Cloth,  $1.75  net. 

A  demand  for  such  a  work  as  this,  treating  the  subjects  fro?n  the  nurses'  point  of  view, 
has  long  existed.  Dr.  Lewis  has  based  the  plan  and  scope  of  this  work  on  the  methods 
employed  by  him  in  teaching  these  branches,  making  the  text  unusually  simple  and  clear. 

The  Nurses  Journal  of  the   Pacific  Coast 

"  It  is  not  in  any  sense  rudimentary,  but  comprehensive  in  its  treatment  of  the  subjects 
in  hand.  The  application  of  the  knowledge  of  anatomy  in  the  care  of  the  patient  is 
emphasized." 

Friedenwald  and  Ruhrah's  Dietetics  Recently  issued 

Dietetics  for  Nurses.  By  Julius  Friedenwald,  M.D.,  Clinical 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.D.,  Clinical 
Professor  of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.      121110  volume  of  365  pages.     Cloth,  $1.50  net. 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse,  both  in  the  training 
school  and  after  graduation.  It  aims  to  give  the  essentials  of  dietetics,  considering  briefly 
the  physiology  of  digestion  and  the  various  classes  of  foods  and  the  part  they  play  in 
nutrition. 

American  Journal  of  Nursing 

"  It  is  exactly  the  book  for  which  nurses  and  others  have  long  and  vainly  sought.  A 
simple  manual  of  dietetics,  which  does  not  turn  into  a  cook-book  at  the  end  of  the  first 
or  second  chapter. 


NURSING  AND  CHILDREN.  15 


Paul's  Fever  Nursing  Recently  issued 

Nursing  in  the  Acute  Infectious  Fevers.  By  George  P.  Paul, 
M.D.,  Assistant  Visiting  Physician  to  the  Samaritan  Hospital,  Troy,  N.  Y. 
121110  of  200  pages.     Cloth,  $1.00  net. 

Dr.  Paul  has  taken  great  pains  in  the  presentation  of  the  care  and  management  of  each 
fever.  The  book  treats  of  lovers  in  general,  then  each  fever  is  discussed  individually,  and 
the  latter  part  of  the  book  deals  with  practical  procedures  and  valuable  information. 

The  London  Lancet 

"  The  book  is  an  excellent  one  and  will  be  of  value  to  those  for  whom  it  is  intended. 
It  is  well  arranged,  the  text  is  clear  and  full,  and  the  illustrations  are  good." 

Paul's  Materia  Medica  for  Nurses  Recently  issued 

Materia  Medica  for  Nurses.  By  George  P.  Paul,  M.D.,  Assistant 
Visiting  Physician  to  the  Samaritan  Hospital,  Troy.  121110  of  240  pages. 
Cloth,  $1.50  net. 

Dr.  Paul  arranges  the  physiologic  actions  of  the  drugs  according  to  the  action  of  the 
drug  and  not  the  organ  acted  upon.  An  important  section  is  that  on  pretoxic  signs, 
giving  the  warnings  of  the  full  action  or  the  beginning  toxic  effects  of  the  drug,  which, 
if  heeded,  may  prevent  many  cases  of  drug  poisoning. 

The  Medical  Record,  New  York 

"This  volume  will  be  of  real  help  to  nurses;  the  material  is  well  selected  and  well 
arranged,  and  the  book  is  as  readable  as  it  is  useful." 

_     ,    ,      _  ,    __  Recently  Issued 

Pyle  s  Personal  Hygiene  The  New  (3d)  Edition 

A  Manual  of  Personal  Hygiene:  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pvle,  A.M., 
M.D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  451  pages,  fully  illustrated.     Cloth,  §1.50  net. 

To  this  new  edition  there  have  been  added,  and  fully  illustrated,  chapters  on  Domestic 
Hygiene    and    Home  Gvmnastics,  besides  an  appendix  containing  methods  of   Hydro- 
therapy,   Mechanotherapy,   and    First  Aid   Measures.     There  is  also   a  Glossary  of  the 
medical  terms  used. 
Boston  Medical  and  Surgical  Journal 

"  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
have  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound 
knowledge." 

Galbraith's  Four  Epochs  of  Woman's  Life     JSffiSSS 

The   Four   Epochs  of  Woman's    Life.     By  Anna  M.   Galrraith, 
M.D.      With  an  Introductory  Note  by  John  H.  Musser,  M.D.,  Univer- 
sity of  Pennsylvania.      121110  of  247  pages.      Cloth,  $1.50  net. 
Birmingham  Medical  Review 

■  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public  ; 
but  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  whole- 
some." 

Starr  on  Children  second  Edition 

American  Text-Book  of  Diseases  of  Children.  Edited  by  Louis 
Starr,  M.D.,  assisted  by  Thompson  S.  Westcott,  M.D.  Octavo,  1244 
pages,  illustrated.     Cloth,  $7-°°  net;  Half  Morocco,  $8.50  net. 


a6  SAUNDERS'   BOOKS  ON  CHILDREN. 


.       .  Fifth  Edition,   Revised 

American  Pocket  Dictionary  Recently  issued 

American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  New- 
man Dorland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the' 
University  of  Pennsylvania.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  Dean 
of  the  Jefferson  Medical  College,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  Recently  issued 

Immediate  Care  of  the  Injured.  By  Albert  S.  Morrow,  M.  D., 
Attending  Surgeon  to  the  New  York  City  Hospital  for  the  Aged  and 
Infirm.     Octavo  of  340  pages,  with  238  illustrations.     Cloth,  $2.50  net. 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practical  book  for  every 
day  use,  and  the  large  number  of  excellent  illustrations  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.    Physicians  and  nurses  will  find  it  indispensible. 

Powell's    Diseases    Of   Children  Third  Edition,  Revised 

Essentials  of  the  Diseases  of  Children.  By  William  M.  Powell, 
M.  D.  Revised  by  Alfred  Hand,  Jr.,  A.  B.,  M.  D.,  Dispensary 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  $1.00  net.  hi  Saunders' 
Question-  Compend  Series. 

Shaw  on  Nervous  Diseases  and  Insanity      SE3*S£ 

Essentials  of  Nervous  Diseases  and  Insanity  :  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the  late 
John  C.  Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  $1.00  net.  Jn  Saunders'  Question- Com- 
petid  Series. 

"  Clearly  and  intelligently  written ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted." 
— Boston   Medical  and  Surgical  Journal. 

Starr's  Diets  for  Infants  and  Children 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By 
Louis  Starr,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hospital, 
Philadelphia.  230  blanks  (pocket-book  size).  Bound  in  flexible  leather, 
$1.25  net. 

Grafstrom's  Mechano-Therapy  secon^RevTsidEdition 

A  Text-book  of  Mechano-therapy  (Massage  and  Medical  Gymnas- 
tics). By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  Attending  Physician  to 
the  Gustavus  Adolphus  Orphange,  Jamestown,  New  York.  i2mo,  200 
pages,  illustrated.     Cloth,  $1.25  net. 


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